American Public Health Association: Epidemiology Section National Award

The North Dakota Adolescent Suicide Prevention Project was named as the national Field Project award winner for American Public Health Association, epidemiology section. This award highlighted the North Dakota Adolescent Suicide Prevention Project as a project demonstrating measurable relevance to public health improvement. The award highlights a project using innovative and creative public health approaches with state, local and community-based public health action.

Outcomes

The project works closely with the North Dakota Suicide Prevention Task Force and dozens of tribal and rural partners throughout the state.

  • Since the project’s inception in 2000, it has trained over 40,000 North Dakotan’s in suicide prevention strategies, including 7500 teen leaders, 8000 professionals, 1500 faith-based partners with 35% of the projects activities taking place in tribal settings.
  • The five year trend since the start of the project shows a sustained 47% reduction in ND 10-24 year old suicide fatalities ages 10-19 from 2000-2004 compared to compared to the ten year average in the 1990’s. Ages 10-24 suicide fatalities were reduced by 32% comparing 2000-2004 to the 1990’s ten year average.
  • North Dakota Youth Risk Behavior Survey’s comparing years 1999 to 2003 9th -12th grade responses to suicide questions show the following: 29% reduction in teens having seriously thought about suicide, 20% reduction in teens having made a suicide plan, 20% reduction in teens having made suicide attempt needing medical attention..
  • Every state and tribal region has initiated at least 3 of 7 recommended strategies:
    • multi-targeted gatekeeper training
    • professional training
    • early screening and referral strategies
    • teen-led or peer-led efforts
    • mentoring
    • increasing community level support groups including survivor support
    • increase access to treatment through development of home tracking or school/community based mental health access
  • Besides the North Dakota Suicide Prevention Task Force, there have been ten local, tribal, or regional coalitions/committees working on suicide prevention that have received training or technical assistance from the state project.
    • Standing Rock Suicide Prevention
    • Valley City region – Wellness in the Valley
    • Spirit Lake Suicide Prevention
    • Grand Forks – T.E.A.R.S.
    • Turtle Mountain Suicide Prevention
    • Three Affiliated Tribes – Boys and Girls Club, schools, and wrap-a-round services
    • Dickinson area –
    • Wells County suicide prevention – Harvey ALIVE
    • Bismarck/Mandan Crisis Team – Region VII
    • United Tribes Native American Injury Prevention Task Force
  • A Sources of Strength gatekeeper curriculum has been developed, implemented, and dispersed targeting four specific groups: teen leaders-college students, parents, school staff, and community caretakers. Participation satisfaction and usefulness ratings from these trainings have averaged 8.6 on a 1-10 scale with ten being the most useful. Funding for independent evaluation is being pursued.
  • 35 new teen-led prevention projects received start-up training – 15 in tribal communities
  • 8000 professionals received updated training on suicide intervention and prevention strategies (physicians, nurses, pastors, law enforcement, EMT’s, residential treatment and detention, school staff, recreation programs, and mental health specialists)
  • 26 new schools and communities were implementing screening strategies – Prairie Screening Project partnership, National Depression Screening Day, plus targeted screening groups.
  • North Dakota Tribal-Rural Mentoring Partnership was developed by the state project with 9 mentor coordinators working with 475 youth, 325 mentors in 20 tribal communities and 5 rural communities of North Dakota with funding from a Safe and Drug Free Schools Grant.
  • Over sixty third year medical students from UND School of Medicine, fifty University of Mary nursing students, and thirty United Tribes nursing students have participated in year long mentoring to middle school adolescents and have received training on evidence-based suicide prevention efforts, substance abuse prevention, and a holistic model for suicide interventions.
  • Adolescents involved in the medical student mentoring project showed a 35% reduction in suicidal ideation and 38% reduction in feelings that their families did not care about them.
  • 2005 data from youth involved in the ND Tribal-Rural Mentoring Partnership showed an average contact of 5.2 hours per month, 65% increased academic grades, 60% were better able to avoid early drinking/tobacco, 80% better able to avoid early parenting- STD’s, 63% better able to avoid legal trouble. Sixty percent of parents reported better home relationships, 80% reported more involvement in positive activities, 74% more helpfulness and generosity, and 71% improved relations with other adults.
  • Over 95 tribal and rural entities have signed coalition agreements and belong to councils working on specified mentoring and suicide prevention activities.
  • Over 50 Native American Injury Prevention from United Tribes have been trained on suicide prevention strategies and are being placed in numerous tribal communities. Suicide prevention is becoming part of their core curriculum.
  • Eight detention centers, attendant care sites, and residential centers have updated their suicide response protocol.
  • Through training the trainer sessions over 20 gatekeeper trainers have been certified and provided training in North Dakota increasing capacity.
  • National attention has come to the ND Suicide Prevention Project and in the last 20 months the following national and regional trainings have been conducted by the project director…
    • San Diego – Indian Health Service and SAMSHA Behavioral Health Conference
    • Seattle – Native Aspirations training with nine tribal areas ( Alaska, Montana, South Dakota)
    • Anchorage – Frontiers in Mentoring
    • Denver – West Denver’s Girl’s Inc. Project
    • Minneapolis – Bemidji Indian Health Services
    • Rapid City – Aberdeen Area Tribal Chairman’s Health suicide conference
    • United Tribes – Regional Native Lifesavers Conference
    • Red Lake/Bemidji – Regional suicide prevention task force training
    • Oklahoma City – Oklahoma Suicide Prevention Conference
    • Philadelphia – Annual Conference of the American Public Health Association
    • Minneapolis – CSAP’s Native American Prevention Sharing Conference
    • Rapid City – National Suicide Prevention Resource Center training
    • Sources of Strength materials and curriculum have been distributed and used in approximately 28 states at last count.

2006 Targeted Areas

  • Provide 5000 with four pronged gatekeeper training to teens, parents, school-staff, and community caretakers.
  • Provide 1000 professionals training in updated suicide prevention training focusing on holistic cross system referrals and age/gender specific awareness of suicide risks and protective factors.
  • Develop statewide suicide prevention website.
  • Market project with greater visability – target key stakeholders, legislators, funders.
  • Raise between $250,000 – $300,000 in 2006 to sustain mentor project, teen leader efforts, and suicide prevention efforts.
  • Develop nation’s first contagion response system for tribal/rural settings.
  • Pilot home-based tracking model in at least two North Dakota settings for suicide attempters and families.
  • Develop a partnership with colleges and universities around college suicide prevention initiatives.
  • Implement new North Dakota Suicide Prevention Plan.

A Blended Approach to Prevention

The North Dakota Adolescent Suicide Prevention Project has taken a holistic approach toward suicide prevention blending three overall strategies.

  • Awareness/Education
  • Increase Treatment Access
  • Resiliency and Asset Building

The North Dakota experience has led to a prevention philosophy that believes education, treatment access, and resiliency strategies are interwoven – one impacts the other. Also that increasing strengths and protective factors is as important as being risk focused. This is significant in tribal and rural communities that have experienced risk factor statistics as discouraging rather than empowering.

Sources of Strengths

The strength-based model that is woven through all gatekeeper and professional education is incorporated in the phrase “Sources of Strength.” The eight protective factors are ….

  1. Family Support
  2. Positive Friends
  3. Positive Activities
  4. Caring Adults – Intergenerational mentors
  5. Generosity or Leadership Opportunities
  6. Spirituality
  7. Access to Mental Health Services
  8. Access to Medical Services

These protective factors are common pathways to health and healing mentioned by youth and young adults that struggle with the four most common risk factors associated with youth suicide. These are…

  1. Depression
  2. Aggression/Conflict
  3. Trauma
  4. Substance Abuse

The Sources of Strength are presented with several different teaching points…

  1. During a suicide intervention or crisis, multiple areas of strength should be activated beginning with medical or mental health referrals, but followed with other strengths as well. .
  2. No one area should be considered strong enough to keep a suicidal individual safe.
  3. The more strengths or protective factors one has the better an individual’s ability to cope with life’s difficulties, addictions, depressions, traumatic incidents, and conflicts.
  4. Cross system referrals are important for professionals.
  5. For leaders and natural helpers use the Sources of Strength as a self-assessment checklist when struggling with anger, anxiety, or depression to determine balance in one’s life.
  6. While always starting with a referral to mental health and medical services, do not be naively optimistic about the institutional systems ability to retain and treat suicidal individuals. Less than 30% are receiving services after a medically involved suicide attempt. Go beyond institutional intervention and activate village-based supports.
  7. The whole community needs to be involved in suicide prevention – there are important roles for everyone.

History

1998 – Region VII (Bismarck) targeted as states highest youth suicide fatality area averaging 7 fatalities a year from 1993-1997 – 123 gatekeeper and teen led training sessions held – Region VII teen suicide fatalities drop from 7 to 2 per year for next five years 1993-2002

1998 -14 North Dakotans participate in SPAN Conference helping developing 1 st national suicide prevention plan

1999 – ND Adolescent Suicide Prevention Task Force formed

  • Initial state surveys, data analysis completed
  • 1 st North Dakota state plan developed with recommendations

2000 – Awareness Phase

  • Mental Health Assoc. in North Dakota lead agency in grant project ($75,000 ND CSCC)
  • All of North Dakota state regions and tribal areas receive awareness and planning workshops
  • 126 workshops to 2600 participants

2001 Action Phase

  • Implementation of five core strategies
  • 145 workshops to 3200 participants
  • $75,000 grant ND CSCC

2002 Capacity Building

  • Three regions fund part time suicide prevention coordinators
  • Funding $80,000 from five grant sources to continue state coordination efforts

2003 Integration

  • 8 rural and tribal mentoring coordinators hired – $180,000 a year Safe and Drug Free School grant through 2005
  • Train the trainer sessions continue
  • Developing system (rapid community mobilization) of targeted prevention response to suicide contagion or impact areas
  • Continue pursuing pilot project for home-base tracking in rural and tribal settings
  • ND legislature turns down request for suicide prevention coordinator in ND Health Dept. budget – continue to fund through grants
  • 175 workshops/technical assistance sessions to over 4500 participants to date in 2003

2004 Funding – Research – Capacity Building

  • Prevention research grant pursued through United Tribes
  • ND Suicide Prevention Conference to focus on action efforts
  • Expand state suicide prevention plan to include all ages
  • Involve stakeholders, survivors in legislative funding effort
  • Regional training the trainer around gatekeeper, mentoring, teen-led efforts, support groups, screening efforts, and crisis response through rapid community mobilization.
  • Expand infrastructure through partnerships with local, regional, statewide groups.

2005 National Recognition – Limited Funding

  • Project receives American Public Health Association national Field Award from the Epidemiology Section
  • ND State Task Force develops new across the lifespan suicide prevention plan.
  • Annual funding for MHAND project and gatekeeper strategies down to $16,000 – 64 attend training the trainer Sources of Strength gatekeeper sessions develops over 20 trainers statewide – overall suicide specific activities down due to lack funding.
  • North Dakota Tribal-Rural Mentoring Partnership grows significantly with Department of Education School-based mentoring grant – 400 youth being mentored.

2006 National Training for Tribal Areas – Funding Critical in North Dakota

  • Project Director begins training nationally on Sources of Strengths and community strengthening model ( Oklahoma, Philadelphia, Alaska, Colorado, Bemidji Area, Red Lake, San Diego, Seattle,

Targeted Populations

Adolescents and young adults became the primary focus for North Dakota’s suicide prevention efforts with data indicating suicide fatalities for 10-24 year olds at almost twice the national rate. North Dakotan’s of all ages rated 26 th nationally and North Dakota suicide fatalities for elderly were significantly under the national average. Males made up 85% of all suicide fatalities and Native American youth and young adults were 35% of the suicide fatalities while representing only 8% of North Dakota’s youth. In 2004 the North Dakota Suicide Prevention Task Force will rewrite the state plan to address goals and objectives for all ages related to suicide.

Public Awareness – Education – Gatekeeper Training

Over 40,000 have participated in workshops and technical assistance sessions to implement recommended suicide prevention strategies. Of primary focus for awareness sessions, gatekeeper training, or professional training has been to initiate the following.

  • Present audiences with facts and up to date data and research related to North Dakota’s suicide.
  • Reduce stigma associated with mental health disorders and treatment.
  • Expand suicide knowledge beyond depression awareness to include other risk factors and protective factors.
  • Expand professionals response to include a multilevel intervention approach based on multiple sources of support.
  • Present interventionists with research and training on “common errors.”
  • Provide strategies that encouraged efforts beyond one-shot awareness and move postvention crisis teams toward activating local community mobilization and long term natural helper support.
  • Community and peer gatekeeper training should address basic steps of intervention and referral with a significant emphasis on addressing ‘codes of silence’ for youth/young adult audiences. The project’s own Peer Gatekeeper Curriculum, QPR, and Yellow Ribbon are the most commonly used in the state.

Teen-led Efforts in Suicide Prevention

Over 8000 teens have been trained with 35 new teen-led startup efforts involving teens in ongoing prevention efforts. Our focus has encouraged a three phase effort – one phase leading to the other.

  1. Peer Gatekeeper – an interactive four hour curriculum developed to address “codes of silence” and partnering with adults
  2. Peer to peer messages on risk factors, protective factors, codes of silence, and where to get help
  3. Long-term teen-led prevention efforts that had five clear benchmarks (training, supervision, planning input, clear mission and role, and recognition.

Screening

Universal and targeted screening strategies have been initiated in 26 new schools, 8 detention or youth facilities, and over 400 faith-based youth leaders, pastors, and spiritual leaders have received training on screening tools. Physicians and medical students have received training on new clinic friendly tools.

  • A screening toolkit packet with a variety of screening devices have been regularly distributed.
  • Partnership with Colombia Teen Screen and DISC-R – Prairie Screening Project
  • Addressing significant stigma issues around screening with comparison to hearing and vision tests.

Mentoring

North Dakota’s suicide prevention efforts have linked the very promising research on mentoring for violence and substance abuse with suicide issues. Initial efforts to start rural and tribal mentoring were linked with significant basic infrastructure problems so the North Dakota Tribal-Rural Mentoring Partnership was formed to provide the core components identified in research on successful mentoring.

  • Teens, college students, adults, and elders mentor in what has become North Dakota’s largest mentoring effort and one of the nation’s largest tribal mentoring projects. A variety of mentoring styles community-based, cultural, faith-based, school-based – allow for strong local involvement
  • 9 mentor coordinators have been hired for seven tribal-rural areas of the state (Turtle Mountain/Rolette County, Trenton Indian Health District, Three Affiliated Tribes, Wells County, Standing Rock, United Tribes, and Spirit Lake)
  • As of June 2005 – 475 youth are being mentored weekly, 350 individual mentor matches, 175 in group mentoring.
  • 52% of mentors are Native American.
  • The ND Tribal-Rural Mentoring Partnership is being highlighted by the National Mentoring Center for their 2006 case study in model programs. The project is listed also listed in the Corporation for National and Community Services – Effective Practices Collection.
  • Outcome studies show positive impact in youth self-esteem, self-confidence, family conflict, ability to get along with other adults, academic performance, absenteeism, ability to handle moods, ability to refuse alcohol and drugs, and positive impact on youth struggling with suicidal ideation.
  • The project is partnering with Abt Associates and the U.S. Dept. of Education as one of 20 national sites chosen for 2005-06 school-based research project. This research project is the nation’s largest research effort ever conducted on the impact of school-based mentoring. At present this project has 19 MOA’s with schools in tribal/rural communities.

Home-Based Tracking

Approximately 70% of youth and young adults having medical contact due to a suicide attempt in rural and tribal North Dakota receive no services two weeks later. Significant promise has been shown in tribal communities around home-based tracking models for pre and post natal support, asthma, and diabetes. A pilot project using this model is presently being implemented on the Sioux Standing Rock Nation.

Support Groups

The project through MHAND has provided technical assistance in the startup of a dozen support groups throughout the state. These groups vary from depression, survivor, talking circle groups, and groups addressing trauma. They can be sponsored by community, faith, or schools, but have the primary purpose of provided emotional support and a caring community to support them. These would not be considered therapy groups, but rather support groups. The North Dakota HELPLINE regularly monitors and refers individuals to a variety of support groups throughout the state. We presently have 33 support groups statewide and would like to expand to 50 by the end of the year.

Statewide Hotline and Resource Center – 2-1-1

The Mental Health Association in North Dakota (MHAND) just celebrated it’s 50 th anniversary and provides a statewide HELPLINE (701-472-2911) answered in person 24 hours per day. The HELPLINE has an extensive data system which provides local referral and resources to individuals needing assistance whether of a crisis or informational nature. The HELPLINE has just been chosen to expand and become North Dakota’s 2-1-1 system. The MHAND Resource Center also carries an extensive system of several thousand types of pamphlets or print materials and over 500 videos related to mental health and youth related issues.

Crisis Response – Postvention Focus

We are encouraging schools and community’s to have a Crisis Response Plan in place that enables communities to responds to traumatic events and tragic fatalities that impact the school or a community. Sample models of written crisis response plans are available upon request from the Mental Health Association in North Dakota. We are strongly encouraging crisis teams to move beyond a single session critical incident debriefing model and focus on long term support. A model in which medical and mental health experts partner with local natural helpers to provide long term support to impacted individuals and families.

In areas dealing with potential contagion or pandemic suicide situations we strongly encourage a “rapid community mobilization model” which encourages whole communities to gather quickly after a second or third “area suicide fatality.” This community response moves beyond the traditional mental health and school response and encourages involvement of youth leaders, parents, elders, spiritual communities, 1 st responders, health, mental health, media, business, and school. A series of recommendations are mentioned in the North Dakota Suicide Prevention Newsletter – short term crisis response.

Human Service Center’s and Indian Health Services have mental health professionals available in all of the regional and tribal areas of the state and are encouraged as an immediate point of contact. The statewide HELP-LINE or 2-1-1 System will provide access to these regional and local support number’s 24 hours per day.