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Youth Suicide Prevention Online: Skills For School Staff, Parents And Peers
Grant # 1R43HD049197-01A2;
Laura Backen Jones, Ph.D., Principal Investigator; John Seeley, Co-Investigator
Phase I Project Period: Start Date: 08-01-06 through 3-19-08

Phase II Program Content. Based on feedback we received from the suicide crisis contacts and school staff, we will expand the Recognize and Respond modules to include many more examples of youth at varying levels of risk and more examples of how to effectively connect with students at these different levels. In addition, we will incorporate more interactive exercises in each module to promote skills, a journaling function, and an expert-moderated online discussion forum for school staff. We will also add a new module targeting school climate. Please see expanded description of these additional features in the Innovative Online Delivery Platform section below.

The proposed Phase II program Skills in Youth Suicide Prevention: Online Multimedia Training for School Staff will be an online training resource for staff intended to complement existing gatekeeper programs. The program is meant to be used by individual end-users, although the staff training materials will also be available in linear form (DVD and print) with a training package for group presentation by trainers. Content material will be grounded in Social Cognitive Theory, and will be developed in collaboration with Peter Gutierrez, Ph.D., a recognized expert in suicide prevention with specific expertise in cultural sensitivity, and President of the American Association of Suicidology, and Diane Ryerson, director of SAFE:TEEN, one of the most widely used gatekeeper program in the U.S., and Jeffrey Sprague, Ph.D. one of the developers of SWPBS. The program will consist of four primary modules, each with supportive instructional tools. Content objectives for each module will undergo review by our consultants and key informants during Phase II and content will be created based on their input. Possible content for each of the modules is described below.

Module 1: Implementation Guide. This module contains a guide for setting up a school environment that sensitizes school staff to recognize youth in distress and respond effectively. Administrative tools will be included that aid program implementers in supporting staff training compliance. Content will be created in collaboration with our consultants and expert key informants representing school district administrators, crisis team coordinators, and other key staff who would be responsible for disseminating and managing the program. Program content will include templates for establishing policies and procedures and building a community resource list, a grid for responding to students and their parents at different levels of risk, and training in engaging and supporting parents and students through the referral process. Video sequences will be used to model action plans for helpful and appropriate referral. For example, we will demonstrate skills for intervening by presenting a video vignette showing how to develop an action plan when a staff member does identify a student at risk. Other additional content will include: steps in creating a Crisis Response Team, Postvention strategies, and an Implementation Fidelity Checklist.

Module 2: Relate. Material in this module will be grounded in universal principles of School Wide Positive Behavior Support (SWPBS). We will work with our Co-Investigator Jeff Sprague, one of the developers of SWPBS, to expand the model to include material targeting staff behaviors known to reduce the risk of suicide in adolescent youth. The training will impart practical, easy-to-implement steps in applying school wide positive behavior support (SWPBS) strategies to:

(1) Build positive relationships with students,
(2) Encourage positive behavior,
(3) Respond appropriately to problem behavior, and
(4) Communicate effectively with students.

In studies of SWPS, these factors have contributed to creating a positive school climate, a predictor of reduced risk of suicide for youth. In the training, we will create more intensive training in aspects targeting youth internalizing behavior (e.g., strengthening relationships and improved communication with youth) and will also include strategies for promoting student contribution, a known protective factor in youth suicide prevention (Toumbourou & Gregg, 2002).

Module 3: Recognize. This session will build on the Phase I materials developed that demonstrate how school staff can become skilled at recognizing youth at risk for depression or suicide. Content material will include information on teen development and situational vignettes that link a range of student affective behavior to signs of distress, suicidal intention, and symptomology of depression/ mood disorders in adolescents. For example, a series of vignettes depicting particular behaviors associated with a student contemplating suicide or what a potentially suicidal student might say will be portrayed. Intended learner outcomes are: an improved ability to identify signs of distress/suicidal intentions in youth, and an enhanced sense of efficacy in recognizing youth at risk (see Appendix A and C for Phase I Recognize Module content and video segments).

Module 4: Respond. Session content be expanded from the Phase I module, emphasizing the staff's critical role in responding to youth in distress. Staff will receive training in the skills needed to approach students in distress and in helpful and supportive ways to respond. Content material will be grounded in an understanding of adolescent development, offering informative video models and training that demonstrates the effective communications skills needed for supporting distressed students and helping them feel connected with school. Using examples and non-examples, situational vignettes will differentiate effective approaches from ineffective ones. The intended outcomes for this session are for staff to increase their knowledge of effective communication strategies and the limits of their role, to practice and improve their skills in responding helpfully with distressed youth, and to develop a stronger sense of efficacy in responding to youth (see Appendix A and C for Phase I Respond Module content and video segments).

Training Package for Inservice. Phase I suicide crisis contact evaluation participants and key informants emphasized the need for a group training package to complement the online program. With this package, suicide crisis contacts and administrators have the tools necessary to conduct a school inservice on youth suicide prevention with school staff. A library of DVD vignettes featuring youth warning signs at different levels of risk, and helpful ways for staff to connect with distressed youth will be included with an accompanying print guide. The guide will include information for using the vignettes in training, a Powerpoint presentation for inservice training, and laminated cards that summarize key points for staff to take away from the training. Additional material will be determined in Phase II. Dr. Jones has extensive experience developing trainings in group facilitation. She trains parent educators from across the U.S. for Birth to Three, and co-authored a 30-session group-based parenting program, Parenting: The First Three Years, that contains an comprehensive Facilitator's Guide. The staff at IRIS Media also has significant expertise in developing Facilitator's Guides for their group-based school staff training.

Innovative Online Delivery Platform
The Skills in Youth Suicide Prevention: Online Multimedia Training for School Staff program is delivered on IRIS Ed Online (IEO). This training format encourages active adult participation, individual problem solving, and expert feedback, characteristics of effective instruction that lead to greater skill acquisition than is possible from a lecture presentation (Joyce & Showers, 1995). The feasibility of this approach was established in Phase I (see Final Report). A discussion of the impact of IEO technology and details about the production of IEO components are provided in the Commercialization Plan. Below is a brief description of the instructional path implicit in each module and associated components. Please see Appendix A and C for a pictorial depiction of the online components.

(a) Video-driven lessons model youth who are showing signs of risk and effective and ineffective staff responses to issues related youth distress. Racially and ethnically diverse staff members are portrayed in these short model-based video sequences. One or two targeted skills are modeled in each sequence. A motivational component increases awareness of youth depression and warning signs of suicidal ideation.

(b) Interactive assessments allow staff to apply knowledge and skills in recognizing and responding to youth in distress in ways similar to real-world situations. Learning will occur through attempts to make sense of the situations with which they are presented, and by choosing strategies to effectively handle problems typically encountered with youth. Mastery of these contextual and problem-based scenarios will contribute to self-efficacy (see theoretical framework). Self-assessments and"errorless knowledge checks" give users the opportunity to test their knowledge, and receive immediate feedback. Additional assessment features include random question rotation;"save and complete later" function; questions accompanied by pictures/Flash video; multiple choice, yes/no and text field answer options; and percent-complete visual display. The goals of the self-assessment are increased confidence and competence in interacting with youth.

(c) Interactive mastery exercises guide the user in practicing newly learned skills. For example, users will engage in simulated online interactions with distressed youth, make choices about correct strategies to employ, and experience the outcomes of their choices and decisions. The interactive mastery exercises use Macromedia Flash and a Flash Component Application Programming Interface (API) to send personalized results such as individual action plans and graphical user profiles to the IEO site database.

(d) A journaling tool prompts the user to plan action steps and monitor progress in meeting these goals. The system tracks user's journal entries by date and time of completion. Journal activity will be stored as part of the user's profile and can be printed by staff and/or administrators depending on configuration.

(e) A discussion forum encourages peer support. School staff have the opportunity to share experiences and ideas, and support from others with the expert-moderated web-based community. Users will be guided to implement steps in their action plan using the journaling tool and are then encouraged to use the discussion forum to share their experiences (specific to the action plan) with peers. This approach is intended to promote high comprehension, retention, and a sense of efficacy that fosters action (see theoretical framework).

For the purpose of conducting online research, IEO also contains an Evaluation tool that allows for the posting and administration of evaluation surveys (pre and post assessments) and for the collection of response and user activity data (participant responses, number of user attempts, date and time of access, and percentage of assessment completion), which is stored in a data base on a secure server.

Other features of IEO include printable resource materials, including tip sheets underlining key principles, and/or charts that allow users to track progress, a glossary of terms gives simple definitions to technical terms such as depression, suicidal ideation, etc., and EdClips, automated emails that reconnect the user to the material over an extended time after they have completed the instructional program. EdClips are described in the following section.

Countering Limitations to Online Training
Online training offers the potential for expanding the availability of training to staff, as recommended by leading researchers (Guskey, 1986, Joyce and Showers, 1995), but mechanisms for ensuring fidelity and long-term implementation are also needed if the training is to elicit successful, durable, and substantial behavior or system change (Cuban, 1990; Hall & Hord, 2001; Smylie, 1988; Sugai & Horner, 1999). In order to enhance fidelity of implementation and the probability that knowledge and behavior change gains are maintained,the online program will contain an Implementation Guide and a set of administrative tools (Admin Tools).

Ensuring Training Fidelity. Despite anticipated repeated use by large numbers of staff, content and delivery of the program will remain constant, consistent with recommendations from researchers (e.g., Gresham, MacMillan, Beebe-Frankenberger, & Bocian, 2000; Reschly and Gresham, 2006). The threat to fidelity due to users not completing the training will be offset by an administrative data system contained within the online Implementation Guide (IG) that will support staff training compliance and allow administrators to track a user's progress and completion. School administrators, trainers, or school behavior teams will be able to assign training to specific staff members, and track their progress. The IG will use multimedia and printable text resources to provide directions for implementing, monitoring, and assessing the training intervention. Critical components of the IG are guidelines for administrators, or behavior teams who directly support staff efforts, particularly when staff needs to troubleshoot and solve problems. The IG will also contain an Implementation Fidelity Checklist for school administrators to help ensure training fidelity. This checklist will be developed along with the program materials.

Tailoring Training to the School. The IG will also provide simple instructions on how to access IEO's content management system, referred to as Admin Tools. The tools allow school and district administrators to tailor the training to their site and control how the training is delivered. The tools also will allow administrators to:

a) designate which staff (e.g., teachers, educational assistants, behavior support teams) will receive training,
b) add district-specific content (e.g. school rules, assessments, schedules),
c) designate which components must be completed by the trainee in order to fulfill district standards, to assess proficiency (knowledge, efficacy, behavioral intentions, etc.), and
d) issue certifications or provide other incentives for completion.

Admin Tools also allow program implementers to receive staff-generated journals, track individual user usage (time spent interacting with the online program, module completion, and assessments results) and set up EdClips (automated emails that reconnect user with training material over time - see Behavior Change Maintenance section). IRIS Media works extensively with schools across the nation and we have used this approach successfully in the past.

Promoting Behavior Change Maintenance. To achieve a high public health impact, behavior change interventions must include methods for sustaining short-term gains in behavior change (Klesges, Estabrooks, Dzewaltowski, Bull, & Glasgow, 2005). Desired changes are more likely to be sustained if the program is easy to use and requires minimal time and other investments on the part of the participant. School staff were especially impressed with the Phase 1 prototype's efficiency and ease of use. Additional recommendations for strengthening maintenance include built-in mechanisms for social support and a means for continuing contact with the participant after the primary training has ended. As noted above, the web forum gives participants opportunities for social support. To further maximize the potential for lasting behavior change, the program will use an automated email prompting system. With edCLIPS program implementers can set up a maintenance schedule for review and/or re-access to the program so that participants can refresh their knowledge and skills. edCLIPS will enhance learning by:

(1) delivery of frequent, routine, engaging content that users can access at their convenience, and
(2) inclusion of multimedia material addressing multiple learning modalities thus enhancing comprehension and retention of information and skills. Ongoing contact with the program via edCLIPS will maximize the potential for sustaining gains.

Skills in Youth Suicide Prevention: Online Multimedia Training for School Staff The proposed program has strong potential significance because it will address the problem of adolescent depression and suicide. Although 1 in 5 adolescents experience depression, schools recognize and refer only about 1% of depressed youth to appropriate mental health resources. Given that suicide is the third leading cause of death in adolescence, and depression underlies suicidal behavior in 90% of adolescents, it is important that school staff are prepared to recognize youth at risk and respond effectively. We recognize that websites with facts about suicide prevention are prevalent, so a website for school staff is not innovative per se; however, the proposed program is innovative because it:

(1) expands the School Wide Positive Behavior Support (SWPBS) system to target adolescent internalizing behaviors,
(2) includes the SWPBS model in youth suicide prevention,
(3) allows for school branding via administrative tools, so schools can personalize the program, and add their own components, including links to community mental health resources,
(4) incorporates an Implementation Guide that will help behavior support teams and school administrators develop an infrastructure to support maintenance of the program, and
(5) has instructional tools for skill-building, including an expert-moderated online forum, that will give school staff opportunities to share their ideas and experiences with youth, and edCLIPS for maintenance of knowledge and skills.

Our consultant, John Kalafat, passed away unexpectedly last month. Although Dr. Kalafat reviewed drafts and gave feedback on the program, he was not able to submit his invoice prior to his untimely death; therefore, the hours listed above are an estimate.