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Adapting Suicide Safety Plans for Youth with Intellectual and Developmental Disabilities

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Title: Adapting Suicide Safety Plans for Youth with Intellectual and Developmental Disabilities
Language: English
Authors: Daniel Q. Earixson, Karen C. Hall, Marisa E. Marraccini, Casey D. Calhoun
Source: Journal of Applied Research in Intellectual Disabilities. 2024 37(2).
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 5
Publication Date: 2024
Sponsoring Agency: National Institute of Mental Health (NIMH) (DHHS/NIH)
US Department of Health and Human Services
National Institutes of Health (NIH) (DHHS)
Document Type: Journal Articles
Reports - Research
Descriptors: Suicide, Intellectual Disability, Developmental Disabilities, Prevention, Safety, Intervention, Risk Management, Youth
DOI: 10.1111/jar.13198
ISSN: 1360-2322
1468-3148
Abstract: Introduction: Although risk for suicide appears elevated in individuals with intellectual and developmental disorders (I/DD), few interventions or tools addressing suicide prevention have been adapted for this population. Among evidence-based interventions for preventing suicide, safety planning interventions are an effective and commonly employed intervention for reducing suicide-related risk. Methods: By drawing on Special Education praxis for supporting the learning needs of individuals with I/DD, we provide recommendations for adapting suicide safety planning interventions for youth with I/DD. Results: Specific visual, content, teaching, and communication components of the safety plan intervention can be adapted to better meet the needs of youth with I/DD. Discussion: Although future research is needed to evaluate these recommendations, these modifications may support clinicians serving youth with I/DD and suicide-related risk.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1413004
Database: ERIC
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  Value: <anid>AN0175502858;e0301mar.24;2024Feb20.05:26;v2.2.500</anid> <title id="AN0175502858-1">Adapting suicide safety plans for youth with intellectual and developmental disabilities </title> <p>Introduction: Although risk for suicide appears elevated in individuals with intellectual and developmental disorders (I/DD), few interventions or tools addressing suicide prevention have been adapted for this population. Among evidence‐based interventions for preventing suicide, safety planning interventions are an effective and commonly employed intervention for reducing suicide‐related risk. Methods: By drawing on Special Education praxis for supporting the learning needs of individuals with I/DD, we provide recommendations for adapting suicide safety planning interventions for youth with I/DD. Results: Specific visual, content, teaching, and communication components of the safety plan intervention can be adapted to better meet the needs of youth with I/DD. Discussion: Although future research is needed to evaluate these recommendations, these modifications may support clinicians serving youth with I/DD and suicide‐related risk.</p> <p>Keywords: intellectual and developmental disabilities; prevention; safety planning; suicide</p> <hd id="AN0175502858-2">INTRODUCTION</hd> <p>Individuals with intellectual and developmental disabilities (I/DD) are at increased risk of suicide‐related behaviours regardless of cognitive or adaptive functioning (Nagraj & Omar, [<reflink idref="bib11" id="ref1">11</reflink>]). With higher rates of co‐occurring psychiatric conditions than the general population (King, [<reflink idref="bib9" id="ref2">9</reflink>]), they receive psychiatric emergency crisis services at a higher rate compared to neurotypical peers (Kalb et al., [<reflink idref="bib8" id="ref3">8</reflink>]). Unfortunately, few therapeutic tools address suicide‐related risk for individuals with I/DD (Nagraj & Omar, [<reflink idref="bib11" id="ref4">11</reflink>]). Although safety planning interventions (SPIs) appear effective in reducing the risk of suicide in adult populations (Doupnik et al., [<reflink idref="bib5" id="ref5">5</reflink>]), few studies have addressed adaptations for children and adolescents (Drapeau, [<reflink idref="bib6" id="ref6">6</reflink>]) or tailored them for youth with I/DD. In this brief report, we provide an overview of SPIs and the learning needs of individuals with I/DD, offering recommendations for adapting SPIs for youth with I/DD according to best practice special education approaches for working with this population.</p> <hd id="AN0175502858-3">BACKGROUND</hd> <p>The SPI, which was created for adult populations (Stanley et al., [<reflink idref="bib15" id="ref7">15</reflink>]), is a brief intervention that aims to lower the risk for suicide‐related behaviour. The effectiveness of SPIs for reducing suicide attempts and increasing follow‐up care in adults is well established, with a growing number of studies supporting its feasibility in adolescents (e.g., Doupnik et al., [<reflink idref="bib5" id="ref8">5</reflink>]). The components of SPIs include: (<reflink idref="bib1" id="ref9">1</reflink>) identifying individualised warning signs for a crisis; (<reflink idref="bib2" id="ref10">2</reflink>) describing coping strategies to manage strong emotions and reduce suicide‐related thoughts and urges; (<reflink idref="bib3" id="ref11">3</reflink>) identifying individuals who can help distract from suicide‐related urges; (<reflink idref="bib4" id="ref12">4</reflink>) identifying individuals who can provide support during a suicide‐related crisis; (<reflink idref="bib5" id="ref13">5</reflink>) identifying mental health providers and emergency contact information to contact during a crisis; and (<reflink idref="bib6" id="ref14">6</reflink>) identifying ways in which the environment can be made safer (Stanley et al., [<reflink idref="bib15" id="ref15">15</reflink>]). A key premise of SPIs involve collaboration between the clinician and patient (Stanley et al., [<reflink idref="bib15" id="ref16">15</reflink>]). The clinician may provide verbal prompts to the patient to learn more about the patient's crisis, allowing them to 'tell their story'. Although designed to be brief and accessible to adults, SPIs usually rely on written text (i.e., on a worksheet) and verbal prompts by the clinician, with minimal visual aids. Accordingly, most collaborative SPIs require at least average cognitive skills and the ability to self‐reflect about one's own thoughts, behaviours, and emotions.</p> <p>Intellectual disabilities are characterised by differences in intellectual functioning and adaptive behaviour (e.g., social and life skills); developmental disabilities include lifelong intellectual, physical, or intellectual and physical difficulties (NIH, [<reflink idref="bib12" id="ref17">12</reflink>]). Although youth with I/DD are a heterogenous group of learners, in general, many I/DD learners have visual learning strengths and strengths with learning rote or concrete information (Van Bourgondien & Coonrod, [<reflink idref="bib17" id="ref18">17</reflink>]). Many also have deficits in cognitive processing (e.g., judgement and insight), executive functioning (e.g., organisation, planning, focusing or sustaining attention), and memory. Additionally, individuals with I/DD may have difficulty with cognitive flexibility, including multi‐step tasks and abstract thinking (Van Bourgondien & Coonrod, [<reflink idref="bib17" id="ref19">17</reflink>]).</p> <p>Special educators frequently and successfully adapt learning materials for children and adolescents with I/DD through leveraging visual strengths, and adapting content, teaching strategies, and communication modalities (Martin., 2009). Recommendations and praxis found within the special education literature hold implications for adapting SPIs to better suit the needs of youth with I/DD. Accordingly, in the remainder of this brief report, we explain how best practice approaches drawn from special education praxis can be applied to the SPI. The strengths and areas of growth specific to youth with I/DD require careful consideration when collaborating on SPIs, especially since the few studies conducted with adolescents use techniques relying on verbal communication as a primary mechanism for change (Balán et al., [<reflink idref="bib2" id="ref20">2</reflink>]).</p> <p>Although the recommendations and examples of instructional adaptation provided in this report are based on the theoretical applications of special education praxis to safety planning, they have not been empirically evaluated. The authors of this report are experienced in special education, as well as the clinical application of the SPI in different settings. Practical adaptations of the SPI in real‐world clinical work prompted the authors to draw from special education praxis to create this framework. Although future research examining the best approach to SPI is needed, this report aims to support professionals and clinicians supporting youth with I/DD and suicide‐related thoughts and behaviours by drawing from educational practices applicable to most skills‐acquisition areas for youth with I/DD (Westwood, [<reflink idref="bib19" id="ref21">19</reflink>]).</p> <hd id="AN0175502858-4">RECOMMENDATIONS AND IMPLICATIONS FOR PRACTICE</hd> <p>Targeting I/DD learners' strengths and deficits means providing developmentally appropriate modifications that rely less on verbal cues and integrate other communication and learning approaches when delivering information. To minimise barriers to learning, while capitalising on visual learning strengths and supporting attention, cognitive processing, and memory, we offer suggestions for applying general developmental and cognitive principles to the specific components of SPIs (see Table 1). Drawing from trauma‐informed approaches for mitigating risk in youth with suicide‐related risk (O'Neill et al., [<reflink idref="bib13" id="ref22">13</reflink>]), it is important to integrate a strengths‐based approach to safety planning, collaborating with the individual and their caregivers to identify individual and family strengths during the rapport building process, as well as through any clinical contact prior to beginning safety planning and throughout each step of the SPI. What follows are suggestions for applying these general principles from Table 1 to the specific components of the SPI, as well as additional considerations. Figure 1 is used as an example of a visually adapted SPI meant to be used as a method of guiding an individual through the SPI process using another sensory modality in addition to the verbal instruction required to instruct a client in the SPI. This figure is meant for illustrative purposes only.</p> <p>1 TABLE Methods for adapting material to I/DD learners.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Modality</th><th align="left">Recommendation</th></tr></thead><tbody valign="top"><tr><td align="left">Visual</td><td align="left">Present information using visual cues</td></tr><tr><td align="left" /><td align="left">Avoid visual clutter by using large, easy to read font (14‐point or higher)</td></tr><tr><td align="left" /><td align="left">Use only one side of the page</td></tr><tr><td align="left" /><td align="left">Break up large chunks of text (use multiple pages if necessary)</td></tr><tr><td align="left">Content</td><td align="left">Use simple and concrete language (avoid abstract language and verbosity)</td></tr><tr><td align="left" /><td align="left">Present information in an organised and structured way</td></tr><tr><td align="left" /><td align="left">Limit the amount of information on a page</td></tr><tr><td align="left">Teaching</td><td align="left">When teaching new information, use repetition of small chunks</td></tr><tr><td align="left" /><td align="left">Allow opportunity for learner to repeat information to clarify comprehension</td></tr><tr><td align="left" /><td align="left">When appropriate, model and practice</td></tr><tr><td align="left">Augmentative and Alternative Communication</td><td align="left">Ensure device or communication strategy/materials are preloaded with vocabulary related to subject matter</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note</emph>: Recommendations based on accommodation suggestions from PACER Center, [<reflink idref="bib14" id="ref23">14</reflink>]; Martin, [<reflink idref="bib10" id="ref24">10</reflink>]; and Van Bourgondien & Coonrod, [<reflink idref="bib17" id="ref25">17</reflink>].</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/E03/01mar24/jar13198-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="jar13198-fig-0001.jpg" title="1 Coping and safety plan example." /> </p> <p></p> <hd id="AN0175502858-6">Step 1: Warning signs</hd> <p>When identifying warning signs, it is important to consider differences in communication between youth with I/DD compared with the neurotypical population (García et al., [<reflink idref="bib7" id="ref26">7</reflink>]). The SPI does not include a step identifying the individual's daily needs. Rather, it is expected the individual is able to introspect and identify the warning signs of a mental health crisis, distinguishing these warning signs from other general discomfort (e.g., discomfort that may be caused by not having an individual's daily needs met). By integrating an inventory of the individual's daily needs, clinicians can collaborate with the individual and their caregivers to understand warning signs. This brief, systematic approach helps the individual conceptualise their basic human needs starting with food, safety, and shelter, then moving to relationships (e.g., friendships, feeling loved) and self‐esteem (e.g., confidence, respect). Because youth with I/DD are often not independent in their activities of daily living (ADLs; a central diagnostic criterion for intellectual disability), a needs inventory can identify concerns that may otherwise be overlooked. Caregivers can also share information about situational and behavioural/affective warning signs they detect. Questions such as 'What might others do or say that makes the individual feel particularly upset'. or 'How do you know when the individual is feeling upset or about to have a meltdown?' are important to help identify when the individual may be displaying warning signs behaviourally.</p> <hd id="AN0175502858-7">Step 2: Identifying internal coping strategies</hd> <p>When clinicians and patients collaborate to identify coping strategies to use instead of acting on suicidal urges, youth with I/DD may benefit from structured teaching of internal coping strategies. It is important to note that internal coping strategies geared toward relaxing the body when in a heightened anxious or upset state, such as deep breathing or progressive muscle relaxation, are an important therapeutic skillset for any individual in a mental health crisis (Davis et al., [<reflink idref="bib3" id="ref27">3</reflink>]). Developing familiarity with these skills is likely to be extremely helpful for youth with I/DD when they experience a crisis. These types of strategies are typically taught through reading about relaxation techniques in workbooks, or sometimes pairing workbook learning with coaching from a clinician.</p> <p>For youth with I/DD, teaching coping strategies requires adaptations to typical instruction, through adapting and simplifying instructional materials, as well as using multi‐modal instruction, such as verbal instruction paired with visual representations (e.g., picture representation of repetitive deep breathing, video models of progressive muscle relaxation). Additionally, incorporating the individual's strengths and interests can support the identification of internal coping strategies and salient metaphors for teaching strategies (Weinstein et al., [<reflink idref="bib18" id="ref28">18</reflink>]). For example, if an individual has strength in visual–spatial abilities (i.e., nonverbal reasoning and problem‐solving abilities) and an interest in a certain fictional character, the clinician can work to create visual representations of relaxation processes using images of the fictional character paired with verbal instruction. After teaching a variety of relaxation/coping techniques, a clinician can work with the individual then to identify which strategies they would likely turn to in a crisis and create visual or verbal cues to help the individual remember their chosen technique.</p> <hd id="AN0175502858-8">Steps 3 and 4: Social contacts for distraction and for support</hd> <p>People with I/DD may have limited social networks, and some have reduced ability to independently reach out to and communicate with others (van Asselt‐Goverts et al., [<reflink idref="bib16" id="ref29">16</reflink>]). Contacts for people with I/DD may include family and friends, but also personal care assistants, respite care families, behavioural therapists and other home health care workers, special educators and paraprofessionals, or other individuals with I/DD. Collaboration should identify barriers to contacting identified individuals, including limited access when using a phone or the internet, as adolescents with I/DD are significantly less likely to have access to internet‐enabled devices (Alfredsson Ågren et al., [<reflink idref="bib1" id="ref30">1</reflink>]).</p> <hd id="AN0175502858-9">Step 5: Contacting professionals</hd> <p>Although youth with I/DD may struggle with the judgement and insight required to independently contact professionals, they can provide assent for the clinician to collaborate with caregivers, as well as brainstorm ideas for contacting professionals. Working collaboratively with the individual's caregivers will help identify mental health professionals who are familiar with the individual and equipped to respond in the event of a crisis. Contact information for crisis agencies can be taught through chunking information and rehearsal with a visual cue, and youth can practice using a script of important information to provide (e.g., identifying they are in a crisis, asking for help directly).</p> <hd id="AN0175502858-10">Step 6: Environmental safety considerations</hd> <p>Although the responsibility for making a plan to secure and limit access to lethal means will likely be created through a collaborative approach between the caregiver and the clinician, collaboration with the patient remains important. Yet, brainstorming what lethal means the individual might turn to, and the types of restrictions limiting their access, continue to rely on verbal skills. Although individuals could benefit from visual representations of lethal means in their environment to help the clinician and caregiver identify the means the individual may likely consider, additional caution is merited among individuals prone to rumination (i.e., it is important to avoid reinforcement of rumination related to suicide‐related means). Indeed, restricted interests and rumination have been shown to strongly predict suicide‐related thoughts and behaviours among autistic individuals (Dell'Osso et al., [<reflink idref="bib4" id="ref31">4</reflink>]). Accordingly, collaborative brainstorming should be considered within the context of the individual's specific behaviours and symptoms.</p> <hd id="AN0175502858-11">Additional safety planning considerations for individuals with I/DD</hd> <p>When summarising and reviewing the SPI with individuals with I/DD, clinicians can leverage key learning principles such as rehearsal (e.g., repeating the steps of the SPI to aid in automatization), practice (e.g. performing focused breathing exercises repeatedly to habituate the individual to the exercise), modelling (e.g., watching another person perform the expected task, such as contacting a mental health professional), and environmental supports (e.g., visual representations of warning signs, coping skills, or other steps of the SPI that are strategically positioned for easy access). Insight into specific individualised learning supports can be obtained by asking the patient or caregivers about successful strategies used by the individual when learning a new routine at home. For example, some individuals may benefit from a large, poster‐sized version of the safety plan on a wall in their home. Others may need to reference their needs inventory and safety plan daily to ensure comprehension.</p> <hd id="AN0175502858-12">CONCLUSION</hd> <p>The goal of tailoring SPIs for individuals with I/DD is to facilitate independence by leveraging pre‐existing learning strengths and routines through forming a collaborative relationship between clinicians, individuals, and their caregivers in which the individual's context and abilities are illuminated through clinician‐caregiver‐client interactions. Additional communication methods, such as drawing pictures, typing plans, and verbal/augmentative/alternative communication‐generated responses that the facilitator transcripts to the page, could support the construction of the safety plan. This individualization recognises the inherent diversity of patients with I/DD who reflect a range of experiences and bring variable strengths and needs.</p> <hd id="AN0175502858-13">ACKNOWLEDGMENTS</hd> <p>The authors would like to acknowledge the individuals and families in the intellectual and developmental disability community who have engaged or may engage with mental health care. Additionally, the researchers would like to acknowledge the work of clinicians in the area of suicide prevention, as well as special educators who have made this work possible.</p> <hd id="AN0175502858-14">FUNDING INFORMATION</hd> <p>U.S. Department of Health and Human Services > National Institutes of Health > National Institute of Mental Health.</p> <hd id="AN0175502858-15">DATA AVAILABILITY STATEMENT</hd> <p>Data sharing is not applicable to this article as no new data were created or analyzed in this study.</p> <ref id="AN0175502858-16"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref9" type="bt">1</bibl> <bibtext> Alfredsson Ågren, K., Kjellberg, A., & Hemmingsson, H. (2020). Digital participation? Internet use among adolescents with and without intellectual disabilities: A comparative study. New Media & Society, 22 (12), 2128 – 2145.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref10" type="bt">2</bibl> <bibtext> Balán, I. C., Lejuez, C. W., Hoffer, M., & Blanco, C. (2016). Integrating motivational interviewing and brief behavioral activation therapy: Theoretical and practical considerations. Cognitive and Behavioral Practice, 23 (2), 205 – 220.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref11" type="bt">3</bibl> <bibtext> Davis, M., Eshelman, E. R., & McKay, M. (2008). The relaxation and stress reduction workbook. New Harbinger Publications.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref12" type="bt">4</bibl> <bibtext> Dell'Osso, L., Carpita, B., Muti, D., Morelli, V., Salarpi, G., Salerni, A., Scotto, J., Massimetti, G., Gesi, C., Ballerio, M., Signorelli, M. S., Luciano, M., Politi, P., Aguglia, E., Carmassi, C., & Maj, M. (2019). Mood symptoms and suicidality across the autism spectrum. Comprehensive Psychiatry, 91, 34 – 38.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref5" type="bt">5</bibl> <bibtext> Doupnik, S. K., Rudd, B., Schmutte, T., Worsley, D., Bowden, C. 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  Label: Sponsoring Agency
  Group: SrcSuprt
  Data: National Institute of Mental Health (NIMH) (DHHS/NIH)<br />US Department of Health and Human Services<br />National Institutes of Health (NIH) (DHHS)
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Suicide%22">Suicide</searchLink><br /><searchLink fieldCode="DE" term="%22Intellectual+Disability%22">Intellectual Disability</searchLink><br /><searchLink fieldCode="DE" term="%22Developmental+Disabilities%22">Developmental Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Safety%22">Safety</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Risk+Management%22">Risk Management</searchLink><br /><searchLink fieldCode="DE" term="%22Youth%22">Youth</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/jar.13198
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1360-2322<br />1468-3148
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Introduction: Although risk for suicide appears elevated in individuals with intellectual and developmental disorders (I/DD), few interventions or tools addressing suicide prevention have been adapted for this population. Among evidence-based interventions for preventing suicide, safety planning interventions are an effective and commonly employed intervention for reducing suicide-related risk. Methods: By drawing on Special Education praxis for supporting the learning needs of individuals with I/DD, we provide recommendations for adapting suicide safety planning interventions for youth with I/DD. Results: Specific visual, content, teaching, and communication components of the safety plan intervention can be adapted to better meet the needs of youth with I/DD. Discussion: Although future research is needed to evaluate these recommendations, these modifications may support clinicians serving youth with I/DD and suicide-related risk.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2024
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1413004
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1413004
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/jar.13198
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 5
    Subjects:
      – SubjectFull: Suicide
        Type: general
      – SubjectFull: Intellectual Disability
        Type: general
      – SubjectFull: Developmental Disabilities
        Type: general
      – SubjectFull: Prevention
        Type: general
      – SubjectFull: Safety
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Risk Management
        Type: general
      – SubjectFull: Youth
        Type: general
    Titles:
      – TitleFull: Adapting Suicide Safety Plans for Youth with Intellectual and Developmental Disabilities
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Daniel Q. Earixson
      – PersonEntity:
          Name:
            NameFull: Karen C. Hall
      – PersonEntity:
          Name:
            NameFull: Marisa E. Marraccini
      – PersonEntity:
          Name:
            NameFull: Casey D. Calhoun
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2024
          Identifiers:
            – Type: issn-print
              Value: 1360-2322
            – Type: issn-electronic
              Value: 1468-3148
          Numbering:
            – Type: volume
              Value: 37
            – Type: issue
              Value: 2
          Titles:
            – TitleFull: Journal of Applied Research in Intellectual Disabilities
              Type: main
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