Hello and welcome to the online learning webinar Child Sexual Abuse and Suicide Essentials for the Forensic Nurse. Thank you for choosing this selection. My name is Gail Horner. I'm a forensic nurse specialist with the International Association of Forensic Nurses. I've been with IFN for about eight months now. Prior to working for IFN, I was employed by Nationwide Children's Hospital in Columbus, Ohio for 41 years. 28 of those years as a pediatric nurse practitioner in the child abuse program in a hospital-based child advocacy center and I also coordinated a team of sexual assault nurse examiners in the emergency department. So as far as disclosures go, the planners, presenters, and content reviewers of this course have no conflicts of interest to disclose. Upon attending the course in its entirety and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. So for the next hour or so, we will discuss sexual abuse and suicide, describe mechanisms linking sexual abuse and suicide, and then finally explore implications for forensic nursing practice regarding screening, suicide risk assessment, and mental health resources. I think we all agree that sexual abuse is a pediatric health care problem of epidemic proportions. According to the U.S. Department of Health and Human Services, in 2019, 61,000 American children experienced sexual abuse. However, this number represents a mere fraction of actual victims. Retrospective studies of adults have shown that approximately one in five victims never disclosed their sexual abuse victimization, and this is according to Tanner and Murphy, 2015. Sexual abuse can result in significant negative sequelae for victims. One particularly harmful consequence is that of suicidal ideation, which can lead to suicide attempts and even death. The past decade has seen a significant increase in rates of suicide, with the largest rise occurring among 10 to 14-year-old female adolescents. This is according to Curtin, 2016. According to the Center for Disease Control and Prevention, 2021, suicide was the second leading cause of death among individuals 10 to 14 years and 15 to 19 years old in the United States. Forensic nurses play a crucial role in the medical forensic care of child and adolescent victims of sexual abuse, and they may be the first person with whom the child or adolescent shares their abuse experiences. A thorough understanding of the relationship between sexual abuse and suicidal ideation and behaviors can assist the forensic nurse in the development of practice behaviors to better identify, intervene, and prevent suicidal ideation and behaviors among youth experiencing sexual abuse. Numerous studies in adults and adolescents have shown an association between childhood sexual abuse and suicidal thoughts and behaviors, and we see listed at the bottom of the slide several studies that discuss the association between sexual abuse and suicide. Younger child victims are also vulnerable to suicide. Children who experience sexual abuse often experience subsequent difficulties in relationships with non-abusive family members, and many develop trauma symptoms that closely mimic attention deficit hyperactivity disorder or attention deficit disorder. These are both problems that when present in children aged 5 to 11 years are strongly correlated with death by suicide. Additional studies also suggest that the relationship between child sexual abuse and suicidal ideation and behaviors extends beyond childhood and adolescence and into middle age and older adulthood. Let's clarify some terms. According to Perez-Gonzalez and Perdia, 2015, suicidal ideation is defined as thoughts of harming or killing oneself, whereas suicidal behavior refers to self-inflicted destructive acts committed with the intent to cause one's own death. Suicidal ideation and behaviors differ from self-interest behaviors, which involve actions carried out to cause bodily harm to oneself, but not death. Victims of sexual abuse have up to two times greater risk to endorse suicidal ideation than non-victims, and suicidal behaviors occur more than three times more often in sexual abuse victims than non-victims. Understanding the mechanisms underlying the association between child sexual abuse and suicide can better equip the forensic nurse to develop proactive interventions to minimize the risk of suicidal ideation and behaviors in children and adolescents who have experienced sexual abuse. Take a look at those mechanisms. We will discuss each of these in greater detail. All forms of child maltreatment, physical abuse, sexual abuse, emotional abuse, and neglect, have been found to be significantly associated with suicidal ideation, yet sexual abuse may well be a unique contributor to suicidal ideation in adolescents. Child sexual abuse is a distinctive form of trauma exposure, often accompanied by feelings of shame, guilt, and betrayal. These feelings may be exacerbated when the perpetrator is a parent or other close adult. When the child experiences sexual abuse by a significant adult, they may feel trapped in a relationship with their perpetrator, leading to feelings of helplessness. Self-critical emotions, such as shame and guilt, develop. Shame is often associated with feelings of worthlessness, inferiority, and powerlessness. Victims with shame-related feelings show an increased proclivity for suicidal ideation and behaviors. Guilt is accompanied by feelings of remorse, regret, worries about hurting others, and responsibility for the sexual abuse. Shame and guilt can easily become heavy pervasive emotions, which can lead to depression. Thus, the feelings invoked after experiencing sexual abuse may affect victims more profoundly or in different ways than victims of other forms of child abuse. A meta-analysis by Franklin in 2017 found internalizing psychopathology such as depression, externalizing psychopathology such as impulsivity or aggression, demographic characteristics such as age or gender, and social factors such as a history of child maltreatment or other traumatic events to be relatively consistent risk factors for suicidal ideation and behaviors. Individuals who have experienced sexual abuse may face a variety of negative mental health outcomes, including depression, internalizing behaviors, and externalizing behaviors. Sexual abuse can alter the victim's processing of self and of the world and affect their thoughts, feelings, and behaviors. Sexual abuse can also disrupt the victim's ability to trust. It disrupts their feeling that the world is a safe place and the individual's ability to trust others is impaired. The sexual abuse victim's ability to cope with even everyday stress can become severely compromised. Anger management difficulties may develop and impulsivity can become heightened, increasing engagement and high-risk behaviors. Depression coupled with impulsivity and coping difficulties contribute to increased suicide risk. Neurobiology also offers an explanation for elevated suicide risk in victims of child sexual abuse. Sexual abuse results in blunted hypothalmic pituitary adrenal axis responses to stressors, and both emotional reactivity and emotional regulation abilities are altered. Children who have been abused respond to stress with elevated neuroactivity to salient areas of the brain such as the amygdala, which is responsible for the autonomic responses of fear and survival, and they require greater activation of brain regions responsible for emotion regulation to decrease emotional reactivity. Sexual abuse can also interrupt development, yielding disturbances in self-capacities. Self-capacities refer to an individual's ability to maintain a sense of personal identity and self-awareness across various experiences. Also, their ability to tolerate and control strong negative emotions without avoidance, which is in effect affect or emotional regulation, and develop and maintain meaningful healthy relationships without dysfunctional behavior or preoccupation with rejection or avoidance. Affect or emotional dysregulation has been associated with experiencing sexual abuse. Victims have difficulty in identifying their emotions, differentiating and expressing them appropriately, and adjusting and regulating them adequately. The child may be unable to cope with negative emotions associated with the sexual abuse, which leads them to resort to drastic maladaptive affect regulation strategies such as affect avoidance, as to avoid emotions and feelings. Affect or emotional dysregulation has been linked with a number of mental health symptoms and disorders, including depression and suicidality. Girard, in 2021, found affect dysregulation to be an explanatory mechanism in the association between depression and suicidal ideation in adolescent sexual abuse victims. The child develops a negative worldview and may perceive people as unsafe and harmful. The sexual abuse victim faced with a lack of healthy affect regulation strategies, no understanding of their feelings, or suppression of their emotions, which is affect avoidance, may begin to think of suicide as a way to cope with their emotional burdens. Now, let's talk a bit about family attachment style and its association with suicidal ideation in the sexually abused child. Anxious attachment style, a type of insecure attachment style based on a fear of abandonment and feelings of insecurity related to being underappreciated, has been associated with increased suicidal ideation. Emotional attachment style may be emotional security can be defined as the sense of safety, stability, and well-being that develops from positive, stable family relationships, even in the presence of common stressors, such as inter-parental conflict, and is linked to fewer emotional difficulties in children. Emotional security becomes thwarted when children are exposed to stressful or frightening events within the family, such as sexual abuse, and the caregiver's comforting response to the child is non-existent or inadequate. Children then develop strategies, like disengagement, to attempt to preserve feelings of emotional security. Disengagement is the tendency to minimize the importance of the family and to emotionally detach oneself from it. Disengagement has been found to be associated with suicidal ideation at the time of crisis. Resiliency in children and adolescents is composed of three components, mastery, sense of relatedness, and emotional reactivity. Masterly and relatedness are protective components of resiliency, and emotional reactivity is threatening to resiliency. Sexual abuse is a trauma exposure that can lead to trauma-related distress and suicidal ideation and behaviors. Resiliency in trauma-exposed individuals has been proven to lessen suicide risk. DeKalb and Lynch in 2019 suggest that in adolescents with both depression and a history of sexual abuse, emotional reactivity may be directly implicated in the association between depression and suicidal ideation. It is thought that high levels of depression acuity obscure the protective resiliency factors of mastery and relatedness in adolescents with and without a history of sexual abuse. However, emotional reactivity appears to heighten suicide risk only in adolescents who have experienced sexual abuse. Now let's talk about what all of this means for forensic nursing. Child and adolescent victims of both acute and historical sexual abuse are vulnerable to a significantly increased risk of suicidal ideation regardless of when the abuse occurred. Because of the increasing prevalence of suicidal ideation, especially among children and adolescents, the Joint Commission added a National Patient Safety Goal in 2019, Reduce the Risk for Suicide, which states the need for health care providers to screen all patients for suicidal ideation who are being treated or evaluated for behavioral health concerns as their primary presenting problem using a validated screening tool. The American Academy of Pediatrics states that medical care of children presenting with a concern of sexual abuse should include an assessment for mental health problems, and if any are identified, they need appropriate emergency mental health services. Adolescents who have experienced acute sexual assault should also be screened for suicidal ideation. The U.S. Department of Justice in National Protocols Guiding the Medical Forensic Examinations of Adults and Adolescents Experiencing Sexual Assault and also the Medical Forensic Examinations of Children Experiencing Sexual Abuse recommends suicidal ideation screening. Cochran in 2019 used an evidence-based screening tool to assess suicidality after acute sexual abuse, sexual assault in a sample of patients aged 13 years of age and older. Two-thirds of the victims screened medium to high risk for suicidality. So we know that we as forensic nurses are taking care of a population of patients that are at increased risk to suffer from suicidal ideation and behaviors, but also there are barriers to suicide risk screening in the health care setting. These barriers have been identified, and they include lack of provider knowledge regarding suicide risk, provider discomfort, and the provider discomfort with screening and follow-up procedures, time constraints, and perceived parental disapproval. It is imperative that forensic nurses overcome these barriers to feel comfortable and competent, utilizing evidence-based techniques to assess and intervene for suicidal ideation and behaviors in child and adolescent sexual abuse, sexual assault patients. The forensic nurse must also fully understand the implications of a positive screen for suicidal ideation. Health screening can be defined as the presumptive identification of unrecognized conditions via the application of tests, examinations, or other procedures that can be performed rapidly to identify those individuals likely to have a condition versus those who probably do not and for whom prompt intervention can improve outcomes. Therefore, a positive suicidal ideation screen is not diagnostic of imminent suicide intent. Rather, it indicates that further evaluation is needed. Every individual who expresses suicidal ideation will not go on to attempt or complete suicide. However, the forensic nurse must not ignore suicidal ideation. In an international study, Nock in 2013 stated that the lifetime prevalence of suicidal ideation is about 9%. So, in an individual's lifetime, about 9% of people will at some point in time have suicidal thoughts. And about one-third, 34% of those individuals will have a plan of how to kill themselves. And nearly three-fourths, 72% of individuals with a suicide plan will indeed attempt suicide. Forensic nurses often initially feel uncomfortable asking children and adolescents questions about suicide. However, we need to keep in mind that the research indicates that over 90%, and this was in two studies, Ballard in 2017 and Ross in 2016. So, research indicates that over 90% of youth are comfortable with non-mental health clinicians asking them about suicidal ideation in the healthcare setting. Addressing the concerns of forensic nurses and providing training is crucial to successful screening for suicidal ideation and behaviors in children and adolescents following sexual abuse assault. Screening for suicidal risk requires careful planning and a detailed protocol. The crucial first step when designing a protocol for screening for suicide risk among children and adolescent victims of sexual abuse, sexual assault, is choosing the appropriate screening tool. The use of an evidence-based validated tool with high sensitivity and specificity is key. Depression screening tools are often used to screen for suicide risk. However, the use of a validated evidence-based depression screening tool to also screen for suicidal ideation may be inadequate. The tool may lack the sensitivity and the specificity to detect suicidal ideation. Here we see examples of tools that are highly reliable and valid for depression screening in children and adolescents, although not specific enough to screen for suicidality. There are no suicide risk screening tools available for use in children less than eight years of age that have been validated in this population, yet children as young as five years of age have died by suicide. It is important that the forensic nurse explore potential suicide risk with both the caregiver and the child. They should assess for risk factors, including sexual abuse, difficulties in family relationships, and a diagnosis of ADD or ADHD. In addition, they should ask the child a few screening questions. However, given that communication skills are still developing in this age group, know that a negative answer does not rule out the possibility of suicidal ideation, but ask a couple of questions like, have you ever wanted to die or not wake up in the morning? Have you ever thought about hurting or killing yourself? Have you ever hurt yourself? Forensic nurses must have an open discussion with the caregiver regarding any previous self-injurious behaviors or statements made by the child. Does the caregiver have any concerns that the child will harm themselves? If assessment raises any concerns for potential suicide risk, the young child needs an immediate suicide risk assessment completed by a mental health clinician. The child should be supervised by healthcare personnel and any potentially dangerous items should be removed from the environment. Suicide risk screening tools do exist for children aged eight years and older. Registered nurses can administer suicide risk screening tools. The Columbia Suicide Severity Rating Scale Screen version, the shorter version of the full C-SSRS, is an example of a screening tool. Although the full Columbia Suicide Severity Rating Scale Risk Assessment has been fully validated for use in children and adolescents, the screen version has not, so that is a limitation of using the Columbia Suicide Severity Rating Scale Screen version. A positive screen using the C-SSRS screen version indicates that a full risk assessment is indicated. The Ask Suicide Screening Questions, ASQ, offers an evidence-based, valid, and reliable method to screen for suicidal ideation. The Ask has been tested, the Ask Suicide Screening Questions, the ASQ, has been tested in the psychiatric setting with 98 percent sensitivity and 66 percent specificity and in a general pediatric emergency department population with 97 percent sensitivity and 88 percent specificity. High sensitivity is crucial to identifying individuals at risk for suicide with few missed cases. The ASQ also has a high negative predictive value of 99.7 percent, indicating the probability that a child or adolescent who screen negative for suicide is indeed not at risk for suicide. The ASQ, or the Ask Suicide Screening Questionnaire, is a brief four-item screen available in 13 languages and valid for use in children between the ages of 8 and 21 years. An online toolkit for use is available via the National Institute of Mental Health. A forensic nurse of any educational level can administer the screening tool. Ideally, caregiver and child should be separated when the tool is administered. If the child answers yes to any of the four initial screening questions, then a fifth question is triggered to gauge suicidal acuity. A positive answer to question five indicates imminent suicide risk and requires the initiation of safety precautions, such as constant direct observation by staff and removal of potentially dangerous items, and a full urgent mental health evaluation by a skilled mental health clinician is also indicated. Answering yes to any of the four screening questions is considered a positive screen and further risk assessment is then indicated. You see the website there for the online toolkit. It offers the screening. It also offers training for screening. It also talks about the risk assessment tool. So here we see the ASQ Suicide Risk Screening Pathway. The first concern is the patient cognitively able to answer questions. If yes, administer the screen. If no, screen when the patient is cognitively capable. Then administer the ASQ. If answer to questions one to four is no, one through four is no, then it's a negative screen and no further intervention is indicated. If the patient answers yes to any question one through four, then ask question five. If the answer is no to question five, it is considered a non-acute positive screen and patient needs a brief suicide risk assessment conducted. If the patient answers yes to question five, patient is at imminent suicide risk and needs an urgent full mental health evaluation by a mental health provider and safety precautions must be initiated. Here we see some examples of suicide risk assessment tools. Keep in mind that the Columbia Suicide Severity Rating Scale screen version and the ASQ are screening tools designed to identify individuals at a potential risk for suicide. A positive screen should trigger a more comprehensive suicide risk assessment. And that's what these screening tools listed on this slide are. They are a more comprehensive suicide risk assessment. Suicide risk assessments are most oftentimes completed by a mental health specialist, such as an advanced practice mental health nurse, social worker, psychiatrist, or psychologist, and are conducted to confirm suspected suicide risk, assess imminent danger of suicide, and decide upon the treatment interventions. The C-SSRS, or the Suicide Assessment Five-Step Evaluation and Triage, are available online and can be used for conducting the suicide risk assessment. The ASQ toolkit also contains a tool that can be utilized to complete the suicide risk assessment, the ASQ Brief Suicide Safety Assessment, or the BSSA. It's also available online. The BSSA can be completed in about 15 minutes and is designed to be performed by providers, such as mental health clinicians, physicians, nurse practitioners, or physician assistants who have received appropriate training in completing suicide risk assessment. The BSSA should be conducted without the caregiver in the room with the child. The BSSA evaluation assesses for the following, frequency of suicidal thoughts, past or current suicide plan, past suicidal behaviors, symptoms such as depression, anxiety, impulsivity, isolation, loss of interest or pleasure, sleep and appetite, substance use, and irritability. The BSSA evaluation classifies suicide risk as high or imminent risk based on clinical assessment. Patients classified as low risk via BSSA do not require a full suicide safety assessment in the clinical setting. Typically, a referral to community mental health treatment, if the patient is not already linked, is indicated, as well as a discussion of basic safety information with the patient and the caregiver, such as safe storage and removal of lethal means, providing crisis resources and notifications of the patient's primary care provider of the positive ASQ screen and the low risk BSSA. When the BSSA is high risk, a full suicide safety assessment by a trained mental health clinician is necessary prior to discharge to determine whether discharge home with an outpatient mental health care plan is safe, or if acute psychiatric care is indicated. An imminent risk BSSA result indicates that the patient has endorsed current active thoughts of suicide, requiring immediate attention to maintain patient safety while still in the pediatric emergency department or whatever your facility may be. Safety precautions must be initiated. Further mental health evaluation, including a full suicide evaluation by a trained mental health clinician, is indicated, and the patient may require inpatient psychiatric admission. After completion of the BSSA interview, the provider conducting the interview meets with the patient and the caregiver together to discuss a safety plan, to determine an intervention plan, such as emergency mental health evaluation, non-emergency mental health follow-up, or no intervention, and also to provide crisis hotline numbers to patient and caregivers. Any safety planning must include the caregiver and other appropriate family members stressing their roles in supporting the patient in maintaining safety. Child and adolescents who have experienced sexual abuse and who are also endorsing active thoughts of suicide must be provided with the resources to treat and alleviate their suicidal ideation before they can begin to heal from their trauma exposure. Therefore, forensic nurses must be knowledgeable regarding evidence-based suicide prevention mental health interventions available in their community. Two such evidence-based interventions are cognitive behavioral therapy suicide prevention and dialectical behavior therapy. Cognitive behavioral therapy slash suicide prevention, or we'll call it CBT slash SP, was developed to address risk factors for youth suicide that are modifiable, such as depression, with an emphasis on the prevention of future suicidal behavior. Essential elements of CBT SP include safety planning, developing a hope kit that contains objects or quotes that stimulate memories of wanting to live, analysis to explore circumstances that led to previous suicide attempts, determining crucial coping skills to develop to address similar circumstances in the future by identifying immediate suicidal precipitance and long-term risk factors, developing identified coping skills such as emotional regulation or mood monitoring or distress tolerance, and preventing relapse by revisiting the suicide attempt and reviewing the event through the frame of skills learned. It also includes family sessions as support, which is key to suicide prevention. DBT, or dialectical behavior therapy, helps to prevent suicidal behaviors by focusing on the individual's reasons for living. DBT is based on behavioral and Zen principles and a philosophy on dialectics. The original DBT model has been adapted for use in adolescents and young adults aged 11 to 20 years. DBT also includes family members in skills training groups and family sessions. Efficacy in decreasing self-harm behaviors and suicidal ideation in adolescents has been found with DBT. It is essential to screen children and adolescents for suicidal ideation when providing medical forensic care after disclosure of sexual abuse assault. Forensic nurses must feel confident in their abilities to assess suicide risk and provide appropriate interventions and referrals. Whereas many forensic nurses practice in clinical settings where mental health professionals are readily available for consultation, others may not. It is vital that forensic nurses be knowledgeable regarding local resources for patients requiring further mental health evaluation and psychiatric resources available for patients endorsing active suicidal ideation. Forensic nurses possess the knowledge and skills to enhance the care and safety of victims of sexual abuse when they are most vulnerable, which must include assessing for suicide risk and providing evidence-based interventions. It's important to know your resources. Any questions? Please shoot me an email and I would gladly chat with you regarding any questions or comments that you have regarding the webinar. This presentation is based upon an article by Sarah Tucker and myself that has been accepted for publication in the Journal of Forensic Nurses. Here is a partial list of references. A complete list of references is available upon request. And again, thank you for choosing this session.

child sexual abuse

suicide

prevalence

negative consequences

forensic nurses

screening

validated screening tools

suicidal ideation