Scanlan Center for School Mental Health
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Suicide is the 3rd leading cause of death for youth ages 10-24 (CDC, WISQARS 2022). Rates of suicide for youth continue to rise each year. Just in 2020 alone, 6,663 young people (age 5-24) died by suicide (CDC, WISQARS 2022). Additionally, 18.8% of high school students in the US reported considering suicide, 15.7% reported creating a suicide plan, and 8.9% reported trying to take their own life during 2019 (Ivey-Stepheson et al., 2019).

 

There are notable differences within minoritized populations as well. For example, when examining the breakdown of suicide for youth from different racial or ethnic groups, the highest suicide rates can be found among those identifying as American Indian/Alaska Native (CDC, 2019). There is also a significant difference in adolescents seriously considering suicide based on their sexual identity (heterosexual: 14.5%; LGB: 46.8%; not sure: 30.4%; Ivey-Stepheson et al., 2019).

Suicide affects many of our youth and can have serious consequences, including a range of negative mental health outcomes, increased risk of subsequent attempts, and death. Educators, and specifically school counselors, are well positioned within the school system to identify and intervene when children and adolescents are struggling with suicidal thoughts and behaviors.

This practice brief provides educators with information and resources on suicide prevention, intervention, and postvention that is evidence-based and applicable to the K-12 school setting. Subsequently, suicide prevention, intervention, and postvention efforts are essential as educators continue to meet their students’ needs and require the collaboration of the entire school community.

Prevention and Identification Strategies

Suicide prevention work relies on creating a culture where educators have positive attitudes regarding help-seeking behaviors at the school level. A school climate that supports mental health and advocacy efforts is more likely to result in students recognizing that depression, anxiety, and stressors that lead to suicidal ideation are significant enough to talk about with someone they trust (Erbacher et al., 2014).

Schools may adopt prevention programs which embrace an attitude that students are resilient and can learn to rely on positive coping skills before becoming susceptible to suicide risk (Suicide Prevention Resource Center, 2012). Classroom lessons that focus on mindfulness, emotional regulation, and social skill development have all been effective in reducing risky behaviors and helped prevent suicide (Broderick & Jennings, 2013; Rudd, 2017). Schools can use a specialized curriculum that fosters school connectedness and includes factors such as: school belonging, positive social relationships, feeling cared about by adults at school, and supportive learning environments (Miller, 2018).

In addition, gatekeeper training programs, which provide information about warning signs and help educators become more comfortable talking with students about suicide, are also highly effective. Some well-known gatekeeper trainings used in schools include: Question, Persuade, Refer (QPR), Applied Suicide Intervention Skills Training (ASIST), and Signs of Suicide (SOS). Signs of Suicide is one common program that includes both a gatekeeper training curriculum and a suicide risk screener. The Suicide Prevention Resource Center provides a list registry of evidence-based programs at: https://sprc.org/keys-to-success-2/evidence-based-prevention/.

Although best practice would be for a school district to bring in an evidence-based program annually to train all staff, providing supplemental trainings or reminders regarding warning signs and risk factors would also be beneficial. Warning signs are indications that an individual may be at risk of suicide and are widely endorsed within the field of suicide prevention. The following list provides some of the most noted indicators in students:

  • Withdrawal from activities
  • Social isolation
  • Perception of being a burden
  • Risk-taking, recklessness (e.g., self-harm, substance use)
  • Sleep problems
  • Agitation
  • Anxiety (Joiner, 2005; Rudd, 2017)

All schools should have a protocol in place for how they will address suicide. Protocols provide step-by-step instructions for how to respond when a student is suicidal, who is responsible for responding, resources, strategies for responding, and how to document the process. The Substance Abuse and Mental Health Services Administration’s toolkit has examples of protocols that can be easily adapted to a district’s needs (2012). The toolkit can be found at https://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669.

Schools can also work with families and the community to increase suicide prevention efforts. For example, school counselors can provide education on identifying behaviors that may indicate more serious signs of a student who may be struggling with suicidal ideation and help family members become more comfortable initiating conversations with their children. Schools can also work with community partners (local chapters of National Association of Mental Illness, American Foundation for Suicide Prevention, or the Red Cross) to gather a list of resources, provide recommendations, and increase outreach.

 

Intervention Strategies

Suicide prevention/intervention can be structured within (a) Tier 1 (universal approaches), (b) Tier 2 (selective interventions targeted towards groups of students who demonstrate risk factors), and (c) Tier 3 (intensive interventions targeted at students who screened positive for a risk factor).

Universal Approaches (Tier 1)

All adults in the school are part of Tier 1. Universal approaches target ALL students and promote a schoolwide culture that is proactive and focused on healthy behaviors and positive social, emotional, and behavioral skills. These skills can be taught through classroom lessons, small group instruction, or peer support programs.

Sources of Strength (2020) and Hope Squad (n.d.) are two examples of peer programs that incorporate upstream prevention strategies and utilize protective factors to create a help-seeking culture within the school environment. They emphasize relationship building, forming connections, and identifying supports. Both programs are evidence-based and offer schools a format to train students and staff in suicide prevention. Through classroom and small group instruction, students can be taught about common warning signs of suicide, myths of suicide, and how to seek out trusted adults when confronted with challenges.

It is important to educate teachers and other staff through gatekeeper trainings about how to appropriately respond to students. These trainings help adults learn to respond to students without judgment and with more empathy, increasing the likelihood that the student will be open to support. Universal screeners are also utilized as part of Tier 1 interventions when approved by the school district. Universal screeners can assist with identifying students who may need more individualized support.

Targeted Interventions (Tier 2)

Targeted interventions support students at risk for suicide who have demonstrated warning signs such as changes in behavior (e.g., social isolation, poor sleep habits, substance use). Programs such as Reconnecting Youth (Eggert et al., 2009) and Coping and Support Training (CAST) are two evidence-based programs that work on skill development to help students build resiliency and are specifically designed as Tier 2 interventions.

School counselors may schedule regular check-ins with these students to build a relationship and to provide ongoing support. Teachers who work with these students may also offer extra help or encouragement in the form of extra time, positive notes, or phone calls home. An important aspect of suicide prevention work is that a student finds a trusted adult in their life they can connect with on a regular basis.

Intensive Interventions (Tier 3)

Students who have reported or been identified as individuals with suicidal ideation would qualify for a Tier 3 intervention. Students may express suicidal ideation in various ways such as verbally or behaviorally. Some signs are overt, for example a student saying they want to die, while other times it is implied, “I wish I would go to sleep and not wake up.” Students may write in an assignment or draw something that alarms the teacher. Some educators have also received training on asking directly about possible suicidal thoughts or plans and may directly broach the topic with students.

Educating the school community (students, staff, families) to seek out the support of a qualified mental health professional (school counselor, social worker, school psychologist) to further talk with the student of concern is critical. This includes how to conduct a referral that utilizes a warm handoff, which involves the educator personally connecting the student with the school mental health provider, such as the school counselor. Spending some face-to-face contact during the referral is different than simply asking the student to go see the provider. Conducting a warm handoff increases the likelihood the student will earnestly engage in counseling and get the help they need. Thus, educators can play a pivotal role in supporting students through the suicide intervention process.

Once students have been identified as needing support for possible suicidal thoughts or behaviors, school counselors have an ethical obligation to intervene (ASCA, 2022; A.9). School counselors should conduct a suicide risk assessment, a process that includes asking a student about their suicidality and taking precautions to keep them safe. An important aspect of interviewing the student about their suicidal thoughts or behaviors includes spending an adequate amount of time listening. Collaborating with the student, validating their feelings, and attempting to build a relationship is more likely to create a therapeutic experience (Sommers-Flanagan & Sommers-Flanagan, 2021). Conducting a risk assessment should be viewed as an opportunity to engage with the student in a manner they would find helpful.

Some recommendations for intervening with students who are experiencing suicidal ideation include asking directly about possible suicidal thoughts or plans, asking about their current mood or level of agitation, gathering information about their level of suicide intent, and inquiring about any past attempts. Sometimes educators or parents will provide critical information in these areas, and this knowledge is incorporated into the formal suicide risk assessment. School counselors can also talk with students about what they list as their reasons to live and reasons to die- it can be helpful to understand their current level of functioning and to incorporate it into safety planning.

Other recommendations include consulting with one or more professionals, developing a safety plan, ensuring detailed documentation of the assessment and decision-making process and notifying parents/guardians, and offering support for the next steps (Sommers-Flanagan & Sommers-Flanagan, 2021). School counselors need to be mindful when using a risk assessment tool. They should have proper training in using the tool and never minimize risk when sharing the results with parents/guardians.

Safety planning is an important step in the suicide intervention process. Suicide experts no longer advocate using no-suicide contracts (Rudd, 2017; Sommers-Flanagan & Sommers-Flanagan, 2021). Stanley and Brown (2008) have created a popular safety planning tool for suicide risk.

However, schools should work to develop a tool appropriate for the developmental level and population of the students they serve. Safety plans generally include identification of warning signs, coping strategies, substitute activities, individuals/agencies to contact for support, and efforts to reduce their access to the method to carry out their suicide plan.

It is best if safety planning is a collaborative process between the school counselor and the student, but it may depend on the age of the child. Parents or guardians may also need to be a collaborator in this process, especially in reducing access to the method of their suicide plan. Unless child abuse is suspected, parents/guardians would be notified of a student’s thoughts of suicide. School counselors should check with their school district on all suicide intervention procedures, including specific forms related to safety planning.

When creating a safety plan, school counselors should emphasize protective factors over risk factors and wellness over diagnosis. Protective factors are defined as characteristics associated with positive outcomes or outcomes that counter risk factors. Common protective factors include family support (and acceptance of identities), a sense of safety at school, close friends, emotional regulation, and a sense of hope and life satisfaction (SAMHSA, 2012).

Risk factors are characteristics associated with a higher likelihood of negative outcomes. Young people are resilient, and focusing on their strengths and supports can help build their coping and problem-solving skills (Sommers-Flanagan & Sommers-Flanagan, 2021). Recognizing the student’s reasons for living can help in the safety planning process and become an important factor in helping a child recognize their ambivalence about suicide. Schools can also share resources such as the Suicide Prevention Lifeline, 988, with students and their families.

Educators can serve an important role after a student has been referred to a school mental health professional. While they might not be privy to the confidential information the student has shared with the mental health professional, it is important to follow up with the student post-referral. Educators can work with the counselor to identify strategies for checking in with the student, supporting them through their journey, and monitoring for any additional signs of concern. Educators can be enlisted as supportive adults to further enhance protective factors.

 

Postvention Strategies

Postvention is an intervention conducted after a suicide occurs. Schools will benefit greatly from creating a postvention plan BEFORE a tragedy happens. In the unfortunate event a student dies by suicide, staff may be overwhelmed with the fallout and have difficulty coming up with a plan in the moment.

The postvention plan conducted after a student death from suicide can help reduce suicide contagion among those students most vulnerable. Suicide contagion is the increased risk of others resorting to suicide after one suicide occurs. Therefore, schools should view and treat all student deaths in the same way. For example, losing a student to illness or accident should be approached in the same way as losing a student to suicide to avoid inadvertently simplifying, glamorizing, or romanticizing the decedent (Suicide Prevention Resource Center; SPRC, 2018).

Other postvention recommendations include consulting reputable organizations that promote best practices and evidence-based tools when creating planning documents and working with multiple entities within the school and community to develop and respond to the postvention plan. Engaging in these efforts is important to support the staff, students, and family members in identifying and gathering all the resources needed to carry out the plan. SPRC offers a toolkit to help school districts with postvention efforts, this can be found at https://tinyurl.com/ynx5t4ck. Finally, documenting and evaluating the crisis response and reviewing and revising the crisis plan annually is essential for ensuring an effective and applicable plan.

Key Implications for Practice

  1. Invest in a suicide prevention curriculum for students and gatekeeper training for all staff
  2. Have suicide/crisis protocols in place (includes postvention)
  3. Ensure informed use of risk assessment tools (proper training, validated instruments, developmentally and culturally appropriate)
  4. Have community resources list available (updated regularly)
  5. Make sure all school mental health professionals receive up-to-date suicide assessment training
  6. Consider parent education on identifying suicide warning signs
  7. Create school climates that promote belonging and help-seeking

Related Resources

https://doi.org/10.17077/rep.006644 

American School Counselor Association. (2022). ASCA Ethical Standards for School Counselors. https://schoolcounselor.org/getmedia/44f30280-ffe8-4b41-9ad8-f15909c3d164/EthicalStandards.pdf

Broderick, P. C., & Jennings, P. A. (2013). Mindfulness for adolescents: A promising approach to supporting emotion regulation and preventing risky behavior. New Directions for Youth Development, 2012(136), 111–126. https://doi.org/10.1002/yd.20042

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (CDC). (2022). Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. 2022. Retrieved from https://www.cdc.gov/injury/wisqars

Centers for Disease Control and Prevention (2019). Youth risk behavior survey data summary & trends report: 2009-2019. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Adolescent and School Health. http://www.cdc.gov/healthyyouth

Eggert, L. L., Thompson, E. A., Randell,., B.P., & Pike, K. C. (2002). Preliminary effects of brief school-based prevention approaches for reducing youth suicide-risk behaviors, depression, and drug involvment. Journal of Child and Adolescent Psychiatric Nursing: Official Publication of the Association of Child and Adolescent Psychiatric Nurses, Inc., 15, 48-64.

Erbacher, T.A., Singer, J.B., & Poland, S. (2014). Suicide in Schools: A Practitioner’s Guide to Multi-level Prevention, Assessment, Intervention, and Postvention. Routledge.

Hope Squad (n.d.). https://hopesquad.com/evidence/

Ivey-Stephenson A. Z., Demissie Z, Crosby A.E., Stone, D. M., Gaylor, G., Wilkins, N., Lowry, R., & Brown, M. (2019). Suicidal Ideation and Behaviors Among High School Students — Youth Risk Behavior Survey, United States, 2019. MMWR Suppl 2020;69(Suppl-1):47–55. http://dx.doi.org/10.15585/mmwr.su6901a6

Joiner, T. (2005). Why people die by suicide. Harvard University Press.

Miller, D. N. (2018). Suicidal behavior in children: Issues and implications for elementary schools. Contemporary School Psychology, 23(4), 357–366. https://doi.org/10.1007/s40688-018-0203-0

Rudd, M. D. (2017, June). Suicide awareness and prevention. Presentation at the Western States Suicide Conference, Boise, ID.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2021). Suicide Assessment and Treatment Planning: A Strengths-Based Approach. United Kingdom: Wiley.

Sources of Strength (2020). https://sourcesofstrength.org/about/#evidence-base

Stanley, B., & Brown, G. K. (2008). Patient safety plan template. https://suicidesafetyplan.com/forms/content/uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA) (2012). Preventing suicide: A toolkit for high schools. https://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669

Suicide Prevention Resource Center. (2012). Expanding suicide prevention to include upstream approaches. https://sprc.org/event-training/expanding-suicide-prevention-to-include-upstream-approaches/

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