In 2014, suicide was the second leading cause of death among teenagers and young adults age 15 to 24 years.1 According to the 2015 Youth Risk Behavior Survey, nearly 17.7% of high school students reported having seriously considered attempting suicide, 14.6% made a suicide plan, 8.6% made a suicide attempt, and 2.8% made an attempt that resulted in injury, poisoning, or overdose that had to be treated by a doctor or nurse.2 The average time from first serious thought of suicide to first suicide attempt in youth is 12 months.3 Among the many reasons we should focus on youth suicide prevention, one of the most compelling is that reducing youth suicide risk is one of the best ways to reduce the adult suicide rate.
The best place to identify and respond to youth suicide risk is in schools. Youth spend more waking hours in school or school-related activities than any other place, including home. Schools are a unique environment in which adults can monitor and interact with youth across a spectrum of functioning. School-based professionals have a unique perspective on what is normative in discrete and extended time periods. They know which times of day and which days in a season students are experiencing more joy or stress. Given that one of the guidelines for assessing suicide risk for people of all ages is determining whether there has been a significant change in behavior, there is no other group of professionals better equipped to recognize and interpret changes in youth behavior than school professionals.
School professionals have neither the time, institutional support, nor training to provide comprehensive assessment and intervention to youth who are suicidal.4 Community providers should be the primary providers for these youth, and school staff should provide monitoring and contextual information about risk. School staff cannot fulfill their potential without coordination with community providers, including outpatient and inpatient mental health professionals, juvenile court, child welfare, law enforcement, sports teams, and faith communities.5 This article will provide a brief overview of the current best-practice approaches to school-based suicide prevention and discuss the role of community supports in preventing youth suicide.
Risk Factors and Warning Signs
One of the cornerstones of suicide risk assessment is the identification of risk factors and warning signs. Risk factors are characteristics that are more common among people who have died of suicide than people who have not. For example, access to a gun in the home is a risk factor because youth with access to a gun in the home are more likely to die of suicide than youth without access to a gun in the home.6 The problem with risk factors is that they tell us nothing about the individual that we are currently assessing for suicide risk. In contrast, warning signs are indicators that the individual you are assessing might be at imminent risk for suicide. A good analogy is that the risk factors for heart disease are not the same as the warning signs of a heart attack.Warning signs were established specifically for youth up to age 24 years (Table 1).
Suicide Warning Signs for Youth Up to Age 24 Years
Comprehensive school-based suicide prevention includes screening to identify youth at risk for suicide and related factors (eg, depression and substance use), awareness and information about risk factors and warning signs, access to in-school and community mental health resources, and planning for crisis response and the aftermath of a suicide death (also referred to as postvention).4 A key component of effective youth suicide prevention is the availability of adults whom youth see as approachable and capable of providing help.7
Most youth suicide prevention programs are designed for students and faculty in middle and high school. The exception is the Good Behavior Game (GBG), a program for 1st and 2nd graders to help with socialization, reduction of aggressive behaviors, and improve school connectedness.8 Although not designed as a suicide prevention program, a follow-up study of students who participated in the GBG compared to students in the same school district who received a different program (Mastery Learning) or no program, found that students who participated in the GBG were 50% less likely to report suicidal ideation or suicide attempt.8 The GBG is the only suicide prevention or intervention program that has been shown to reduce suicide attempts by 50%.8 One implication is that early prevention programs that address aggression, impulsivity, and school connectedness might be effective ways of reducing youth suicide.
Middle and High School
Rates of suicide per 100,000 students increase significantly between elementary school (.06), middle school (1.63), and high school (8.91).1 This increase coincides with the rise in rates of depression, substance use, interpersonal violence, nonsuicidal self-injury, stress related to academics and sports, and increased independence from conflict with parents as well as decreased parental monitoring.9 There are several suicide prevention programs used in schools, including awareness and information programs like Sources of Strength and gatekeeper trainings like Question, Persuade and Refer, with mixed evidence of effectiveness.10,11 The suicide prevention program with the most empirical support in middle and high school is Signs of Suicide (SOS).12 SOS is delivered by teachers in a single class period, and combines a brief depression screen with education and awareness about depression and suicide. In randomized control trials, youth who participated in the SOS program reported a reduction in suicide attempts of 40% to 64%.12,13 Adults identify youth suicide risk in two ways: (1) the depression screen and (2) reports from students. Youth are taught to “ACT” (Acknowledge, Care, Tell [a trusted adult]) when a peer discloses suicidal thoughts. One of the biggest barriers to implementing universal screening or gatekeeper training is the requirement to create a referral list of community mental health providers to refer at-risk youth. Community mental health providers with expertise in working with youth who are suicidal should contact local schools and let the school counselor or social worker know about their training and availability.
Although not exclusively suicide prevention programs, Gay-Straight Alliances (GSA) and Crisis Teams are two programs that schools should establish to address suicide risk. Research by Hatzenbuehler et al.14 found that sexual minority youth were at a lower risk for suicide in schools with GSAs. Crisis teams, particularly those established using the PREPaRE model, provide an essential structure for addressing suicidal crises and responding to suicide deaths in school.15
There are three main interventions for youth who have been identified as being at risk for suicide: (1) monitoring by school mental health professionals,4 (2) referral for outpatient treatment (eg, attachment-based family therapy, see Hunt et al., this issue),16 and (3) hospitalization.
Suicide-Risk Monitoring Form
School-based mental health professionals are in a unique position to gather data on short-term and long-term changes in suicidal ideation and related risk factors. Although pediatric providers have long known that rapid fluctuation was a hallmark of youth suicide risk, there has been almost no research into short-term fluctuation of suicidal ideation.4 A recent study provided the first empirical evidence to support this practice wisdom. In 2017, Kleiman et al.17 analyzed data from two groups of adults at risk for suicide (one cohort who had attempted suicide within the past year and another cohort who was currently hospitalized for a suicide attempt). These adults provided information multiple times per day about the intensity of their suicidal ideation and known risk factors. Using ecological momentary assessment, the researchers determined that for nearly all participants suicidal ideation fluctuated considerably over a matter of several hours and that well-known risk factors, including hopelessness, burdensomeness, and loneliness also varied. The researchers noted that although the risk factors correlated with the intensity of ideation, their predictive power was limited. There are several clinical implications from this research that apply both to adults and youth: (1) decisions to increase or decrease the level of care should be made using multiple data points; (2) interventions should focus on how to deal with rapid changes in ideation; and (3) mobile devices hold promise as a tool for gathering clinically useful data on suicidal ideation.17
School-based mental health providers can gather information about short-term changes in youth suicide risk using a tool developed by Erbacher et al.4 The Suicide Risk Monitoring Tool was developed for use with youth at known risk for suicide (ie, youth recently discharged from a hospital). The form can be completed by the student or the school staff member. The monitoring form uses a 5-point scale to gather the following information:
Suicidal ideation, including the frequency, intensity, duration, and location
Intent (desire to die and to live)
Plan (including access to method)
Providers can plot these data so that they can quickly and visually identify changes in risk. The monitoring tool can be used multiple times per day or as needed. As noted above, community providers (eg, psychiatrists, social workers, psychologists), not school-based mental health providers, are expected to be the primary service providers for youth who are suicidal. Community providers can ask school staff to make the most of their unique position to gather information on changes in suicide risk using the Suicide Risk Monitoring Tool. Assuming that the requisite release of information forms has been signed, collecting data at school and sharing it with community providers would represent an invaluable step forward in continuity of care for youth who are suicidal.
Outpatient Mental Health
There are several psychotherapies with emerging or promising evidence for reducing youth suicide risk including attachment-based family therapy, integrative cognitive-behavioral therapy, mentalization-based therapy, and dialectical-behavior therapy for adolescents.18,19 The fact that there are treatments for suicidal youth is an important step toward meeting the public health goal of implementing effective treatments for those at risk for suicidal behaviors.20 Despite the empirical support for the psychotherapies mentioned above, there are few places in the United States where outpatient mental health providers can be trained in these treatments. Furthermore, none of the treatments are designed for delivery within a school setting.
Hospitalization is a last resort intervention for youth whose safety cannot be maintained in the community. Although many youth psychiatric hospitalization stays are 48 to 72 hours, for youth whose health insurance permits longer hospital stays, dialectical-behavior therapy and mentalization-based therapy have been shown to reduce suicide risk.19 Even for youth whose stay is less than 72 hours, hospitalization provides the opportunity for a medication evaluation (or reevaluation) and access to a mental health professional trained in working with youth in an acute suicidal crisis. An ideal outcome of a brief hospitalization is a thorough assessment of what contributed to the current suicidal crisis, decisions about medication, and direction for future treatment. Hospitalization is most effective when it is considered part of a comprehensive community treatment program.
Re-entry Into School
Youth are at the highest risk for suicide attempt during the 2 weeks after being released from psychiatric hospitalization.21 Among the reasons for this increased risk, the stress associated with re-entering school is one that adults have some control over. However, there are some concerns that youth have regarding school re-entry (Table 2).4,22 One of the best ways to address these concerns is by holding a re-entry meeting prior to the student's return. The purpose of the meeting is to create a re-entry plan to address any student and family concerns as well as to address follow-up services.4 Hospital staff should proactively engage with school professionals to ensure that key information from the hospital stay is communicated in advance of the meeting. If the youth is discharged prior to the meeting, hospital staff should provide all pertinent documentation to the school staff responsible for coordinating the re-entry meeting. If the youth's family does not want staff from the hospital and the school to communicate, hospital staff should emphasize the importance of a safe transition from the hospital back into the community, including the re-entry into school.
School Re-entry Concerns For Youth Who Are Suicidal
Schools provide a unique environment in which to identify and respond to youth suicide risk. Effective identification and response to youth suicide risk, however, requires a multilevel systemic collaboration between school professionals and community mental health providers. School staff are in a unique position to gather and interpret data about subtle changes in youth suicide risk. Community providers, including psychiatrists, psychologists, and social workers are essential in managing ongoing youth suicide risk.
- Centers for Disease Control and PreventionNational Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). www.cdc.gov/injury/wisqars. Updated June 1, 2017. Accessed July 13, 2017.
- Centers for Disease Control and Prevention. Youth Risk Behavior Survey (YRBS). Trends in the prevalence of suicide-related behaviors: national YRBS: 1991–2015. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trends/2015_us_suicide_trend_yrbs.pdf. Accessed July 3, 2017.
- Nock MK, Green JG, Hwang I, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70(3):300–310. doi:. doi:10.1001/2013.jamapsychiatry.55 [CrossRef]
- Erbacher TA, Singer JB, Poland S. Suicide in Schools: A Practitioner's Guide to Multi-Level Prevention, Assessment, Intervention, and Postvention. New York, NY: Routledge; 2015.
- Stiffman AR, Stelk W, Horwitz SM, Evans ME, Outlaw FH, Atkins M. A public health approach to children's mental health services: possible solutions to current service inadequacies. Admin Policy Ment Health. 2010;37(1–2):120–124. doi:. doi:10.1007/s10488-009-0259-2 [CrossRef]
- Brent DA, Miller MJ, Loeber R, Mulvey EP, Birmaher B. Ending the silence on gun violence. J Am Acad Child Adolesc Psychiatry. 2013;52(4):333–338. doi:. doi:10.1016/j.jaac.2013.01.006 [CrossRef]
- Pisani AR, Schmeelk-Cone K, Gunzler D, et al. Associations between suicidal high school students' help-seeking and their attitudes and perceptions of social environment. J Youth Adolesc. 2012;41(10):1312–1324. doi:. doi:10.1007/s10964-012-9766-7 [CrossRef]
- Wilcox HC, Kellam SG, Brown CH, et al. The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempt. Drug Alcohol Depend. 2008;95(Suppl 1):S60–S73. doi:. doi:10.1016/j.drugalcdep.2008.01.005 [CrossRef]
- Merikangas KR, He J-P, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980–989. doi:. doi:10.1016/j.jaac.2010.05.017 [CrossRef]
- Robinson J, Cox G, Malone A, et al. A systematic review of school-based interventions aimed at preventing, treating, and responding to suicide-related behavior in young people. Crisis. 2013;34(3):164–182. doi:. doi:10.1027/0227-5910/a000168 [CrossRef]
- Calear AL, Christensen H, Freeman A, et al. A systematic review of psychosocial suicide prevention interventions for youth. Eur Child Adolesc Psychiatry. 2016;25(5):467–482. doi:. doi:10.1007/s00787-015-0783-4 [CrossRef]
- Schilling EA, Aseltine RH, James A. The SOS suicide prevention program: further evidence of efficacy and effectiveness. Prev Sci. 2016;17(2):157–166. doi:. doi:10.1007/s11121-015-0594-3 [CrossRef]
- Aseltine RH Jr, James A, Schilling EA, Glanovsky J. Evaluating the SOS suicide prevention program: a replication and extension. BMC Public Health. 2007;7:161. doi:. doi:10.1186/1471-2458-7-161 [CrossRef]
- Hatzenbuehler ML, Birkett M, Van Wagenen A, Meyer IH. Protective school climates and reduced risk for suicide ideation in sexual minority youths. Am J Public Health. 2014;104(2):279–286. doi:. doi:10.2105/AJPH.2013.301508 [CrossRef]
- Brock SE, Nickerson AB, Reeves MA, et al. School Crisis Prevention and Intervention: The PREPaRE Model. 2nd ed. Bethesda, MD: National Association of School Psychologists; 2016.
- Diamond GS, Wintersteen MB, Brown GK, et al. Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2010;49(2):122–131.
- Kleiman EM, Turner BJ, Fedor S, Beale EE, Huffman JC, Nock MK. Examination of real-time fluctuations in suicidal ideation and its risk factors: results from two ecological momentary assessment studies. [published online ahead of print May 8, 2017]. J Abnorm Psychol. doi:10.1037/abn0000273 [CrossRef].
- Singer JB, O'Brien KHM, LeCloux M. Three psychotherapies for suicidal adolescents: overview of conceptual frameworks and intervention techniques. Child Adolesc Soc Work J. 2017;34(2):95–106. doi:. doi:10.1007/s10560-016-0453-5 [CrossRef]
- Singer JB, O'Brien KHM. Assessment, prevention, and intervention with suicidal youth. In: Corcoran K, Roberts AR, eds. Social Workers' Desk Reference. 3rd ed. New York, NY: Oxford University Press; 2015:516–527.
- U.S. Department of Health and Human Services. 2012 national strategy for suicide prevention: goals and objectives for action. http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf. Accessed July 3, 2017.
- Czyz EK, Liu Z, King CA. Social connectedness and one-year trajectories among suicidal adolescents following psychiatric hospitalization. J Clin Child Adolesc Psychol. 2012;41(2):214–226. doi:. doi:10.1080/15374416.2012.651998 [CrossRef]
- Preyde M, Parekh S, Warne A, Heintzman J. School reintegration and perceived needs: the perspectives of child and adolescent patients during psychiatric hospitalization. Child Adolesc Soc Work J. 2017;1–10. doi:10.1007/s10560-017-0490-8 [CrossRef].
- Youth Suicide Warning Signs website. http://www.youthsuicidewarningsigns.org/healthcare-professionals. Accessed July 3, 2017.
Suicide Warning Signs for Youth Up to Age 24 Years
Talking about or making plans for suicide
Expressing hopelessness about the future
Displaying severe/overwhelming emotional pain or distress
Showing worrisome behavioral cues or marked changes in behavior, particularly in the presence of the warning signs above. Specifically, this includes significant:
Withdrawal from or changing in social connections/situations
Changes in sleep (increased or decreased)
Anger or hostility that seems out of character or out of context
Recent increased agitation or irritability
School Re-entry Concerns For Youth Who Are Suicidal
Anticipating stressful social situations including being teased or harassed about being hospitalized, or even fielding innocent peer questions about the youth's absence
Concerns about their academic standing because of missed work
Feeling overwhelmed with school, particularly if the school environment (eg, bullying, academic stress) contributed to prehospitalization suicide risk
Difficulty managing their emotions