NASP President’s Call to Action to Prevent Suicide

The following paper is a Call to Action for school psychologists to work together to prevent youth suicide. NASP and school psychologists have long been committed to preserving the health, safety, and welfare of children and youth, and suicide prevention must be a top priority in this effort. As our society has become more complex, the educational and interpersonal demands have become more daunting, and the incidence of genetic and congenital disabilities has risen, our youth have developed greater risk for poor problem-solving and self-harm. Suicide is the most tragic of outcomes from these increased risks. School psychologists, the most extensively trained mental health professionals in schools, must take action now to prevent the loss of lives and promise for the future that youth suicide represents. The noblest goal of any organization or individual is to save lives!

I am deeply grateful, as NASP President, for the vision and outstanding work of Philip J. Lazarus and NASP’s National Emergency Assistance Team (NEAT) in drafting this Call to Action. Through their leadership and that of the NASP PREPaRE workgroup and the editors and authors of many NASP publications, including the special series on school-based suicide prevention in the most recent issue of School Psychology Review, school psychologists have a myriad of resources to make effective suicide prevention a priority in every school and community across the country. I challenge you to take strides to make a difference in suicide prevention – to utilize the extensive suicide prevention resources on the NASP website, evidence-based programs like Signs of Suicide (SOS) and Teen Screen, and the School-Based Youth Suicide Prevention Guide to start or to enhance programs in your schools.

Gene Cash, NASP President 2008-09

Call to Action to Prevent Youth Suicide

Few if any problems confronting our nation’s schools are more urgent than youth suicidal behavior. Youth suicide continues to be a significant public health problem at a national level. According to the Centers for Disease Control and Prevention (CDC), suicide is the third-leading cause of death among young people in the United States, trailing only accidents and homicide (CDC, 2006a). In the last decade, more teenagers and young adults died from suicide than from cancer, birth defects, AIDS, stroke, pneumonia, influenza and chronic lung disease combined (Miller, Eckert, & Mazza, 2009). An alarming fact is that every five hours a child or adolescent in the United States dies as a result of suicide (CDC, 2006b).

It is the responsibility of all school psychologists to vigorously promote and to support efforts to prevent suicide from occurring, a position consistent with the Surgeon General’s Call to Action to Prevent Suicide (U.S. Public Health Service, 1999). In this document, former Surgeon General David Satcher wrote, “Suicide is an enormous trauma for millions of Americans who experience the loss of someone close to them. The nation must address suicide as a significant public health problem and put into place national strategies to prevent the loss of life and suffering suicide causes” (p. 1).

THE SCOPE OF THE PROBLEM

The seriousness of the problem of youth suicidal behaviors becomes clear when considering the prevalence of symptoms of depression, suicidal ideation, suicide plans, and suicide attempts in addition to suicide. According to the most recent 2007 Youth Risk Behavior Surveillance System (YRBSS, CDC, 2008), a national survey of students in grades 9-12, approximately 28.5 % reported feeling sad or hopeless in the previous 12 months (35.8% of females and 21.2% of males), and 14.5%  reported having seriously considered attempting suicide (18.7% of females and 10.3% of males). During the same one-year period, 11.3%  made a suicide plan (13.4% of females and 9.2% of males), 6.9% reported making at least one suicide attempt (9.3% of females and 4.6% of males), and 2% reported making at least one attempt that resulted in an injury, poisoning, or an overdose that had to be treated by a doctor or nurse. Collectively, these data suggest that in 2007 approximately 1 out of 7 high school students engaged in serious suicidal ideation, 1 in 10 made a suicide plan, and 1 in 14 made a suicide attempt, some to a degree that required medical treatment or hospitalization.

Youth suicide transcends all boundaries related to socioeconomic status, age, gender, ethnicity, geographical region, and sexual orientation. Depression, comorbidity, childhood adversity, trauma history, and feelings of helplessness and hopelessness all contribute to this problem ( Lieberman, Poland , & Cassel, 2008). No child or family is immune. Viewed from this perspective, youth suicidal behavior clearly is a significant national public health problem that should be of urgent concern to all citizens, especially to those involved in the education, social services, and medical communities and to those formulating public policy.

THE ROLE OF THE SCHOOLS

Schools are the primary institutions responsible for the education and socialization of students and have substantial access to and influence on at-risk youths. Thus, schools offer a logical setting for suicide prevention (Kalafat & Lazarus, 2002). In addition, given the current state of the social service delivery system in the United States , no other institution has as much access to help meet the mental health needs of children (Gould et al., 2005; Mazza & Reynolds, 2008). In many states, schools are the primary providers of mental health services to children, and in some cases, such as in rural areas, schools provide the only mental health services in the community (Roanes & Hoagwood, 2000). School districts must be encouraged to ensure that they have effective policies and procedures in place to respond effectively to suicidal youth. Consequently, suicide prevention and intervention need to be part of the job description of every school psychologist. Not only is this best practice, but it also can save lives and prevent school districts from facing costly lawsuits.

If suicide prevention is to be taken seriously, then schools must take on their share of this responsibility. To accomplish this task will require both leadership and funding at the state and national levels. However, schools cannot do this alone. This effort requires collaboration with community agencies, the medical profession, social service organizations, and faith-based institutions, among others.

THE ROLE OF SCHOOL PSYCHOLOGISTS

School psychologists can do a great deal to prevent suicidal behavior. They are the most highly trained mental health professionals in the schools and are in a vital position to consult with stakeholders and to provide in-service training for school personnel (Lieberman et al., 2008). They can provide workshops for school staff members and community members on topics related to suicidal behaviors (e.g., risk and protective factors, identifying suicidal youth, myths surrounding suicide, policies and procedures, mobilizing a support system, and legal and ethical issues). School psychologists can also help to teach students how to respond helpfully to at-risk, depressed, or suicidal classmates and demonstrate how to contact a caring adult if they suspect a friend is considering suicide.

School psychologists can also play an important role in checking on the impact of antidepressant medications, which may be prescribed for students with a history and/or potential for engaging in suicidal behavior (Miller & Eckert, 2009). Monitoring the effects of medication is an appropriate role for school psychologists, and one that research suggests they are willing and able to perform (Gureasko-Moore, DuPaul, & Power, 2005). In this process, school psychologists can check in regularly with the student and collaborate with the student’s family and physician.

School psychologists can be instrumental in establishing a circle of care around every student displaying suicidal behavior (Lieberman et al., 2008). School psychologists are critical in providing referrals, interfacing with other mental health professionals, coordinating a crisis response, following up and supporting impacted families, and developing school reentry plans. In those tragic cases when a suicide happens, school psychologists can coordinate postvention activities (Brock, 2002). Throughout all phases of prevention and intervention, collaboration with other professionals is critical, as it increases shared responsibility, reduces anxiety, and ensures a more thorough and informed response to suicidal youth.

School psychologists can also advocate for prevention strategies and programs that are culturally sensitive to the unique subcultures within the school community (Goldston et al., 2008). They can collaborate with other school personnel to develop local policies and procedures for responding to suicidal youth. At the state and national level they can work with the American Association of Suicidology and the American Foundation for Suicide Prevention to support legislation and to advocate for public policies (Lazarus & Kalafat, 2001) that are consistent with the Surgeon General’s Call to Action to Prevent Suicide (U.S. Public Health Service, 1999).

A THREE TIERED PREVENTION AND INTERVENTION MODEL

To reduce suicidal behavior among school-age youth, a three-tiered public health model of prevention, intervention, and postvention is advocated. Universal prevention programs should focus on developing a district-wide school policy concerning suicide; educating school professionals about suicide warning signs and risk factors; encouraging collaboration among teachers, nurses, and mental health personnel, including suicide prevention education in the classroom curriculum; developing a peer assistance program; and implementing activities aimed at increasing school connectedness (Kalafat, 2003; King, 2001; Mazza & Reynolds, 2008). Programs should also support school and family partnerships and establish a school crisis team (Kalafat & Lazarus, 2002).

As part of a comprehensive intervention model, school-based screening programs for identifying suicidal youth can be particularly useful among middle and high school students. Two of the most widely used options for assessing high risk adolescents are the Columbia TeenScreen (Columbia TeenScreen Program, 2007) and the Signs of Suicide program (Aseltine & DeMartino, 2004). Both programs have been evaluated by the Substance Abuse and Mental Health Services Administration and are listed in their Registry of Evidence-based Programs and Practices (Substance Abuse and Mental Health Services Administration, 2006, 2007). The significant advantages of these programs are that they have a great deal of supporting materials and are well standardized, though there are costs associated with both.

The empirical research shows that asking youth about thoughts related to suicide communicates to them that the school is concerned about their health and safety, which may lead to disclosure of suicidal risk that would have not otherwise have come to light (Gould et al., 2005). The use of large scale screenings is only practical and recommended if the resources exist to provide youth with timely and adequate follow up services within a few days of identification (Brock, Sandoval, & Hart, 2006; Guiterrez & Osman, 2008).

In addition to universal prevention, an effective school-based suicide prevention program should incorporate selected and indicated prevention as well as postvention measures (Mazza, 1997, 2006; Miller & DuPaul, 1996). Selected prevention focuses on children who are at high risk for suicidal behavior; whereas indicated prevention focuses on children who have already engaged in some type of self-harm. Selected and indicated prevention includes identifying children and adolescents who may be at high risk for suicidal behavior, assessing risk, and, when necessary, referring them to appropriate mental health personnel (Brock et al., 2006; Lieberman et al., 2008).

In addition, in severe cases where a student is hospitalized due to suicidal behavior, it is important for schools to develop a reentry plan when the student returns to school. The purposes of this plan are to reacclimate the student to the school, to decrease the amount of academic and emotional pressure the student feels, to provide support from selected school staff, and to increase the likelihood of a successful transition. An essential part of this plan should include frequent monitoring by a designated school mental health professional (Mazza & Reynolds, 2008).

Following a student suicide, it is paramount that schools implement crisis postvention plans (Brock, 2002). At this stage, an emphasis needs to be placed upon addressing the unique feelings of loss associated with suicide (e.g., anger, guilt, and isolation), preventing possible contagion effects, and expanding prevention efforts by maintaining a safe, secure, and positive school climate. Consultation, student advocacy, psychoeducation, psychological first-aid, and suicide prevention training should be provided as part of this response (Zenere & Lazarus, 2009).

WHAT SCHOOLS, COMMUNITIES, AND MENTAL HEALTH PROFESSIONALS CAN DO TOGETHER

Confronting the tragedy of youth suicide is a multifaceted problem. Much needs to be done, and this requires many levels of collaboration and coordination. As adapted from Lazarus and Kalafat (2001) such activities may include:

Increasing Public Awareness and Promoting Appropriate Media Reporting

• Educate the public about the seriousness of youth suicidal behavior.
• Promote public awareness of the available community resources for responding to mental health issues.
• Promote appropriate media reporting of suicide. Work with the media to make sure they do not glorify suicide or provide explicit details on how the youth committed the act.

Identifying and Referring Suicidal Youth

• Identify and appropriately maintain records of all students who experience suicidal ideation, make suicidal threats, or engage in attempts.
• Where appropriate and feasible, conduct screenings for depression and suicide.
• Monitor the progress of students who display suicidal behavior.
• Connect suicidal individuals with immediate help.
• Provide support and follow up after a suicide, and take care of those individuals who have been significantly impacted by the death.

Connecting Youth to Prosocial Institutions

• Enhance individual sense of connection to schools and communities through provision of opportunities and reinforcement for participation and contribution.
• Promote social norms of caring and mutual support.

Increasing Availability and Access to Services

• Improve availability of and access to crisis services in communities and schools.
• Promote coordination and collaboration among service agencies.
• Increase physical, temporal, cultural, psychological, and financial accessibility to mental health services.
• Promote acceptability of seeking help for oneself or others (i.e., reduce the stigma of help seeking and mental illness).

Enhancing Problem-Solving and Skill Building

• Enhance individual interpersonal problem-solving, coping, and decision-making skills.
• Provide skill building, support, and connection for suicidal youth.

Improving Training in Suicide Prevention and Intervention

• Train community and school staff members to identify, to respond to, and to refer at-risk youth.
• Train peers to respond in helpful ways to at-risk youth.
• Improve professional training in risk assessment, treatment, and management of suicidal individuals as well as in the treatment of mental disorders such as depression, anxiety, and substance abuse.

Creating Safe Environments

• Work with parents and school staff to reduce access to lethal means at home and in school.

Evaluating Results and Supporting Research

• Evaluate the results of prevention and intervention efforts with suicidal youth.
• Support and conduct research aimed at developing more effective ways for schools and communities to reduce suicidal behavior among our nation’s youth.

Advocating for Increased Funding

• Advocate for the necessary funding to support all the aforementioned activities, including the increase of school-based mental health services.

CONCLUSION

The number of child and adolescent suicides has increased over 300% since the 1950’s (Berman, Jobes, & Silverman, 2006). Despite fluctuating rates over time (overall suicide rates among youth declined somewhat from 1990 to 2004), some have suggested that child and adolescent suicide will increase in the future (Gutierrez & Osman, 2008). Sadly, the one group that has shown some of the most notable increases over the last two decades are youth ages 10 to 14 years, with suicide rates increasing in this age group by more than 50% between 1981 and 2006 (American Association of Suicidology, 2009).

Within the typical high school classroom, it is likely that three students (two girls and one boy) have made a suicide attempt within the past year. Adding to this concern is the possibility that the number of reported youth suicides and suicide attempts may be an underestimate of the actual occurrence (Lieberman et al., 2008). Moreover, only one of three children or adolescents who made an attempt received medical attention. That is, for every three youth who attempted suicide, two got up and went to school the following day without medical or psychiatric follow-up (Lieberman et al., 2008). This underscores the necessity for schools to respond to the urgent mental health needs of students, as many youth do not receive any form of treatment following a suicide attempt.  

There is a growing and unmet need for mental health services for children and youth, including suicide prevention and intervention. NASP advocates for the inclusion of effective mental health services in the schools (NASP, 2008) that should be coordinated, comprehensive, and accessible to all students and families. This is not only good public policy, but it is also a wise investment. As part of this effort, school districts should develop suicide prevention policies and procedures and utilize a multi-tiered approach ranging from universal prevention to intensive intervention. In using this approach, it is especially important to identify suicidal youth and to get them the services they so desperately need.

If suicidal youth are identified by the schools and if appropriate treatment is provided, suicide can be dramatically reduced (Kalafat & Ryerson, 1999; Zenere & Lazarus, 1997, 2009). By the nature of their training and experience, school psychologists are in an ideal position to help develop district level and school-based strategies and policies to ensure that these at-risk students are identified and subsequently referred. If this happens, lives will be saved.

Authored by: Philip J. Lazarus, PhD, as past chair of NASP’s National Emergency Assistance Team (NEAT).

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