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
to Action to Prevent Youth Suicide
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
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).
OF THE PROBLEM
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.
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 (
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.
ROLE OF THE 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
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.
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.
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,
THREE TIERED PREVENTION AND INTERVENTION MODEL
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).
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
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,
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).
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).
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
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
Identifying and Referring Suicidal
- 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
- 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
availability of and access to crisis services in communities and schools.
coordination and collaboration among service agencies.
- Increase physical,
temporal, cultural, psychological, and financial accessibility to mental
acceptability of seeking help for oneself or others (i.e., reduce the
stigma of help seeking and mental illness).
Enhancing Problem-Solving and
- 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
- Train peers to
respond in helpful ways to at-risk youth.
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
- 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.
for Increased Funding
- Advocate for the
necessary funding to support all the aforementioned activities, including
the increase of school-based mental health services.
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).
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.
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
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.
by: Philip J. Lazarus, PhD, as past chair of NASP’s National Emergency
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