Preventing Suicide, Part 2

Times of Tragedy: Preventing Suicide in Troubled Children and Youth, Part II

Tips for School Personnel or Crisis Team Members

Children and youth exposed to extreme trauma like the terrorist attacks on the United States or a school shooting can be at increased risk of suicide, particularly youngsters who have experienced a personal loss, abuse, or previous traumatic event or who suffer from depression or other mental illness. School personnel will need to be more vigilant the weeks following a large-scale crisis, identify students who may be at greater risk, and watch for warning signs. The following information is a companion piece to After A National Tragedy: Preventing Suicide in Troubled Children and Youth, Part I, which outlines warning signs and tips for parents and teachers, available from the National Association of School Psychologists online at www.nasponline.org. (See also “Save a Friend: Tips for Teens to Prevent Suicide”, also on the NASP website.)

Tips for School Personnel or Crisis Team Members

Collaborate with colleagues. Having support and consultation from an administrator and one other staff member (perhaps the school nurse, counselor, or social worker) is both reassuring and prudent.
Assign a “designated reporter.” Schools should identify one or more individuals to receive and act upon all reports from teachers, other staff and students about students who may be suicidal. This individual is frequently the school psychologist, counselor, nurse or social worker.
Supervise the student. It is best to always inform the student what you are going to do every step of the way. Solicit the student’s assistance where appropriate. Under no circumstances should the student be allowed to leave school or be alone (even in the restroom). Reassure and supervise the student until a parent, mental health professional or law enforcement representative can assume responsibility.
Mobilize a support system. Assessment of the student's support system will contribute to evaluating the student’s risk. It is often sensible to just ask the student, “who do you want or who do you think will be there for you now?” and assist the student achieving that support. It is important for students to feel some control over their fate.
No-Suicide Contracts. No-suicide contracts have been shown to be effective in preventing youth suicide. In cases where the suicide risk is judged to be low enough not to require an immediate treatment (e.g., there is only ideation and no suicide plan), a no-suicide contract is still recommended to provide the student with alternatives should their suicide risk level increase in the future. Such a contract is a personal agreement to postpone suicidal behaviors until help can be obtained. The contract can also serve as an effective assessment tool. If a student refuses to sign, they cannot guarantee they will not hurt themselves. The assessment immediately rises to high risk and the student should be supervised until parents can assume responsibility in taking the student for immediate psychiatric evaluation.
Suicide-proof the environment. Whether a child is in imminent danger or not, it is recommended both the home and school be suicide-proofed. Before the child returns home and thereafter, all guns, poisons, medications, and sharp objects must be removed or made inaccessible.
Call police. All school crisis teams should have a representative from local law enforcement. If a student resists, becomes combative or attempts to flee, law enforcement can be of invaluable assistance. In some cases they can assume responsibility for securing a “72-hour hold” which will place the youth in protective custody up to three days for psychiatric observation.
Documentation. Every school district should develop a documentation form for support personnel and crisis team members to record their actions in responding to a referral of a suicidal student.

A Suicide Intervention Model

1. Assessment.

Designated Reporters are often asked to make critical risk assessments under extraordinary time constraints. Thus, it is important for a risk assessment protocol to have a specific set of questions that will quickly and reliably obtain needed information. Questions often used address the following:

What warning signs(s) initiated the referral?
Has the student thought about suicide (thoughts or threats alone, whether direct or indirect, may indicate low risk)?
Has the student tried to hurt himself before (previous attempts may indicate moderate risk)?
Does the student have a plan to harm herself now?
What method is the student planning to use and does he have access to the means (these questions would indicate high risk)?
What is the support system that surrounds this child (including the parent in the risk assessment is critical to determining the adequacy of the student’s support system)?

2. Duty to Warn Parents.

There is no question that parents must be notified. In addressing this aspect of suicide intervention, four critical questions need to be addressed.

First, is the parent available?
Second, is the parent cooperative?
Third, what information does the parent have that might contribute to the assessment of risk?
Fourth, what mental health insurance, if any, does the family possess?

If the parent is available and cooperative and the student is judged high risk, the psychologist or social worker must provide parent(s) with community referral resources specific to where the family resides and based on health insurance status. With parental permission, the school psychologist should contact the agency, provide pertinent referral information and follow up to insure the family’s arrival at the agency. If necessary, assist the parent in transporting the student to the agency. The psychologist should obtain a parent signature on a release of information form and assist school staff in working with parents to develop a school support plan. All actions must be documented.

If a parent is unavailable and the student is judged high risk, then, at the discretion of the school site administrator, two members of the crisis team should escort the child to the nearest emergency mental health facility and coordinate efforts with the agency’s Social Services to contact parent. Alternatively, school law enforcement, local police or a mobile psychiatric response team may be asked to assist in transporting the suicidal youth.

Some parents are reluctant to follow through on crisis team recommendations to secure outside counseling for the suicidal child and may simplify or minimize warning signals (e.g., "she's just doing this for attention"). Cultural and language issues are frequent. Give the parents appropriate opportunity and encouragement to follow through before collaborating with crisis team members on when to proceed to the next step. The school crisis team must decide when it is appropriate to report a parent to child protective services if their reluctance is truly negligence and endangers the life of the child.

If it is determined that a parent is uncooperative and the student is judged to be at high risk for a suicidal behavior, then local law enforcement or child protective services should be contacted and child neglect and endangerment report made.

If the parent is uncooperative and the student is judged low risk for suicidal behavior, then it is recommended that the parent to sign a “Notification of Emergency Conference” form which serves to document that the parents have been notified of their child’s suicidal assessment in a timely fashion.

There will be occasions when a student does not want a parent notified. When children are thinking of harming themselves, they are not thinking clearly and, therefore, may not be the best judge of what might be their parent's response. The crisis team has only one decision to make: Will the child be placed in a more dangerous situation by notifying the parent? In such a situation, child protective services will typically be notified. The parents must still be notified and it is the challenge to school personnel to elicit a supportive response from parents.

The parent often has critical information necessary to make an appropriate assessment of risk. Thus it is critical to include parents in the risk assessment. This information may include previous school and mental health history, family dynamics, recent traumatic events in the student's life, and previous suicidal behaviors. Interviewing the parent will also assist the psychologist in making an appropriate assessment of the support system that surrounds this student.

Finally, it is important to determine what mental health insurance does the parent/family have? This information is essential in directing families to appropriate community agencies. All modern mental health intake interviews include questions regarding insurance coverage and it is wise for the school psychologist to be aware of the various local providers. If a student is directed to an emergency clinic, they may later require emergency transport to an appropriate HMO provider. This may not only further traumatize a suicidal student (because most transports must be done under restraints) but also generate a bill of great expense for the parent. It is certainly in the best interest of the child and family to limit the trauma of any student in need of emergency action.

3. Duty To Provide Referrals.

It is critical to stress the importance of identifying and collaborating with community agencies before the crisis occurs. It is recommended that the school crisis team representative call the agency to provide accurate information that the parent may omit or forget. School districts have an obligation to suggest agencies that are non-proprietary or offer sliding scale of fees.

4. Follow up and support the family.

Finally, it is important for school staff to provide ongoing modifications to the students program, perhaps utilizing student study teams.

Resources for School Teams

National Association of School Psychologists
www.nasponline.org

Center for Mental Health in Schools
http://smhp.psych.ucla.edu/resource.htm#crisis

National Victim's Assistance Organization
http://www.try-nova.org

NASP represents 22,000 school psychologists and related professionals throughout the United States and abroad. NASP’s mission is to promote educationally and psychologically healthy environments for all children and youth by implementing research-based, effective programs that prevent problems, enhance independence and promote optimal learning. This is accomplished through state-of-the-art research and training, advocacy, ongoing program evaluation, and caring professional service.

Modified from material posted on the NASP website, September 2001.