Professional Practice

Model School District Policy for Suicide Prevention

By Kelly M. Vaillancourt & Nicole A. Gibson

We know that schools are regularly encountering suicidal behavior among their students and within their communities. The National Association of School Psychologists teamed with the American Foundation for Suicide Prevention, The Trevor Project, and the American School Counselor Association to create a Model School District Policy on Suicide Prevention (the Model Policy; http://www.thetrevorproject.org/pages/modelschoolpolicy) in order to give some direction to schools on how to best tackle the intricate task of understanding, preventing, and responding to youth suicidal behavior.

These four organizations came together to address a significant gap in the suicide prevention resource base available for schools. Although there are many suicide prevention training programs and educational curricula available for schools and school psychologists to choose from, we noted a dearth in comprehensive policy guidance for schools around suicide prevention, intervention, and postvention. In many states, schools are legally required to have policies in place for preventing and responding to youth self-harm and suicidal behavior. Some states and districts expressed difficulty in drafting such a policy, and collectively, we recognized that model policy language was needed, should be readily available, and should be easily adaptable to fit the particular needs of individual school districts nationwide. In designing the final product, we also kept in mind the school personnel who are most likely to be charged with implementing school suicide prevention, intervention, and postvention policies: teachers, administrators, school psychologists, and other school-employed mental health professionals. Our goal is for schools to use the Model Policy to develop and implement new, comprehensive policies or to supplement existing policies already in place. The Model Policy is intended to be paired with current policies and programs on crisis intervention, school safety, and student mental health.

Rates of Suicide

Suicide is a preventable, yet serious public health problem and a leading cause of death for young people across the United States. Overall, suicide is the third leading cause of death for adolescents and young adults, following accidents and homicides. More than 39,000 Americans took their lives in 2011 (Centers for Disease Control and Prevention, 2014). Among those, in excess of 5,000 (or 13%) were children, teens, and young adults under the age of 25. Suicide deaths before the age of 11 are rare; however, beginning around the time of puberty, the frequency of suicide increases dramatically with age until the early twenties. These rates vary by gender and ethnicity, and the rate of suicide completion for boys is consistently higher than that for girls of the same age. Conversely, girls attempt suicide at a much higher rate than boys. The difference in completion rates is due, in part, to boys' use of highly lethal methods, such as firearms. Among the major ethnic groups in the United States, American Indian and Alaskan Native youth currently have by far the highest suicide rates, with almost 13 suicides for every 100,000 young people in these groups—more than one and a half times the national average (7.9 per 100,000). White youth have a rate slightly higher than the national average (8.7 per 100,000), while Asian/Pacific Islander and Black youth have rates below the national average (4.6 and 5.1 per 100,000, respectively; Centers for Disease Control and Prevention, 2014).

Risk Factors

Uncovering the reasons for an individual suicide death or attempt is both complex and challenging. However, research indicates that the vast majority of people who die by suicide have a potentially treatable mental illness at the time of their death— an illness that often has gone unrecognized and untreated (Bertolote & Fleischmann, 2002). Mental illness can cause terrible suffering, affect a person's ability to think clearly and to make decisions, and can interfere with seeking help, continuing treatment, or taking prescribed medicines. However, an underlying mental illness is usually not the only contributing factor to suicide. The majority of people living with mental illness do not go on to attempt or complete suicide. Those that do, more often than not, were experiencing a combination of deep psychological pain, desperate hopelessness, and challenging life events.

Trying to unravel the complexities behind youth suicidal behavior offers its own unique challenges, as children and teens are only just beginning to develop the signs and symptoms of mental illness such as depression or bipolar disorder, alcohol or substance abuse or dependence, schizophrenia, conduct disorder, eating disorders, or anxiety disorders. Other individual, interpersonal, and environmental factors that increase vulnerability to suicide in children and teens are described below.

Prior suicide attempt. Risk for completed suicide is increased in youth who have made a prior suicide attempt. Studies have shown that 30%-40% of adolescents who kill themselves have a history of one or more previous attempts (Tidemalm, Langstrom, Lichtenstein, & Runeson, 2008).

Access to lethal methods of suicide. Accessibility to lethal means for suicide during a time of increased risk, especially firearms, contributes to suicide among persons of all ages, including children and adolescents.

Impulsivity. Suicidal behavior in teens is frequently associated with impulsive or aggressive-impulsive behavior, particularly in the context of depression or bipolar disorder.

Family History. A family history of mental illness increases the likelihood, but does not guarantee, that a teen will develop a mental disorder. Exposure to parental mental disorders during childhood and adolescence can also result in learned behaviors that may affect how a particular disorder is expressed in the young person. Current research is investigating the potential for genetic markers specific to suicidal behavior (De Leo & Heller, 2008; Guintivano et al., 2014).

Exposure to suicide. Suicide risk is increased in young people who are exposed to another's suicide, particularly when the person has celebrity status or there is a strong identification with the person because of similar age or circumstances.

Stressful life events. While untreated or ineffectively treated mental illness is the single largest cause of suicidal behavior, stressful life events may act as a trigger for some teens. These can include isolated events like death of a parent or close relative, a traumatic break up with a girlfriend or boyfriend, or a failing grade on a test or prolonged stress due to ongoing struggles at home or in personal relationships.

High-risk groups. It is important for schools to be aware of student populations that are at elevated risk for suicidal behavior. In addition to youth who are experiencing one or more of the above risk factors, groups at elevated risk for suicide can include in out-of-home settings; youth experiencing homelessness; American Indian and Alaska Native youth; youth living with chronic medical conditions and disabilities; and lesbian, gay, bisexual, transgender, or questioning (LGBTQ) youth.

Media coverage of suicide deaths of youth known or believed to be LGBTQ has resulted in unprecedented national discussion about suicide risk among LGBTQ youth. There is very little solid information about suicide deaths among LGBT youth or adults. Research has found LGBT youth to have elevated rates of depression and more frequent reports of suicidal ideation and behavior compared to youth who describe themselves as heterosexual. In particular, depression in LGBT youth is associated with family rejection, substance use, and social ostracism and bullying by peers (although it is important to note that the relationship between bullying and youth suicide is complex and mediated by other factors).

Resilience

A variety of factors also contribute to strengthening resilience in young people, reducing risk by helping them cope with negative life events even when those events continue over a period of time. These can include receiving effective mental health care; positive connections to family, peers, community, and culture; and the skills and ability to solve problems. These individual, familial, community, and societal risk and protective factors can carry more or less weight depending on the person, adding to the complexity of answering the “why?” behind any suicide death or attempt.

Key Components of the Model Policy

The Model Policy is intended to give schools and districts a best-practices guide for suicide prevention, intervention, and postvention policies and practices. As school psychologists, it is critical that we play a leading role in the effort to ensure that schools implement policies that follow best practices, are developmentally appropriate, and are culturally responsive. Equally important are parents and guardians, who also play a key role in youth suicide prevention. It is critical that school staff members actively and continuously engage and educate parents on suicide prevention policies and practices in place at the school and in the community.

As the Model Policy is intended to be flexible to meet the different needs of each district, the term school-employed mental health professional is used in the model policy language. In many schools and districts, school psychologists are already a critical player in suicide prevention and intervention policies and practices. If your school district does not have a suicide prevention policy, or if you and other school-employed mental health professionals are not involved in suicide prevention and intervention practices, the end of this article will share ways that you can advocate for your role in the implementation of the Model Policy in schools and districts that you server. Please consult the full Model Policy for detailed guidance surrounding prevention, assessment and referral, postvention, and external communication.

Prevention. The school, especially the school psychologist and other school-employed mental health professionals, plays an integral role in suicide prevention. The Model Policy recommends that each school district designate suicide prevention coordinators at the district and the school levels. These people would help plan and implement suicide prevention policies and practices and be the points of contact when a student, parent, or staff member is concerned that a student is at elevated risk for suicide. Coordinators would work with administrators and other school staff to ensure that additional recommended preventive steps be taken school-wide (for example, that staff receive annual professional development on how to recognize the warning signs of suicide and make referrals for help; and that developmentally appropriate, studentcentered education about mental health and suicide prevention be infused into the K–12 health curriculum). School psychologists are critical resources for schools and are a logical choice for serving as these suicide prevention coordinators. School psychologists should also be involved in the development and implementation of suicide prevention education for staff and students. However, it is equally important that schoolemployed mental health professionals receive annual professional development on best practices in risk assessment and crisis intervention so that they are equipped with the knowledge and tools needed to respond safely and effectively when receiving referrals from staff and students.

A key component of supporting overall student wellness and suicide prevention is access to a continuum of school-based mental health supports. Early identification of at-risk students can enhance opportunities for positive outcomes by addressing problems as they first arise. This enables the school, and in particular the school-employed mental health professional, to support the young person and the family in identifying and implementing potential solutions together, before the problem develops into a crisis situation in need of more intensive intervention or treatment.

Assessment and referral. It is important to take every statement regarding suicide or a wish to die be taken seriously. Although each school and school district will have unique policies and procedures for conducting threat assessments, the Model Policy outlines specific actions to take when a young person is thought to be at risk for suicide, when a suicide attempt is made in school, and when an attempt is made outside of the school setting. In all cases, the school should make every attempt to notify the student's parent or guardian.

When a student makes a verbal or written suicide threat, or if the student presents with several risk factors and a staff member is concerned, this student should be seen by a school-employed mental health professional within the same school day. That professional would conduct the risk assessment and facilitate any necessary referrals to an outside mental health agency. If the school-employed mental health professional is not immediately available, the school nurse or school administrator should assist the student until the mental health professional can be brought in. During this time, the student should be under constant supervision to ensure safety, and the suicide prevention coordinator should be made aware of the situation as soon as possible. Additionally, the school-employed mental health professional or principal should notify the student's parent or guardian to assist them with an urgent referral, if necessary, or to help facilitate an appointment with another health care provider. If such a referral is made, school staff should seek permission from the parent or guardian to exchange information with the outside healthcare provider. When a suicide attempt has been made during the school day, all students should be removed from the immediate area as soon as possible and the health and safety of the student who made the attempt should be of primary concern. The student should be supervised until any necessary medical treatment has been provided, per district emergency medical policy. If appropriate, a mental health assessment should be immediately requested and the principal, school suicide prevention coordinator, and the student's parent or guardian should be contacted. Based on the specific school or district policy, as well as the judgment of the school principal and school mental health staff, additional steps should be taken to ensure the safety and well-being of any students who may have been affected by the suicide attempt.

Re-entry procedure. Each school and district will have specific procedures for handling students who are returning to school after a mental health crisis such as a suicide attempt or psychiatric hospitalization based on the specific needs and unique population of the school. However, The Model Policy recommends that the following three specific components be a part of any re-entry plan:

• A designated school employed mental health professional will coordinate with the student, family, and any outside mental health providers (if permission was granted).
• The parent or guardian will provide documentation from a healthcare provider that the student is no longer a danger to themselves or others.
• The designated school-employed mental health person will determine what supports are needed to help the student readjust to the school community and meet with him or her periodically to address any concerns.

Postvention

Suicide in a school community is tremendously sad, often unexpected, and can leave a school with many uncertainties about what to do next. Schools need reliable information, practical tools, and pragmatic guidance to help students and the community at-large as they struggle to cope with and respond to the loss. The Model Policy, coupled with more detailed guidance from NASP and AFSP (included in the resource section below) can help.

The specific circumstances surrounding a death by suicide will guide the school and community response. However, to prevent suicide contagion while effectively managing the situation, the Model Policy suggests the development and implementation of an action plan with the following steps:

• Verify the death: Even if the student's death is perceived to be suicide, it should not be considered such until confirmed by the coroner's office or local police department.

• Assess the situation: The school/district crisis team should consider the impact of the suicide on the student and community population and determine the appropriate resources and supports needed for individual students as well as the general school population.

• Share information: It is important to report only confirmed and factual information to faculty, students, and families. Additionally, the school should inform parents about supports available to students in school, as well as available resources in the community.

• Avoid suicide contagion: The crisis team should work with teachers and families to identify students who may be at a high risk of suicide and those who are most significantly impacted by the student's death.

• Initiate support services: School-employed mental health professionals should collaboratively determine which students need additional risk assessment or mental health support services and implement those as needed.

• Develop memorial plans: School communities often wish to memorialize a student who has died. It can be challenging for schools to strike a balance between compassionately meeting the needs of grieving students while preserving the ability of the school to fulfill its primary purpose of education. In the case of suicide, schools must consider how to appropriately memorialize the student who died without risking suicide contagion among other students who may themselves be at risk. Treating all deaths in the same way avoids stigma and also protects against inadvertently sensationalizing the suicide loss. Wherever possible, schools should meet with the student's friends and coordinate with the student's family to identify a meaningful, safe approach to acknowledging the loss.

External Communication

Following a student suicide, the media will almost certainly want to become involved in reporting the story. Although the school cannot control everything that is reported, there are steps that schools can take the help contain the media firestorm that often follows the report of a suicide. In many cases, a school district has a designated media spokesperson who will respond to all media inquiries. The Model Policy recommends that the media spokesperson:

• Keep the district suicide coordinator, superintendent, and other relevant administrators updated on how the school is handling the necessary postvention activities.

• Prepare a statement for the media that only includes confirmation of the death, the school's postvention plans, and available resources.

• Encourage the media to respect the privacy of the student who died and the family, and to avoid sensationalizing the suicide (e.g., putting story on the front page, describing the method of suicide). Additionally, the spokesperson should strongly suggest that the media refrain from speculating about the reason for the suicide.

How to Advocate for the Model Policy

As you can see, the Model Policy is very comprehensive, and implementation of the full policy can seem overwhelming to districts, particularly those in which no suicide prevention policies are in place. However, schools and districts can take incremental steps toward addressing all of the components included in the model policy, and as school psychologists, we can play a critical role in making that happen.

Educate yourself and others. One of the first steps we can take is to educate ourselves, and those with whom we work, about the importance of suicide prevention and the importance of school involvement in suicide prevention efforts. The authors of the Model Policy created a webinar (http://www.thetrevorproject.org/pages/modelschoolpolicy) that reviews the current research regarding suicide, reviews the key components of the model, and provides tips on how to work with school administrators to implement the policy. We encourage you to watch this webinar and share it with teachers, principals, and other key school and district staff.

You may also choose to review one or several of the resources included in this article or in the full Model Policy for more detailed information on any portion of the model's scope. Many of the resources listed are available for free online or by request from one of the contributing organizations.

Examine existing policies. In cases where there is a school or district suicide prevention policy in place, see if there are areas that should be improved or expanded upon. Highlight for your administrators areas where you feel well equipped and areas where you could use extra guidance and support. Offer to present the Model Policy to your colleagues and to connect your school with community resources that can help with implementation of the Model Policy.

Advocate for increased access to school-employed mental health professionals. Access to school-employed mental health professionals, and the comprehensive services we provide, is crucial to not only preventing suicide, but to improving the overall well-being and academic success of children and youth. NASP recommends a ratio of 1:500–700 school psychologists to ensure that all students have access to the full range of comprehensive school psychological services. Consult resources on the NASP website (http://www.nasponline.org/advocacy/psychservicesroadmap.aspx) for tips on how to improve the ratio in your schools and districts.

Looking Forward

Youth suicidal behavior is a significant public health problem, and schools can play an important role in youth suicide prevention. But schools cannot do this alone; we need the student's family members and peers, and other professionals and community members, to do their part. School personnel, and particularly school-employed mental health professionals such as school psychologists, have a unique potential to identify when students may be struggling, involve the student's family, and connect them with the appropriate supportive resources. The Model School District Policy on Suicide Prevention can offer a blueprint for how to prevent and respond to youth suicidal behavior and involve the individual, familial, school, and community systems that are necessary to support youth at risk. The manner in which the school responds to suicidal youth can indeed save lives.

Practical Resources

• After a Suicide: A Toolkit for Schools provides detailed information, tools, and guidance to schools that have been touched by the tragedy of suicide, including guidelines for action, dos and don'ts, templates, and sample materials (www.afsp.org/schools).

• Involving Families in LGBT Youth Suicide Prevention is a pilot education program hosted by local AFSP chapters to educate parents and other adults about the key role that families play in reducing suicide risk in LGBT youth and promoting their health, safety, and well-being (http://www.afsp.org/preventing-suicide/our-education-and-prevention-programs/community-programs/involving-families-in-lgbt-youth-suicide-prevention).

• Memorial Activities at Schools contains a list of dos and don'ts regarding memorials (http://www.nasponline.org/resources/crisis_safety/memorialdo_donot.pdf).

• More Than Sad: Teen Depression educates high school students about depression, the leading risk factor for suicide in both teens and adults (http://morethansad.org/indextd.html).

• More Than Sad: Suicide Prevention Education for Teachers and Other School Personnel helps teachers and other school personnel learn more about teen suicide and how they can play a role in its prevention (http://morethansad.org/indexpts.html).

• Suicide: Postvention Strategies for School Personnel is designed to help guide implementation of school postvention services (http://www.nasponline.org/resources/intonline/HCHS2_weekley.pdf).

• Suicidal Ideation and Behaviors is an introduction to intervention strategies (http://www.nasponline.org/resources/intonline/NAS-CBIII-05-1001-017-R02.pdf).

References

Bertolote, J. M., & Fleischmann, A. (2002). Suicide and psychiatric diagnosis: A worldwide perspective. World Psychiatry, 1(3). 181–185.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-Based Injury Statistics Query and Reporting System (WISQARS) [online]. Retrieved from www.cdc.gov/injury/wisqars

De Leo, D., & Heller T. (2008). Social modeling in the transmission of suicidality. Crisis, 29(1). 9–11.

Guintivano, J. Brown, T., Newcomer, A., Jones, M., Cox, O., Maher, B. S., … Kaminsky, Z. A. (2014). Identification and replication of a combined epigenetic and genetic biomarker predicting suicide and suicidal behavior. The American Journal of Psychiatry. doi:10.1176/appi .ajp.2014.14010008

Tidemalm, D., Langstrom, N., Lichtenstein P., & Runeson B. (2008). Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long-term follow-up. BMJ, 337:a2205. Retrieved from http://www.bmj.com/content/337/bmj.a2205

Kelly M. Vaillancourt, PhD, NCSP, is Director of Government Relations for the National Association of School Psychologists. Nicole A. Gibson, MSW, is Senior Manager of State Advocacy with the American Foundation for Suicide Prevention.