Student Services

Suicide Prevention and Intervention

With appropriate attention and thoughtful planning, the risk of student can be minimized.

B y r iChard l ieBerman,SCott P oland, and k atherine C owan

he principal of a large suburban another math class. His attitude had also rates of and behavior high school receives a phone call been affecting his participation in soc- and were more likely than other minor- t that Eric, the younger brother cer, and the coach had recently benched ity students to attempt suicide (Centers of Sam, a 10th-grade student, was found him for not coming to practice. for Disease Control, 2004). dead the night before of apparent sui- Completed are only part cide. Eric had been an 8th-grade student The HardReality of the picture. Other forms of suicidal at the middle school situated across the Adolescents today face tremendous ideation and behaviors are much more playing field from the high school. Eric life pressures that put them at risk for common. It is estimated that for every and Sam were both fairly well-known myriad self-destructive behaviors, youth who dies by suicide, 100–200 as popular athletes in the district. The and suicide is the most devastating youth attempt it. Within a typical high boys’ father had been killed the year consequence of their inability to cope. school classroom, it is likely that three before in an automobile accident. They Although rates have students (one boy and two girls) have at- had missed a few weeks of school and declined slightly since 1992, it is still tempted suicide in the past year. For ev- received some grief counseling at the the third leading cause of death among ery three students who attempt suicide, time. Sam seemed to be adjusting to the 10–24 year olds (Hoyert, Heron, Mur- only one receives medical attention. The new school year well, although he was phy, & Kung, 2006), following automo- other two get up and go to school the involved in two minor fights. He was bile accidents and homicide. Alarm- next day (Poland & Lieberman, 2002). also cited for underage drinking when ingly, the suicide rates for 10–14 year police broke up an unsupervised party. olds increased 196% between 1983–98 The Role of Schools Eric had withdrawn some and had been (U.S. Department of Health and Human Giventhe stakes, having difficulty with his schoolwork. Services, 1999). Equally concerning, andinterventionisakey responsibility His mother had spoken with the school suicide rates among certain subpopu- forschooladministrators.Educating counselor about getting Eric extra sup- lations, such as Black males, White andprotectingstudents is alignedwith port to help him focus. Eric’s friends females, Asian youth, American Indian school mandates (Kalafat &Lazarus, had noticed that he seemed a little edgy youth, and sexual minority youth have 2002) andshouldbeanintegralpartof and occasionally “joked” that he would all increased. Recent data suggest that in school-based mental health services. The rather hang himself than sit through 2003, Hispanic students had the highest learningenvironment lends itself to pre- ventionand earlyinterventioneffortsof Rich Lieberman is the coordinator of the Suicide PreventionUnit of the LosAngeles Unified all types, andprogramsthatare designed School District.Heisafounding member of NASP’s National Emergency AssistanceTeam and a to reachstudents whoare at risk of cochair of NASP’s Crisis Preventionand Intervention Curriculum Development Workgroup. suicide canalsohelpreach students who Scott Poland is afacultymemberatNovaSoutheasternUniversityinFortLauderdale, FL, and arestrugglingwithother mental health the chairman of NASP’s National Emergency AssistanceTeam. issues, such as depressionand anxiety. Katherine Cowan is Director of Marketing and Communications forNASP. School-based programs shouldtake into accountthe unique opportunities Student Servicesisproduced in collaboration with the National Association of School Psychologists andlimitationspresented by theschool (NASP). Articles and related handouts can be downloadedatwww.naspcenter.org/principals. context. Schoolshaveextensive access

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Warning Signs and Triggers to andinfluence over students, allowing individual (e.g., depressionorsubstance staff memberstoraise awarenessofrisk abuse) andenvironmental (e.g., the Warning signs factors,bolster protective factors,and presenceofafirearmorpoverty)risk • Verbal and written statements identify andintervene with students at factors as well as alackofprotective about death and dying risk.However,ma ny of theforces con - factors (e.g., family cohesionand con - tributingtosuicide risk andthe resources nections to caring adults). Often, situ- • Dramatic changes in behavior or personality forintensive intervention fall outside ationalevents(e.g.,the deathofaloved school control. The challenge forprinci- oneoraromanticbreakup)can trigger • Fascination with death and palsistoestablish procedures that both asuicide attempt. dying safeguardstudents andare appropriateto •Giving away prized possessions school resources andlegalauthority.The Planning and Prevention or making out awill foundation of this processmustbethe In addition to developing the capacity • Interpersonal conflicts or loss recognition that suicide is preventable and to identify and intervene with students that preventing it requires theconscious at risk, a key underpinning of school Triggers commitmentofschooladministrators prevention efforts is creating a culture of • Getting into trouble with andstaffmembers. connectedness in which students, both authorities those at risk and their peers who may • Breakup with a boyfriend Suicidal Youth know something, trust and seek the help or a girlfriend Suicidal adolescents feel deep emotional of school staff emm bers. Specifically, • Death of a loved one or pain andisolation.Feelings of hopeless- school suicide prevention programs significant person/loss ness,sadness, worthlessness, anger,and should include awareness education and lonelinessare often compounded by the screening, crisis and mental health team • Knowing someone who died by suicide belief that no oneelsecan understand— coordination, collaboration with com- or help—their pain. Although some munity services, reliance on evidence- • Bullying or victimization youthself-refer,mosteitherattempt to based strategies, and clear intervention • Family conflict/dysfunction keep their decisionasecret(butusually and “postvention” protocols. give warningsigns anyway)orcry for Suicide task force. Every school • Academic crisis or school failure help indirectlybymakingreference to should have a suicide task force to their plans,usuallytopeers.Adolescent coordinate prevention and intervention • Disappointment or rejection girls have higherrates of depression activities. The task force should include • Abuse andare twice as likely to carefully plan school mental health professionals, a andattempt suicide.Boys, however, school administrator, and representa- • Trauma exposure aremore likely to actimpulsively and tives from local mental health and • Serious illness or injury almost fivetimes as likely as females to suicide prevention crisis centers. The • Anniversary of the death die by suicide (Brock,Sandoval, &Hart, purpose of the task force is to develop of a loved one 2006). Adolescents canunderstandthe policies and procedures, assess potential • Forced or extended separation conceptofdeath cognitively.However, risk factors within the school environ- from friends or family. it is notclear that they internalize the ment (e.g., bullying), identify and imple- endoftheir ownlives, particularly ment appropriate prevention programs, Source: Kalafat, J., & Lazarus, P. J. youngeradolescents. It wouldnot be train staff emm bers, assess and provide (2002). Suicide prevention in schools. uncommon forstudents even as oldas interventions for students who are iden- In S. E. Brock, P. J. Lazarus, & S. R. Jimerson, Best practices in school 16 to view deathasmagical,temporary, tified as being at risk, and coordinate crisis prevention and intervention. andreversible(Lieberman, Poland,& with community providers. All concerns Bethesda, MD: National Association of Cassel, in press). Typically, acombi- of suicide risk should be relayed to a School Psychologists. nation of factors compels ayouth to member of the task force who acts as attemptsuicide.This includes both the designated reporter. Depending on

1 PL October 2006 the size of the school, more than one Screen, developedatHarvard andCo- is liability. Schoolshavebeensued designated reporter may be required. lumbia Universities. The SOS program andfound liablefor failingtotake Gatekeeper training. Teaching combines atrainingvideofor gatekeep- proper action,particularlyfor failing the to school erswithabrief screeningfor depression. to notify parents, when astudentwas personnel is referred to as gatekeeper Some very promisi ng research shows thoughttobesuicidal.Thekey issues training. The goal is to ensure that that studentparticipantsincreased their in courtcases have been forseeability school personnel recognize suicidal be- knowledgeabout depressionand suicide; andnegligence andhaveincluded havior, take it seriously, and inform the engagedinmore adult-seeking behavior; casesinwhichschools did notwarn appropriate staff emm ber immediately. andmostimportant,decreased their parentsabout both verbal andwrit- Gatekeeper training should be provided suicide attempts. Teen Screen is designed tenstatementsabout suicide as well for paraprofessionals, coaches, bus driv- to screen youthfor depressionand other as casesinwhichthe school failed to ers, and so forth, and should emphasize mental disordersassociatedwithsuicidal provide supervisionand counseling working as a part of a team, never keep- behaviors. Unfortunately, secondary forsuicidal students. Schoolshavealso ing knowledge of suicidal behavior a schoolshavebeenslowtoimplement been sued over more-complex issues, secret, and knowing the warning signs. screening. The reasonsseemtobedenial such as school climateand failureto Depression screening. The Cen- of thescope of theproblem, reluctance reduce bullying,thatwereclaimed to ters forDisease Controlhas identified to taketimeawayfrom academics, and contribute to thesuicide of astudent. depressionscreeningasapromising thecost. However, screeningtakes very It is importanttokeeprecordsoftrain- strategy foryouthsuicide prevention. little time andmoney. inggiventoschoolstaffmembers and The most widely recognizedprograms Legal issues. Amajor concern to strictly adhere to intervention and areSigns of Suicide (SOS) andTeen forprincipalsinpreventionefforts reportingprotocols.

After the Fact

•Activate the school crisis team. Verify the death and assess the impact on the school community (including staffmembers and pare nts). •Contact the victim’sfamily to offer supportand determine their preferences for student outreach, expressions of grief, and funeral arrangements/attendance. •Determine what and how information is to be shared. Tell the truth. •Informstudents through discussion in classrooms and smaller venues, not assemblies or schoolwide announcements. •Identify at-risk youth. Provide supportand referral when appropriate. Those at particular risk to imitate suicidal behavior arethose who might have facilitated the suicide, f ailed to recognize or ignored warning signs, or had arelationship or identify with the victim. •Focus on survivor coping and efforts to prevent further suicides. This is atime for key prevention information. Emphasize that no one thing or person is to blame and that help is available. •Advocate for appropriate expressions of memorialization. Do not dedicate amemorial (e.g., tree, plaque, or yearbook). Do contribute to asuicide prevention effortinthe community or establish aliving memorial (student assistance programs). •Evaluate the crisis response. •Media representatives should be encouraged to follow American Association of guidelines. These guidelines recommend not making the suicide front page news or publishing apictureofthe deceased, but instead emphasizing suicide prevention, recognition of warning signs, and wheretogo for help.

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Intervention Resources on the Web When a student is identified as poten- tially suicidal, he or she needs to be American Association of Suicidology www.suicidology.org seen by a school mental health profes- American Foundation for Suicide Prevention www.afsp.org sional immediately—no exceptions. If Signs of Suicide (SOS) www.mentalhealthscreening.org there is no mental health professional Teen Screen Program www.teenscreen.org 14 in the building, the designated school Centers for Disease Control www.cdc.gov administrator will need to fill this role National Suicide Hotline: 800.SUICIDE until a mental health professional can be brought in. The goals of intervention are interview. Information provided by parents sign a form indicating they have to ensure student safety, assess and re- the student’s parents may be needed been notified of the suicidal emergency spond to the level of risk, determine the during to the assessment process. The of their child and have received refer- services needed, and ensure appropriate only exception to contacting parents is ral information. It is very important care (Brock et al., 2006). when it appears that the student might that follow-up services be provided at Assessing risk. The designated be a victim of parental abuse, in which school, regardless of whether or not reporter should be trained to determine case an immediate referral should be parents obtain community services. A the student’s level of risk and empow- made to protective services. School staff re-entry planning meeting should be ered to seek administrative support as members should try to meet with the held whenever a student returns from the designated reporter and the student parents and the student together before mental health hospitalization. work through the following steps. There releasing the student to parental care. are three key questions that must be The conference should focus on how Aftermath included in any interview: everyone can work together to obtain A suicide death is generally followed 1. Have you ever thought of commit- the treatment and supervision needed. by a complicated grief process and has ting suicide? One in four students think If the student has mentioned a specific a powerful impact on a school com- about suicide at some time; this alone suicide method, steps need to be taken munity. It is absolutely essential that indicates low risk. to remove access to it. principals are prepared to cope with the 2. Have you ever attempted suicide Providing referrals. It is impor- aftermath. In the case scenario at the be- before? This is an important question tant to collaborate with community ginning of the article, students and staff because the young person who has mental health resources and consider members in both the middle and the attempted before is at moderate risk to cultural, developmental, and sexuality high schools are likely to be affected by attempt again. issues when making referrals. Some- Eric’s death, perhaps placing some other 3. Do you have a plan to harm yourself times students are asked to sign a “no students at risk. Providing leadership in now? The student who has a plan and harm” agreement, although there is no times of crisis is facilitated by having a the means at his or her disposal would research data to prove the effectiveness plan in place. be classified at highest risk. He or she of such contracts. However, helping Follow-up. The principal needs to be must be supervised every moment until the student identify caring adults at in close communication with counsel- transferred to the care of his or her home and at school, appropriate coping ing personnel to ensure that appropriate parents or a treatment facility. strategies, and community resources can services are provided. There is often an When a student is assessed at any be empowering. When used, no harm anniversary date associated with youth level of risk for suicide, the school has a agreements should be viewed as only a suicide, and collaboration between duty to supervise the student, warn his small part of the treatment and safety schools, agencies, and parents is essen- or her parents, and provide appropriate plan and not as a substitute for supervi- tial. It is also not unusual for students to referrals and follow-up. sion and treatment. want to memorialize the suicide victim Warning parents. The parents of Documenting and following up. with plaques or permanent markers at the student must be notified, regard- The staff emm ber needs to document school. The literature and experts cau- less of the information obtained in the the conference and, ideally, have the tion against such remembrances and in-

14 PL October 2006 stead recommend projects and services staff membersalike recognize when they n Kalafat, J.,&Lazarus, P. J. (2002). for the living, such as scholarships in the arestrugglingand feel comfortableseek- Suicide preventioninschools.InS.E. student’s memory. ingappropriate help. P L Brock, P. J. Lazarus, &S.R.Jimerson, Best practices in school crisis prevention and Carefor the Caregivers References intervention. Bethesda,MD: Nat ionalAs - There is nothingeasyabout suicide or n Brock, S. E., Sandoval,J.&Hart, S. sociationofSchoolPsychologists. suicide prevention. However, addressing (2006). Suicidal ideationand behaviors. n Lieberman, R.,PolandS., &Cassel, theissuedirectlyand openly through In G. G. Bear,K.M.Minke,&A.Thomas R. (in press). Best practices in suicide preventionand intervention efforts (Eds.), Children’sneedsII: Development, intervention.InA.Thomas &J.Grimes cangreatly contributetostudentsafety. problems andalternatives (pp. 361–374). (Eds.), Best practices in school psychology Safeguardingstudents is an integral part Bethesda,MD: National Association of V. Bethesda,MD: National Associationof of an educator’srole, but thecomplex School Psychologists. School Psychologists. andpotentiallytragicconsequences of n Centersfor DiseaseControl andPre- n Poland,S., &Lieberman,R.(2002). Best suicide canstraineventhe most sea- vention. (2004). Youthrisk behavior sur- practices in suicide intervention.InA. sonedprofessional. Principalsshould veillance—UnitedStates, 2003. MMWR, Thomas&J.Grimes(Eds.), Best practices notunderestimate theimpactonstaff 53(SS-2), 1–96. in school psychology IV (pp.1151–1167). membersofeitherarash of suicide refer- n Hoyert,D.L., Heron, M. P. ,Murphy, Washington,DC: National Associationof rals or an actual suicide.Inaddition to S. L., &Kung, H. C. (2006) Deaths: Final School Psychologists. ensuring thenecessary resources to sup- data for 2003. National Vital Statistics n U.S. Department of Health andHuman port students, principalsmustbevigilant Report, 54(13). Hyattsville, MD: National Services. (1999). Mental health: Areport of to theneedsofstaffmembers andcreate Center forHealth Statistics. (DHHS thesurgeon general—Executive summary aschoolculture in whichstudents and PublicationNo. (PHS) 2006-1120.) (pp.1164–1165). Rockville, MD: Author.

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