PREVENTING SUICIDE
A Toolkit for High Schools
·
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Ser
vices Administration
Center for Mental Health Services
www.samhsa.gov
PREVENTING SUICIDE
:
A Toolkit for High Schools
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
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PREVENTING SUICIDE: A HIGH S
CHOOL TOOLKIT
ACKNOWLEDGEMENTS
This toolkit was prepared for the Substance Abuse and Mental Health Services
Administration (SAMHSA) by the National Association of State Mental Health Program
Directors (NASMHPD) in collaboration with Education Development Center, Inc.
(EDC), and NASMHPD Research Institute, under contract number
HHSS283200700020I/HHSS2800003T, with SAMHSA, U.S. Department of Health and
Human Services (HHS), Rosalyn Blogier, LCSW-C and Dr. Tarsha Wilson, Government
Project Officers.
Disclaimer
The views, opinions, and content of this publication are those of the author and do not
necessarily reflect the views, opinions, or policies of SAMHSA or HHS.
The people depicted in this toolkit are models only. They are not included to illustrate the
mental health issues addressed in this toolkit nor do the authors of this document have
any reason to believe that they experienced any of the mental health issues addressed in
this toolkit.
Public Domain Notice
All material appearing in this report is in the public domain and may be reproduced or
copied without permission from SAMHSA. Citation of the source is appreciated.
However, this publication may not be reproduced or distributed for a fee without the
specific, written authorization of the Office of Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication
This publication may be downloaded or ordered at http://store.samhsa.gov/product/
SMA12-4669 or by calling SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727). The
Toolkit is available in English.
Recommended Citation
Substance Abuse and Mental Health Services Administration. Preventing Suicide: A
Toolkit for High Schools. HHS Publication No. SMA-12-4669. Rockville, MD:
Center for Mental Health Services, Substance Abuse and Mental Health Services
Administration, 2012.
Originating Office
Center for Mental Health Services, Substance Abuse and Mental Health Services
Administration, 1 Choke Cherry Road, Rockville, MD 20857, HHS Publication No.
SMA-12-4669. Printed 2012.
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PREVENTING SUICIDE: A HIGH S
CHOOL TOOLKIT
CONTENTS
Introduction ................................................................................................7
Chapter 1: Getting Started
.....................................................................15
Getting Started Tools
............................................................................23
Tool 1.A: Suicide Prevention: Facts for Schools
...................................24
Tool 1.B: Chart of School Staff Responsibilities
...................................28
Tool 1.C: Chart of Community Partners
................................................30
Tool 1.D: Risk and Protective Factors and Warning
Signs Factsheets
..................................................................................32
Tool 1.E: Data on Youth Suicide
...........................................................43
Tool 1.F: Suicide and Substance Abuse Information Sheet..................45
Tool 1.G: Suicide and Bullying Information Sheet
................................47
Tool 1.H: The Implications of Culture on Suicide
Prevention Information Sheet
...............................................................50
Tool 1.I: Checklist of Suicide Prevention Activities
..............................52
Tool 1.J: Matrix of School-Based Suicide Prevention Programs
..........54
Tool 1.K: Suicide Prevention Registries Information Sheet
..................56
Chapter 2: Protocols for Helping Students at Risk of Suicide
............57
Protocols for Helping Students at Risk of Suicide Tools
..................67
Tool 2.A: Questions for Mental Health Providers
..................................68
Tool 2.B: Protocol for Helping a Student at Risk of Suicide
..................69
Tool 2.B.1: Suicide Risk Assessment Resources
.................................70
Tool 2.B.2: Self-Injury and Suicide Risk Information Sheet
..................71
Tool 2.B.3 Guidelines for Notifying Parents
..........................................72
Tool 2.B.4: Parent Contact Acknowledgement Form
............................74
Tool 2.B.5: Guidelines for Student Referrals
........................................75
Tool 2.B.6: Student Suicide Risk Documentation Form
........................76
Tool 2.C: Protocol for Responding to a Student Suicide Attempt
.........79
Tool 2.D: Guidelines for Facilitating a Student’s Return to School
.......80
Chapter 3: After a Suicide
.......................................................................83
After a Suicide Tools ............................................................................92
Tool 3.A: Immediate Response Protocol
..............................................93
Tool 3.A.1: Sample Script for Office Staff
.............................................96
Tool 3.A.2: Sources of Postvention Consultation .................................97
Tool 3.A.3: Guidelines for Working with the Family
..............................98
Tool 3.A.4: Guidelines for Notifying Staff
..............................................99
Tool 3.A.5: Sample Announcements...................................................100
Tool 3.A.6: Sample Letter to Families
.................................................103
Tool 3.A.7: Talking Points for Students and Staff after a Suicide
........104
Tool 3.A.8: Guidelines for Memorialization
.........................................105
Tool 3.A.9: Guidelines for Working with the Media
.............................107
Tool 3.B: Long-Term Response Protocol
............................................108
Tool 3.B.1: Guidelines for Anniversaries of a Death
...........................109
Chapter 4: Staff Education and Training
............................................. 111
Staff Education and Training Tools
................................................... 119
Tool 4.A: Matrix of Staff Education and Training Programs
................120
Chapter 5: Parent/Guardian Education and Outreach
.......................125
Parent/Guardian Education and Outreach Tools
.............................133
Tool 5.A: Parent/Guardian Education and Outreach Programs
..........134
Tool 5.B: Suicide Prevention and Schools: Facts for Parents
............136
Chapter 6: Student Programs
...............................................................139
Student Programs Tools.....................................................................149
Tool 6.A: Types of Student Programs Information Sheet
....................150
Tool 6.B: Matrix of Student Programs
.................................................152
Chapter 7: Screening
............................................................................157
Screening Tools
..................................................................................166
Tool 7.A: Matrix of Screening Programs
.............................................167
Tool 7.B: Ideas for Maximizing Parental Response Rate
...................168
Resources
..............................................................................................173
Handouts
................................................................................................209
Contributors
........................................................................................... 229
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PREVENTING SUICIDE: A HIGH SCHOOL TOOLKIT
Introduction
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PREVENTING SUICIDE: A HIGH S
CHOOL TOOLKIT
INTRODUCTION
Preventing Suicide: A Toolkit for High Schools was funded by the U.S. Substance Abuse
and Mental Health Services Administration (SAMHSA) to help high schools, school
districts, and their partners design and implement strategies to prevent suicide and
promote behavioral health among their students. The information and tools in this toolkit
will help schools and their partners:
Assess their ability to prevent suicide among students and respond to suicides
that may occur
Understand strategies that can help students who are at risk for suicide
Understand how to respond to the suicide of a student or other member of the
school community
Identify suicide prevention programs and activities that are effective for
individual schools and respond to the needs and cultures of each school’s students
Integrate suicide prevention into activities that fulll other aspects of the school’s
mission, such as preventing the abuse of alcohol and other drugs
Suicide prevention efforts in high schools are usually led by school counselors, mental
health professionals, or social workers. But it is important to remember that no one—not
the principal, not the counselor, and not the most passionate and involved parent—can
establish effective suicide prevention strategies alone. The participation, support, and
active involvement of others in the school and community are essential for success.
Chapter 1 will help you:
Begin to identify the school staff and community partners who can help
Generate support for suicide prevention in the school system and community
Prioritize and select programs and activities that are right for your school
Chapters 2–7 describe the steps necessary to implement the components of a
comprehensive school-based suicide prevention program. Most chapters include tools to
help you carry out these steps, including forms, worksheets, factsheets, and guidelines.
The “Resources” section is an annotated directory of suicide prevention resources.
Note on Organization: References in the text of the toolkit are found in the Reference List
following Chapter 7. References for each tool are listed with the tool.
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SUICIDE PREVENTION: FACTS FOR SCHOOLS
“What happened in our district could happen anywhere.”
“Every school in our district had a crisis plan if a staff member died of cancer or a
student got in a car accident. But suicide . . . it wasn’t on my agenda,” said a
superintendent. “We just did not think it was going to happen here. Unfortunately we
learned the hard way. It was only after we had a [death in our school community by]
suicide that we realized we needed to take a comprehensive approach to preventing a
tragedy like this. And we realized we needed to involve everybody—the school staff,
students, parents, and the community.”
—Superintendent in a New England School District
Many high school students reported that they had seriously considered
suicide in the past year (CDC, 2010a).
Suicide is the third leading cause of death among teenagers (CDC, 2009a).
One out of every 53 high school students (1.9 percent) reported having made
a suicide attempt that was serious enough to be treated by a doctor or a nurse
(CDC, 2010a).
For each suicide death among young people, there may be as many as 100 –200
suicide attempts (McIntosh, 2010).
Approximately 1 out of every 15 high school students attempts suicide each year
(CDC, 2010a).
The toll among some groups is even higher. For example, the suicide death rate
among 15–19-year-old American Indian/Alaska Native males is 2½ times higher
than the overall rate for males in that age group (Heron, 2007).
FOUR REASONS WHY SCHOOLS SHOULD ADDRESS SUICIDE
While everyone who cares for and about young people should be concerned with youth
suicide, schools have special reasons for taking action to prevent these tragedies:
1. Maintaining a safe school environment is part of a school’s overall mission.
There is an implicit contract that schools have with parents to protect the
safety of their children while they are in the school’s care. Fortunately, suicide
prevention is consistent with many other efforts to protect student safety.
Many activities designed to prevent violence, bullying, and the abuse of
alcohol and other drugs may also reduce suicide risk among students (Epstein
& Spirito, 2009).
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PREVENTING SUICIDE: A HIGH SCHOOL TOOLKIT
Programs that improve school climate and promote connectedness help
reduce risk of suicide, violence, bullying, and substance abuse (Resnick et
al., 1997; Blum, McNeely, & Rinehart, 2002).
Efforts to promote safe schools and adult caring also help protect against suicidal
ideation and attempts among LGB youth (Eisenberg & Resnick, 2006).
Some activities designed to prevent suicide and promote student mental
health can reinforce the benets of other student wellness programs.
2. Students’ mental health can affect their academic performance. Depression
and other mental health issues can interfere with the ability to learn and can
affect academic performance. According to the 2009 Youth Risk Behavior Survey
(CDC, 2010b):
Approximately 1 of 2 high school students receiving grades of mostly Ds and
Fs felt sad or hopeless. But only 1 of 5 students receiving mostly grades of A
felt sad or hopeless.
1 out of 5 high school students receiving grades of mostly Ds and Fs
attempted suicide. Comparatively, 1 out of 25 who receive mostly A grades
attempted suicide.
3. A student suicide can signicantly impact other students and the entire
school community. Knowing what to do following a suicide is critical to helping
students cope with the loss and prevent additional tragedies that may occur.
Adolescents can be susceptible to suicide contagion (sometimes called the
“copycat effect”). This may result in the relatively rare phenomenon of “suicide
clusters” (unusually high numbers of suicides occurring in a small area and brief
time period) (Gould, Wallenstein, Kleinman, O’Carroll, & Mercy, 1990).
4. Schools have been sued for negligence for the following reasons (Doan,
Roggenbaum, & Lazear, 2003; Juhnke, Granello, & Granello, 2011; Lieberman,
2008–2009; Lieberman, Poland, & Cowan, 2006):
Failure to notify parents if their child appears to be suicidal
Failure to get assistance for a student at risk of suicide
Failure to adequately supervise a student at risk of suicide
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REVENTING SUICIDE: A HIGH SCHOOL TOOLKIT
What about FERPA?
Under the Family Educational Rights and Privacy Act (FERPA), parents are generally
required to provide consent before school officials disclose personally identifiable
information from students’ education records. There are exceptions to FERPAs general
consent rule, such as disclosures in connection with health or safety emergencies. This
provision in FERPA permits school officials to disclose information on students, without
consent, to appropriate parties if knowledge of the information is necessary to protect the
health or safety of the student or other individuals. When a student is believed to be suicidal
or has expressed suicidal thoughts, school officials may determine that an articulable and
significant threat to the health or safety of the student exists and that such a disclosure to
appropriate parties is warranted under this exception (Department of Education, 2010).
School Connectedness
School connectedness “is the belief by students that adults and peers in the school care
about their learning as well as about them as individuals” (CDC, 2009b). Making positive
changes to the school climate—increasing students’ sense of connectedness to the school—
can result in improved academic achievement and healthy behaviors among students.
Strategies for building connectedness include (CDC, 2009b):
Providing students with the academic, emotional, and social skills necessary to be
actively engaged in school
Using effective classroom management and teaching methods to foster a positive
learning environment
Creating decision-making processes that facilitate student, family, and community
engagement; academic achievement; and staff empowerment
Providing education and opportunities to enable families to be actively involved in
their children’s academic and school life
Creating trusting and caring relationships that promote open communication among
administrators, teachers, staff, students, families, and communities
Providing professional development and support for teachers and other school
staff to enable them to meet the diverse cognitive, emotional, and social needs
of students
Although suicidal behavior is one of the negative behaviors that can be reduced as
connectedness increases, strategies to increase connectedness should not be substituted for
the types of suicide prevention strategies described in this toolkit. However, combining
suicide prevention with efforts to increase connectedness is a powerful strategy for
furthering both goals.
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HOW SCHOOLS CAN HELP PREVENT SUICIDE
Suicide prevention experts recommend using a multifaceted approach in which specific
components are implemented in a particular sequence. These components include:
Protocols for helping students at risk of suicide, including:
» A protocol for helping students who may be at risk of suicide
» A protocol for responding to students who attempt suicide at school
» Agreements with community providers to provide behavioral health services
to students
Protocols for responding to suicide death, including:
» Steps to take after the suicide of a student or other member of the school
community
» Staff responsible for taking these steps
» Agreements with community partners to help in the event of a suicide
Staff education and training, including:
» Information about the importance of suicide prevention for all staff
» Training, for all staff, on recognizing and responding to students who may be
at risk of suicide.
» Training, for appropriate staff, on assessing, referring, and following up with
students identied as at risk of suicide.
Parent education, including:
» Information for parents about suicide and related behavioral health issues
» Strategies to engage parents in suicide prevention programs
Student education, including:
» One or more programs to engage students in suicide prevention
» Integration of suicide prevention into other student healthy behavioral health
initiatives
Screening:
» A suicide screening program
» Parent, staff, and community mental health provider support for
screening
Preventing Suicide: A Toolkit for High Schools will help you implement these
components. The toolkit represents the best available evidence and expert opinion on
preventing suicide among high school students. It is recommended that you review the
entire toolkit before starting to implement any one component.
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Suicide Prevention and Behavioral Health
In this toolkit, we use SAMHSAs definition of behavioral health: “the promotion of emotional
health; the prevention of mental illnesses and substance use disorders; and treatments and services
for substance abuse, addiction, substance use disorders, mental illnesses, and/or mental
disorders.” SAMHSA has articulated the philosophy that “behavioral health is essential to the
Nation’s health.” Schools have an essential role to play in preventing suicide and in promoting
behavioral health among America’s young people.
CHAPTER 1
Getting Started
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REVENTING SUICIDE: A HIGH SCHOOL TOOLKIT
GETTING STARTED
The steps in Chapter 1 will answer these questions:
What are the most critical steps you should take to protect your students
from suicide?
How can you engage administrators in suicide prevention?
Which school staff and community partners should be involved from the beginning?
How can you educate yourself and the school community about suicide prevention?
A STRATEGIC APPROACH TO PREVENTING SUICIDE IN SCHOOLS
Suicide prevention experts agree that the most effective way to prevent suicide is to use a
number of complementary strategies (which will be described in this toolkit). But even
schools fortunate enough to have the resources to implement all of these strategies should
not try to do them all at the same time.
A comprehensive school-based suicide prevention program should be built on a
foundation that responds to the most serious issues faced by students and the school—a
student at high risk of suicide and a death by suicide of a student (which could put other
students at risk).
The two essential components that every school should have in place are:
Protocols for helping students at possible risk of suicide
Protocols for responding to a suicide death (and thus preventing additional suicides)
Every school should have these two sets of protocols in place regardless of whether
they are going to implement any additional suicide prevention activities. For
guidance in creating these protocols, see Chapters 2 and 3 of this toolkit.
It is essential to implement protocols for responding to students at possible risk of suicide
before implementing strategies to help identify students at risk of suicide (such as
training staff to recognize suicide risk). Identifying students who are at risk of suicide
will be more likely to prevent suicide when the procedures that ensure these students
receive appropriate services are in place. Only after creating these procedures is a school
ready to implement other suicide prevention strategies.
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After developing the two critical protocols, all staff should be engaged in suicide
prevention. This should include the following:
Educating all staff about the importance of suicide prevention
Training all staff to recognize suicide risk
Training selected staff to assess and refer students at risk of suicide to appropriate
services
After a school has created and implemented these three components (the two essential
protocols and the staff education and training outlined above), it is ready to implement
additional suicide prevention strategies, including:
Educating parents about behavioral health promotion and suicide risk
Educating and involving students in behavioral health promotion and suicide
prevention
Screening students for suicide risk
For guidance on these strategies, see Chapters 5, 6, and 7 of this toolkit.
STEPS FOR GETTING STARTED
These steps for getting started are not entirely sequential. You may want to complete
them in a different order—or carry out several of them at the same time.
Step 1. Engage administrators, school boards, and other key players.
The support of school administrators—especially principals—is essential to any activity
carried out within a school. The support of other key players, including superintendents
and school board members, can also be crucial for success. School leaders may be
reluctant to undertake a suicide prevention initiative because of the sensitive nature of
this issue or because of competing demands. Here are some suggestions for gaining
their support:
Explain why it is important to address suicide risk among students. To gain
the support of administrators, school leaders, and other stakeholders, use Tool
1.A: Suicide Prevention: Facts for Schools. Another useful resource is the free
video “School-Based Suicide Prevention: A Matter of Life and Death,” in which
school administrators and staff share their experiences of facing the suicide of a
student. See Getting Started—Information Sheets in the “Resources” section in
this toolkit for information on this video.
Highlight data and information specic to your district, State, or tribe. Local
statistics on suicidal behavior can be very persuasive in convincing stakeholders
that action needs to be taken. The Centers for Disease Control and Prevention’s
Youth Risk Behavior Survey has a Web page at
http://www.cdc.gov/healthyyouth/yrbs/state_district_comparisons.htm which
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includes State and district-level data.
Share your plans. Emphasize that you will take advantage of the many existing
suicide prevention programs that are considered best practices, and that these
strategies can be easily integrated into the activities already in place at the school.
Step 2. Bring people together to start the planning process.
Having the right people in the right room is essential to any successful planning process.
Some schools may want to start by convening a group composed of staff members and
then reach out to the community. Other schools may want to involve both staff and
community partners from the start.
Engage school staff.
You will find it easier to chart a realistic course of action if you engage school staff from
various disciplines and areas of responsibility from the beginning. It is important to have
people with mental health expertise, such as a school counselor or social worker, involved
in planning and possibly leading suicide prevention activities.
Your school may have teams responsible for health or behavioral health issues, such as a
crisis response team or a health promotion team. If you do, consider adding suicide
prevention to their mission and involving members of these teams as you assign
responsibility for suicide prevention strategies.
It is important to understand that the reluctance of some staff to become involved with the
team may be a result of their own personal experiences with suicide or suicide risk. These
personal histories, and the desires of staff not to reveal them, need to be respected.
Tool 1.B: Chart of School Staff Responsibilities will help you decide who should be
involved in planning and implementing the specific components of your suicide
prevention program. Begin by filling in the names of staff who will be responsible for
taking the steps outlined in this chapter.
School staff may also want to engage students and parents in the planning process. Take
advantage of existing mechanisms for involving students and parents in the development
of school policies and implementation of new programs.
Engage community partners.
Schools need community support to help prevent suicide. If your community has a
suicide prevention coalition or group, contact it as soon as you get started. Your State or
tribal suicide prevention contact can help you identify suicide prevention coalitions in
your community. For a list of State and tribal suicide prevention contacts, visit the
Suicide Prevention Resource Center Web site:
State contacts: http://www.sprc.org/states/all/contacts
Tribal contacts: http://www.sprc.org/grantees/listing
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You should also reach out to leaders from the ethnic and cultural communities
represented in your school. They can be critical in ensuring that your efforts are culturally
competent and effective in reaching the students and parents from these communities.
Tool 1.C: Chart of Community Partners will help you identify the individuals and
agencies you might want to engage in your school’s suicide prevention efforts. In
addition, each chapter includes a process for identifying community partners that can help
implement particular activities. Use Tool 1.C. to identify the community partners you
need to get started, that is, to take the steps described in this chapter.
Step 3. Provide key players with basic information about youth suicide and
suicide prevention.
The following tools will help your staff and community partners gain a basic
understanding of suicide prevention:
Tool 1.A: Suicide Prevention: Facts for Schools includes an overview of the problem of
adolescent suicide and the role schools can play in prevention.
Tool 1.D: Risk and Protective Factors and Warning Signs Factsheets describes
characteristics that increase risk of and protection against suicide as well as warning signs
that someone may be at risk of imminent harm. This is important information for all staff
and will be referenced in subsequent activities.
Tool 1.E: Data on Youth Suicide includes information on suicide deaths, attempts, and
methods among young people ages 13–19.
Tool 1.F: Suicide and Substance Abuse Information Sheet provides information on
substance abuse as a major risk factor for suicide and the implications of that
for prevention.
Tool 1.G: Suicide and Bullying Information Sheet provides information on bullying as a
major risk factor for suicide and the implications of that for prevention.
The Getting Started part of the “Resources” section in this toolkit contains other
background documents and factsheets to share with staff.
Step 4: Develop your overall strategy.
Assess your current policies, programs, and school culture.
Before developing an overall strategy for your school, it is important to understand the
programs and policies in your school, community, or State that could facilitate, obstruct,
or otherwise affect your work.
Determine whether there are policies, either State, district, Bureau of Indian
Education, or tribal, to which your activities must conform, e.g., training for staff,
training for students, or protocols for suicide prevention or intervention.
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» The State Information pages of the Suicide Prevention Resource Center Web
site list State policies on suicide prevention in schools:
http://www.sprc.org/states
» The Suicide Prevention Action Network (SPAN) USA Web site has updates
on all State legislation related to suicide prevention:
http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_
id=DDB4817F-AFFD-AB5B-65FFA5FF8FD4DDCC
» For Bureau of Indian Education policies, send an email to
juanita.keesing@bie.edu or call the Bureau of Indian Education Central
Ofce at 202-208-5962.
» Federal civil rights laws require reporting and preventing discrimination
based on sex or disability, which are also potential risk factors for suicide.
Assess the health and behavioral health programs you may already have
in place that could be enhanced with suicide prevention activities. These
programs could include those designed to build connectedness; improve
the school climate; or prevent bullying, violence, or the abuse of alcohol
and other drugs. The School Health Index is a self-assessment and planning
tool that schools can use to improve their health and safety policies and
programs: http://www.cdc.gov/healthyyouth/shi/index.htm.
Inventory the suicide prevention programs in your district and community.
Contact your local mental health department to learn about other programs in
your area. You can also get in touch with your State or tribal suicide prevention
contact person to learn about programs in your community:
State contacts: http://www.sprc.org/states/all/contacts
Tribal contacts: http://www.sprc.org/grantees/listing
Learn how the different cultures represented among the students in your school
address behavioral health issues and suicide risk, and take that into consideration
in developing your strategy. For additional guidance, see Tool 1.H: The
Implications of Culture on Suicide Prevention Information Sheet.
Consider how to address obstacles you might face. For example, some people
might question whether schools should be involved in suicide prevention. You
can address this objection with the information provided in Tool 1.A: Suicide
Prevention: Facts for Schools.
Select components of a comprehensive approach.
After assessing the policy environment and the existing programs in your school into
which suicide prevention strategies can be integrated, you can begin choosing programs
and activities to implement. It is important to remember that the field of suicide
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prevention is relatively young. Even the most carefully constructed and rigorously
evaluated suicide prevention program will have limitations as well as strengths. No
program can claim universal effectiveness (Gould, Greenberg, Velting, & Shaffer, 2003;
Gould, Klomek, & Batejan, 2009; Guo & Harstall, 2002; Miller, Eckert, & Mazza, 2009).
Thus, it is important to examine the evaluation and research to ensure that the programs
and activities you choose are the best fit for your school.
Use Tool 1.I: Checklist of Suicide Prevention Activities to assess what you
already have in place and what is missing. Compare your protocols with those
recommended in Chapter 2 (Protocols to help students at possible risk of suicide)
and Chapter 3 (Protocols to respond appropriately to a death by suicide). You
may nd that your protocols need to be revised or enhanced. Completing this
checklist will prepare you to embark upon the steps outlined in Chapters 2–7.
Review Tool 1.J: Matrix of School-Based Suicide Prevention Programs. This
matrix lists all the school-based suicide prevention programs currently in the
National Registry of Evidence-Based Programs and Practices (NREPP) or the
Best Practices Registry (BPR). This matrix can help you choose programs to
use in your school. Tool 1.K: Suicide Prevention Registries Information Sheet
provides more information about the NREPP and BPR.
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PREVENTING SUICIDE: PREVENTING S
UICIDE: AA HIGH SCHOOL HIGH SCHOOL TTOOLKITOOLKIT
CHAPTER 1: GETTING STARTED TOOLS
Tool 1.A: Suicide Prevention: Facts for Schools
Tool 1.B: Chart of School Staff Responsibilities
Tool 1.C: Chart of Community Partners
Tool 1.D: Risk and Protective Factors and Warning Signs Factsheets
Tool 1.E: Data on Youth Suicide
Tool 1.F: Suicide and Substance Abuse Information Sheet
Tool 1.G: Suicide and Bullying Information Sheet
Tool 1.H: The Implications of Culture on Suicide Prevention Information Sheet
Tool 1.I: Checklist of Suicide Prevention Activities
Tool 1.J: Matrix of School-Based Suicide Prevention Programs
Tool 1.K: Suicide Prevention Registries Information Sheet
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PREVENTING SUICIDE: A HIGH SCHOOL TOOLKIT
Tool 1.A: Suicide Prevention: Facts for Schools
This factsheet can help you gain the support of administrators, school leaders, and other stakeholders for
implementing suicide prevention initiatives in high schools. It includes an overview of the problem of
adolescent suicide, explains why it is important to address suicide risk among students, and discusses the
role that schools can play in prevention.
The information in this factsheet was also included in the Introduction. This handout can be found in the
“Handouts” section of this Toolkit, which begins on page 209.
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PREVENTING SUICIDE: A HIGH SCHOOL TOOLKIT
SUICIDE PREVENTION: FACTS FOR SCHOOLS
“Every school in our district had a crisis plan if a staff member died of cancer or a student got in a car
accident. But suicide . . . it wasn’t on my agenda,” said a superintendent. “We just did not think it was
going to happen here. Unfortunately we learned the hard way. It was only after we had a [death in our
school community by] suicide that we realized we needed to take a comprehensive approach to preventing
a tragedy like this. And we realized we needed to involve everybody—the school staff, students, parents,
and the community.”
—Superintendent in a New England School District
Many high school students reported that they had seriously considered
suicide in the past year (CDC, 2010a).
Suicide is the third leading cause of death among teenagers (CDC, 2009).
One out of every 53 high school students (1.9 percent) reported having made
a suicide attempt that was serious enough to be treated by a doctor or a nurse
(CDC, 2010a).
The toll among some groups is even higher. For example, the suicide rate among
15–19-year-old American Indian/Alaska Native males is 2½ times higher than the
overall rate for males in that age group (Heron, 2007).
FOUR REASONS WHY SCHOOLS SHOULD ADDRESS SUICIDE
While everyone who cares for and about young people should be concerned with youth suicide, schools
have special reasons for taking action to prevent these tragedies:
1. Maintaining a safe school environment is part of a school’s overall mission. There is an implicit
contract between schools and parents about the safety of their children while they are in the
school’s care. Fortunately, suicide prevention is consistent with many other efforts to protect
student safety.
Many activities designed to prevent violence, bullying, and the abuse of alcohol and other
drugs can also reduce suicide risk among students (Epstein & Spirito, 2009).
Programs that improve school climate and promote connectedness help reduce risk of
suicide, violence, bullying, and substance abuse (Resnick et al., 1997; Blum, McNeely, &
Rinehart, 2002).
Efforts to promote safe schools and adult caring also help protect against suicidal ideation and
suicide attempts among LGB youth (Eisenberg & Resnick, 2006).
Some activities designed to prevent suicide and promote student mental health can reinforce
the benets of other student wellness programs.
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2. Students’ mental health can affect their academic performance. Depression and other mental
health issues can interfere with the ability to learn and affect academic performance. According to
a 2009 survey (CDC, 2010b):
Approximately 1 out of 2 high school students receiving grades of mostly D’s and F’s felt sad
or hopeless. But only 1 out of 5 students receiving mostly As felt sad or hopeless.
1 out of 5 high school students receiving grades of mostly D’s and F’s attempted suicide.
Only 1 out of 25 who received grades of mostly As attempted suicide.
3. A student suicide can signicantly impact other students and the entire school community.
Knowing what to do following a suicide is critical to helping students cope with the loss and
prevent additional tragedies that may occur. Adolescents can be susceptible to suicide contagion
(sometimes called the copycat effect).
4. Schools have been sued for negligence for the following reasons (Doan, Roggenbaum, &
Lazear, 2003; Juhnke, Granello, & Granello, 2011; Lieberman, 2008–2009; Lieberman, Poland,
& Cowan, 2006):
Failure to notify parents if their child appears to be suicidal
Failure to get assistance for a student at risk of suicide
Failure to adequately supervise a student at risk
HOW SCHOOLS CAN HELP PREVENT SUICIDE
Suicide prevention experts recommend using a multifaceted approach in which the following components
are implemented in a particular sequence:
Protocols for helping students at risk of suicide
Protocols for responding to suicide death
Staff education training
Parent education
Student education
Screening
Preventing Suicide: A Toolkit for High Schools contains information about how these components can be
implemented in your school. You can download this toolkit free of charge
from http://store.samhsa.gov/product/SMA12-4669.
If you or someone you know is in a suicidal crisis, call 1-800-273-TALK (8255)—National Suicide
Prevention Lifeline.
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REFERENCES
Blum, R. W., McNeely, C., & Rinehart, P. M. (2002). Improving the odds: The untapped power of schools
to improve the health of teens. Minneapolis: Center for Adolescent Health and Development, University
of Minnesota. Retrieved from http://www.med.umn.edu/peds/ahm/prod/groups/med/@pub/@med/
documents/asset/med_21771.pdf
Centers for Disease Control and Prevention. (2009). Web-based Injury Statistics Query and Report ing
System (WISQARS) [online]. National Center for Injury Prevention and Control. Retrieved from http://
www.cdc.gov/injury/wisqars/index.html
Centers for Disease Control and Prevention. (2010a). Youth risk behavior surveillance—United States,
2009. Surveillance Summaries. Morbidity and Mortality Weekly Report, 59(SS–5). Retrieved from http://
www.cdc.gov/mmwr/pdf/ss/ss5905.pdf
Centers for Disease Control and Prevention. (2010b). Youth risk behavior surveillance—United States,
2009. Retrieved from http://www.cdc.gov/healthyyouth/health_and_academics/pdf/yrbs_slides_violence.ppt
Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth suicide prevention school-based guide—Is sue brief
4: Administrative issues. Tampa, FL: Department of Child and Family Studies, Division of State and
Local Support, Louis de la Parte Florida Mental Health Institute, University of South Florida. (FMHI
Series Publication #218–4).
Eisenberg, M. E., & Resnick, M. D. (2006). Suicidality among gay, lesbian and bisexual youth: The role
of protective factors. Journal of Adolescent Health, 39(5), 662–668.
Epstein, J. A., & Spirito, A. (2009). Risk factors for suicidality among a nationally representative sample
of high school students. Suicide and Life-Threatening Behavior, 39(3), 241–251.
Heron, M. P. (2007). Deaths: Leading causes for 2004. National Vital Statistics Reports, l56(5). Hy-
attsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nvsr/
nvsr56/nvsr56_05.pdf
Juhnke, G. A., Granello, D. H., & Granello, P. F. (2011). Suicide, self-injury, and violence in the schools:
Assessment, prevention, and intervention strategies. Hoboken, NJ: John Wiley & Sons.
Lieberman, R. (2008–2009). Legal lessons: Minimizing risk to districts.
Well Aware: A Suicide Pre vention
Bulletin for Wyoming School Administrators, 1(1), 3.
Lieberman, R., Poland, S., & Cowan, K. (2006, October). Suicide prevention and intervention: Prin cipal
leadership, 11–15. Retrieved from http://www.nasponline.org/resources/principals/Suicide%20
Intervention%20in%20Secondary%20Schoools%20NASSP%20Oct%202006.pdf
Resnick, M. D., Bearman, P. S., Blum, R. W., Bauman, K. E., Harris, K. M., Jones, J.,…Udry, J. R.
(1997). Protecting adolescents from harm. Findings from the National Longitudinal Study on Ado lescent
Health. Journal of the American Medical Association, 278(10), 823–832.
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Tool 1.B: Chart of School Staff Responsibilities
As you work on the steps in the chapters of this toolkit, use the chart on the next page to record the names
of the people who will play a role in planning and implementing each component of your program. Check
the column representing the activities in which they will be involved. Staff with differing areas of
expertise will be required to implement the steps in various chapters. However, this does not mean that
you will have to establish separate groups for each component, as you will probably find that many staff
will be involved in several of the components. The following people may be helpful in planning and
implementing components of your school’s suicide prevention program:
Superintendent
Principal
Assistant principal
Curriculum director
Health educator
School nurse
School health coordinator
Guidance counselor/school counselor
School social worker
Student assistance program staff/pupil services coordinator
Special education staff
Members of the Crisis Response Team
School psychologist
School-based health center and/or mental health center staff
Child study team member(s)
School security ofcer/school resource ofcer
Teachers
Technology staff
Athletic staff
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STAFF
PROGRAM COMPONENT AND RELEVANT CHAPTER
Check the box for the component(s) that each staff person will plan and implement.
Name &
Title
Getting
Started
(Ch.1)
Protocols
for Helping
Students
at Risk of
Suicide
(Ch. 2)
Protocols
for After a
Suicide
(Ch. 3)
Staff
Education
and
Training
(Ch. 4)
Parent/
Guardian
Education
and
Outreach
(Ch. 5)
Student
Programs
(Ch. 6)
Screening
(Ch. 7)
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Tool 1.C: Chart of Community Partners
As you go through the steps in each chapter, use the chart on the next page to fill in the names of individuals
or agencies in the community who can help you plan and implement that component of your program.
Check the column representing the activities in which they will be involved. Some partners will probably be
involved with more than one program component. The following types of community partners may be
helpful in implementing components of your school’s suicide prevention program:
Leaders representing the cultural communities of your students
Mental health providers/community mental health agency staff
Substance abuse counselors
Crisis center workers
Healthcare providers
Community health department staff, including injury and violence prevention and maternal and
child health professionals
Hospital staff, including emergency department staff
EMTs, re and rescue personnel, and rst responders
Police
Clergy
County social services staff
Child welfare providers
Juvenile justice professionals
Coroner
Media representatives
Immigrant and refugee organization staff
LGBT youth–serving program staff
Youth development professionals (e.g., YMCA, Boys and Girls Club, community youth center)
In tribal communities consider including Indian Health Service hospitals, clinics, and primary care
providers, and tribal behavioral health and social service programs.
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ORGANIZATION/
INDIVIDUAL
PROGRAM COMPONENT AND RELEVANT CHAPTER
Check the box for the component(s) that each organization/individual will work on.
Name
Getting
Started
(Ch.1)
Protocols
for Helping
Students
at Risk of
Suicide
(Ch. 2)
Protocols
for After
a Suicide
(Ch. 3)
Staff
Education
and
Training
(Ch. 4)
Parent/
Guardian
Education
and
Outreach
(Ch. 5)
Student
Programs
(Ch. 6)
Screening
(Ch. 7)
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Tool 1.D: Risk and Protective Factors and Warning Signs
Factsheets
This tool will help educate school staff and other partners about the factors that are associated with
suicide risk, the factors that are associated with protection against suicide, and the warning signs of
suicide. This tool has been formatted as three separate handouts.
Risk factors for suicide refer to personal or environmental characteristics that are associated with suicide.
People affected by one or more of these risk factors have a greater probability of suicidal behavior.
Protective factors are personal or environmental characteristics that reduce the probability of suicide.
Protective factors can buffer the effects of risk factors. The capacity to resist the effects of risk factors is
known as resilience.
Warning signs are indications that someone may be in danger of suicide, either immediately or in the
near future.
This handout can be found in the “Handouts” section of this Toolkit, which begins on page 209.
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RISK FACTORS FOR YOUTH SUICIDE
Risk factors for suicide refer to personal or environmental characteristics that are associated with suicide.
The environment includes the social and cultural environment as well as the physical environment. People
affected by one or more of these risk factors may have a greater probability of suicidal behavior. Some
risk factors cannot be changed—such as a previous suicide attempt—but they can be used to help identify
someone who may be vulnerable to suicide.
There is no single, agreed-upon list of risk factors. The list below summarizes the risk factors identified
by the most recent research.
Behavioral Health Issues/Disorders
Depressive disorders
Substance abuse or dependence (alcohol and other drugs)
Conduct/disruptive behavior disorders
Other disorders (e.g., anxiety disorders, personality disorders)
Previous suicide attempts
Self-injury (without intent to die)
Genetic/biological vulnerability (mainly abnormalities in serotonin functioning, which can lead to
some of the behavioral health problems listed above)
Note: The presence of multiple behavioral health disorders (especially the combination of mood and
disruptive behavior problems or substance use) increases suicide risk.
Personal Characteristics
Hopelessness
Low self-esteem
Loneliness
Social alienation and isolation, lack of belonging
Low stress and frustration tolerance
Impulsivity
Risk taking, recklessness
Poor problem-solving or coping skills
Perception of self as very underweight or very overweight
Capacity to self-injure
Perception of being a burden (e.g., to family and friends)
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Adverse/Stressful Life Circumstances
Interpersonal difculties or losses (e.g., breaking up with a girlfriend or boyfriend)
Disciplinary or legal problems
Bullying, either as victim or perpetrator
School or work problems (e.g., actual or perceived difculties in school or work, not attending
school or work, not going to college)
Physical, sexual, and/or psychological abuse
Chronic physical illness or disability
Exposure to suicide of peer
Risky Behaviors
Alcohol or drug use
Delinquency
Aggressive/violent behavior
Risky sexual behavior
Family Characteristics
Family history of suicide or suicidal behavior
Parental mental health problems
Parental divorce
Death of parent or other relative
Problems in parent-child relationship (e.g., feelings of detachment from parents, inability to talk
with family members, interpersonal conicts, family nancial problems, family violence or abuse,
parenting style either underprotective or overprotective and highly critical)
Environmental Factors
Negative social and emotional environment at school, including negative attitudes, beliefs,
feelings, and interactions of staff and students
Lack of acceptance of differences
Expression and acts of hostility
Lack of respect and fair treatment
Lack of respect for the cultures of all students
Limitations in school physical environment, including lack of safety and security
Weapons on campus
Poorly lit areas conducive to bullying and violence
Limited access to mental health care
Access to lethal means, particularly in the home
Exposure to other suicides, leading to suicide contagion
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Exposure to stigma and discrimination against students based on sexual orientation; gender
identity; race and ethnicity; disability; or physical characteristics, such as overweight. Stigma and
discrimination lead to:
» Victimization and bullying by others, lack of support from and rejection by family and peers,
dropping out of school, lack of access to work opportunities and health care
» Internalized homophobia, stress from being different and not accepted, and stress around
disclosure of being gay, which can lead to low self-esteem, social isolation, and decreased
help-seeking
» Stress due to the need to adapt to a different culture, especially reconciling differences
between one’s family and the majority culture, which can lead to family conict and rejection
REFERENCES
Beautrais, A. L. (2003). Life course factors associated with suicidal behaviors in young people. American
Behavioral Scientist, 46(9), 1137.
Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). Adolescent suicide: Assessment and intervention
(2nd ed.). Washington, DC: American Psychological Association.
Campo, J. V. (2009). Youth suicide prevention: Does access to care matter? Current Opinions in
Pediatrics, 21(5), 628–634.
Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth suicide prevention school-based guide—Issue
brief 2: School climate. Tampa, FL: Department of Child and Family Studies, Division of State and Local
Support, Louis de la Parte Florida Mental Health Institute, University of South Florida. (FMHI Series
Publication #218–2)
Eaton, D. K., Lowry, R., Brener, N. D., Galuska, D. A., & Crosby, A. E. (2005). Associations of body
mass index and perceived weight with suicide ideation and suicide attempts among US high school
students. Archives of Pediatrics & Adolescent Medicine, 159(6), 513–519.
Epstein, J. A., & Spirito, A. (2009). Risk factors for suicidality among a nationally representative sample
of high school students. Suicide and Life-Threatening Behavior, 39(3), 241–251.
Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive
interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent
Psychiatry, 42(4), 386–405.
Gutierrez, P. M., & Osman, A. (2008). Adolescent suicide: An integrated approach to the assessment of
risk and protective factors. DeKalb, IL: Northern Illinois University Press.
Joiner, T. E., (2009). Suicide prevention in schools as viewed through the interpersonal-psychological
theory of suicidal behavior. School Psychology Review, 38(2), 244–248.
Lofthouse, N., & Yage-Schweller, J. (2009). Nonsuicidal self-injury and suicide risk among adolescents.
Current Opinions in Pediatrics, 21(5), 641–645.
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PREVENTING SUICIDE: A HIGH SCHOOL TOOLKIT
Martin, G., Richardson, A. S., Bergen, H. A., Roeger, L., & Allison, S. (2005). Perceived academic
performance, self-esteem and locus of control as indicators of need for assessment of adolescent suicide
risk: Implications for teachers. Journal of Adolescence, 28(1), 75–87.
Miller, D. N., & Eckert, T. L. (2009). Youth suicidal behavior: An introduction and overview. School
Psychology Review, 38(2), 153–167.
Suicide Prevention Resource Center. (2008). Suicide risk and prevention for lesbian, gay, bisexual, and
transgender youth. Newton, MA: Education Development Center, Inc. Retrieved from http://www.sprc.
org/library/SPRC_LGBT_Youth.pdf
Swahn, M. H., Reynolds, M. R., Tice, M., Miranda-Pierangeli, M. C., Jones, C. R., & Jones, I. R. (2009).
Perceived overweight, BMI, and risk for suicide attempts: Findings from the 2007 Youth Risk Behavior
Survey. Journal of Adolescent Health, 45(3), 292–295.
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PROTECTIVE FACTORS FOR YOUTH SUICIDE
Protective factors are personal or environmental characteristics that reduce the probability of suicide.
Protective factors can buffer the effects of risk factors. The capacity to cope positively with the effects of
risk factors is called “resilience.” Actions by school staff to enhance protective factors are an essential
element of a suicide prevention effort. Strengthening these factors also protects students from other risks,
including violence, substance abuse, and academic failure.
There is no single, agreed-upon list of protective factors. The list below summarizes the protective factors
identified by the most recent research.
Individual Characteristics and Behaviors
Psychological or emotional well-being, positive mood
Emotional intelligence: the ability to perceive, integrate into thoughts, understand, and manage
one’s emotions
Adaptable temperament
Internal locus of control
Strong problem-solving skills
Coping skills, including conict resolution and nonviolent handling of disputes
Self-esteem
Frequent, vigorous physical activity or participation in sports
Spiritual faith or regular church attendance
Cultural and religious beliefs that afrm life and discourage suicide
Resilience: ongoing or continuing sense of hope in the face of adversity
Frustration tolerance and emotional regulation
Body image, care, and protection
Family and Other Social Support
Family support and connectedness to family, closeness to or strong relationship with parents, and
parental involvement
Close friends or family members, a caring adult, and social support
Parental pro-social norms, that is, youth know that parents disapprove of antisocial behavior such
as beating someone up or drinking alcohol
Family support for school
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School
Positive school experiences
Part of a close school community
Safe environment at school (especially for lesbian, gay, bisexual, and transgender youth)
Adequate or better academic achievement
A sense of connectedness to the school
A respect for the cultures of all students
Mental Health and Healthcare Providers and Caregivers
Access to effective care for mental, physical, and substance abuse disorders
Easy access to care and support through ongoing medical and mental health relationships
Access to Means
Restricted access to rearms: guns locked or unloaded, ammunition stored or locked
Safety barriers for bridges, buildings, and other jumping sites
Restricted access to medications (over-the-counter and prescriptions)
Restricted access to alcohol (since there is an increased risk of suicide by rearms if the victim is
drinking at the time)
REFERENCES
Bearman, P. S., & Moody, J. (2004). Suicide and friendships among American adolescents. American
Journal of Public Health, 94(1), 89–95.
Beautrais, A. L. (2003). Life course factors associated with suicidal behaviors in young people. American
Behavioral Scientist, 46(9), 1137–1156.
Beautrais, A., Gibb, S., Fergusson, D., Horwood, L. J., & Larkin, G. L. (2009). Removing bridge barriers
stimulates suicides: An unfortunate natural experiment. Australian and New Zealand Journal of
Psychiatry, 43(6), 495–497.
Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). Adolescent suicide: Assessment and intervention
(2nd ed.). Washington, DC: American Psychological Association.
Birckmayer, J., & Hemenway, D. (1999). Minimum age drinking laws and youth suicide, 1970–1990.
American Journal of Public Health, 89, 1365–1368.
Borowsky, I. W., Resnick, M. D., Ireland, M., & Blum, R. W. (1999). Suicide attempts among American
Indian and Alaska Native youth: Risk and protective factors. Archives of Pediatrics & Adolescent
Medicine, 153(6), 573–580.
Borowsky, I. W., Ireland, M., & Resnick, M. D. (2001). Adolescent suicide attempts: Risks and protectors.
Pediatrics, 31, 489–493.
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Brent, D. A., Perper, J. A., & Allman, D. J. (1987). Alcohol, firearms, and suicide among youth: Temporal
trends in Allegheny County, Pennsylvania, 1960 to1983. Journal of the American Medical Association,
257(24), 3369–3372.
Cha, C., & Nock, M. (2009). Emotional intelligence is a protective factor for suicidal behavior. Journal of
the American Academy of Child & Adolescent Psychiatry. 48(4), 422–430.
Centers for Disease Control and Prevention (CDC). (2009). School connectedness: Strategies for
increasing protective factors among youth. Atlanta, GA: U.S. Department of Health and Human Services.
Colucci, E., & Martin, G. (2008). Religion and spirituality along the suicidal path. Suicide and Life-
Threatening Behavior, 38 (2), 229–244.
Education Development Center, Inc. (Revised 2008). Assessing and managing suicide risk: Core
competencies for mental health professionals. Newton, MA: Suicide Prevention Resource Center,
Education Development Center, Inc. in collaboration with American Association of Suicidology.
Eisenberg, M. E., & Resnick, M. D. (2006). Suicidality among gay, lesbian and bisexual youth: The role
of protective factors. Journal of Adolescent Health, 39(5), 662–668.
Flouri, E., & Buchanan, A. (2002). The protective role of parental involvement in adolescent suicide.
Crisis, 23, 1–17.
Goldsmith, S. K. (2001). Risk factors for suicide: Summary of a workshop. Washington DC: National
Academy Press. National Academy of Sciences. Retrieved from http://books.nap.edu/openbook.
php?record_id=10215&page=18
Grossman, D. C., Mueller, B. A., Riedy, D., Dowd, D. M., Villaveces, A., Prodzinski, J., Harruff, R.
(2005). Gun storage practices and risk of youth suicide and unintentional firearm injuries. Journal of the
American Medical Association, 293(6), 707–714.
Gutierrez, P. M., & Osman, A. (2008). Adolescent suicide: An integrated approach to the assessment of
risk and protective factors. DeKalb, IL: Northern Illinois University Press.
Hall-Lande, J. A., Eisenberg, M. E., Christenson, S. L., & Neumark-Sztainer, D. (2007). Social isolation,
psychological health, and protective factors in adolescence. Adolescence, 42, 265–286.
Hawton, K., Simkin, S., Deeks, J., Cooper, J., Johnston, A., Waters K., Simpson, K. (2004). United
Kingdom legislation on analgesic packs: Before and after study of long term effect on poisonings. British
Medical Journal, 329(7474), 1076.
Kidd, S., Henrich, C. C., Brookmeyer, K. A., Davidson, L., King, R. A., & Shahar, G. (2006). The social
context of adolescent suicide attempts: Interactive effects of parent, peer, and school social relations.
Suicide and Life-Threatening Behavior, 36(4), 386–395.
King, C., & Merchant, C. R. (2008). Social and interpersonal factors relating to adolescent suicidality: A
review of the literature. Archives of Suicide Research, 12(3), 181–196.
Pettingell, S. L., Bearinger, L. H., Skay, C. L., Resnick, M. D., Potthoff, S. J., & Eichhorn, J. (2008).
Protecting urban American Indian young people from suicide. American Journal of Health Behavior,
32(5), 465–476.
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Randell, B. P., Wang, W., Herting, J. R., & Eggert, L. L. (2006). Family factors predicting categories of
suicide risk. Journal of Child and Family Studies, 15(3), 255–270.
Sharaf, A. Y., Thompson, E. A., & Walsh, E. (2009). Protective effects of self-esteem and family support
on suicide risk behaviors among at-risk adolescents. Journal of Child and Adolescent Psychiatric
Nursing, 22(3), 160–168.
Taliaferro, L. A., Rienzo, B. A., Miller, M. D., Pigg, R. M., & Dodd, V. J. (2008). High school youth and
suicide risk: Exploring protection afforded through physical activity and sport participation. Journal of
School Health, 78(10), 545–553.
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RECOGNIZING AND RESPONDING TO WARNING SIGNS
FOR SUICIDE
Warning signs are indications that someone may be in danger of suicide, either immediately or in the
near future.
Warning Signs for Suicide Prevention is a consensus statement developed by an expert working group
brought together by the American Association of Suicidology. The group organized the warning signs by
degree of risk, and emphasized the importance of including clear and specific direction about what to do
if someone exhibits warning signs.
This consensus statement describes the general warning signs of suicide. Warning signs differ by age
group, culture, and even individual.
The recent advent of social media has provided another outlet in which warning signs may be exhibited. The
differences in how and where warning signs may be exhibited demonstrate the importance of adapting
gatekeeper training for the age group and cultural communities with whom the gatekeepers will be interacting.
Warning Signs for Suicide and Corresponding Actions
Seek immediate help from a mental health provider, 9-1-1 or your local emergency provider, or the National
Suicide Prevention Lifeline at 1-800-273-TALK (8255) when you hear or see any one of these behaviors:
Someone threatening to hurt or kill themselves
Someone looking for ways to kill themselves: seeking access to pills, weapons, or other means
Someone talking or writing about death, dying, or suicide, when these actions are out of the
ordinary for the person
Seek help by contacting a mental health professional or calling 1-800-273-TALK for a referral if you
witness, hear, or see anyone exhibiting one or more of these behaviors:
Hopelessness—expresses no reason for living, no sense of purpose in life
Rage, anger, seeking revenge
Recklessness or risky behavior, seemingly without thinking
Expressions of feeling trapped—like there’s no way out
Increased alcohol or drug use
Withdrawal from friends, family, or society
Anxiety, agitation, inability to sleep, or constant sleep
Dramatic mood changes
No reason for living, no sense of purpose in life
If you or someone you know is in a suicidal crisis, call 1-800-273-TALK (8255)—National
Suicide Prevention Lifeline.
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REFERENCE
Rudd, M. D., Berman, A. L., Joiner, T. E. Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., . . . Witte,
T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-
Threatening Behavior, 36(3), 255–262. Retrieved from http://www.wjh.harvard.edu/~nock/nocklab/
Rudd%20et%20al_warning%20signs%20for%20suicide_2006.pdf
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Tool 1.E: Data on Youth Suicide
Suicide Deaths among Young People (CDC, 2009)
In 2009, the most recent year for which data are available, 1,852 young people between the ages of 13 to
19 years died by suicide in the United States. Approximately 78 percent of the fatalities were male and 22
percent were female.
During 2009, an additional 2,702 young people between the ages of 20 and 24 years died by suicide.
About 84 percent of these fatalities were young men and 16.0 percent were young women. It is possible
that many of these deaths could have been prevented if the young people had been identified as being at
risk and had received mental health services while they were in high school.
The rates of suicide deaths among 13–24 year olds are as follows:
American Indian/Alaska Native: 22.11 per 100,000
White: 9.47 per 100,000
Asian/Pacic Islander: 6.32 per 100,000
Hispanic: 6.46 per 100,000
Black: 5.74 per 100,000
In 2009, suicide was the third leading cause of death for people of both sexes and all races 13–19 years of
age. The first and second leading causes of death were unintentional injuries and homicides, respectively.
Suicide Attempts among Young People (CDC, 2010)
Suicide deaths represent only a fraction of the toll that suicidal behavior takes among America’s youth. Data
from the 2009 Youth Risk Behavior Survey (YRBS)* revealed that in the 12 months preceding the survey:
1 out of every 53 high school students (1.9 percent) reported having made a suicide attempt that
was serious enough to be treated by a doctor or a nurse. This included 1 out of every 43 (2.3
percent) female students and 1 out of every 62 (1.6 percent) male students.
The YRBS also revealed the following:
1 out of every 16 high school students (6.3 percent) reported having attempted suicide at least
once. This included 1 out of every 22 male students (4.6 percent) and 1 out of every 12 female
students (8.1 percent).
1 out of every 9 students (10.9 percent) had made a plan about how he or she would attempt
suicide.
1 out of every 7 students (13.8 percent) reported having seriously considered attempting suicide
during the preceding 12 months.
*The YRBS is a national survey of students in grades 9–12. It uses self-reports to monitor six categories
of behaviors, including those that contribute to unintentional injuries, violence, and suicide.
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Suicide Methods (CDC, 2009)
These data are from 2009, the latest year for which data are available.
The leading methods (means) by which young people ages 13–19 took their own lives were:
Suffocation, including hanging (45.2 percent of suicide deaths)
Firearms (42.7 percent)
Poisoning, including carbon monoxide (5.8 percent)
All other means (6.3 percent)
The leading methods among males of this age were:
Firearms (48.5 percent of suicide deaths)
Suffocation, including hanging (40.9 percent)
Poisoning, including carbon monoxide (4.3 percent)
All other means (6.2 percent)
The leading methods among females of this age were:
Suffocation, including hanging (60.3 percent of suicide deaths)
Firearms (22.1 percent)
Poisoning, including carbon monoxide (11.3 percent)
All other means (6.4 percent)
REFERENCES
Centers for Disease Control and Prevention (CDC). (2009). Web-based injury statistics query and
reporting system (WISQARS) [online]. National Center for Injury Prevention and Control. Retrieved
from http://www.cdc.gov/injury/wisqars/index.html
Centers for Disease Control and Prevention (CDC). (2010). Youth risk behavior surveillance—United
States, 2009. Surveillance Summaries. MMWR, 59(SS-5). Retrieved from http://www.cdc.gov/mmwr/
pdf/ss/ss5905.pdf
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Tool 1.F: Suicide and Substance Abuse Information Sheet
Substance abuse is a major risk factor for suicidal behavior among young people (Goldsmith, Pellmar,
Kleinman, & Bunney, 2002; U.S. Department of Health and Human Services, n.d.). The National Household
Survey of Drug Abuse found that young people ages 12–17 who used alcohol or illegal drugs were more
likely to be at risk for suicide than young people who did not use alcohol or drugs (SAMHSA, 2002).
19.6 percent of young people who reported using alcohol were found to be at risk of suicide. Only
8.6 percent of young people who did not report using alcohol were at risk.
25.4 percent of young people who reported using illicit drugs were found to be at risk of suicide.
Only 9.2 percent of young people who did not report using drugs were at risk.
29.4 percent of young people who reported using an illicit drug other than marijuana were found
to be at risk of suicide. Only 10.1 percent of those who did not report using a drug other than
marijuana were at risk.
Substance abuse, suicidality, and depression can share symptoms and risk factors, and often co-occur
(Dunn, Goodrow, Givens, & Austin, 2008; Esposito-Smythers and Goldston, 2008). The use of alcohol
and other drugs by adolescents can be an attempt to self-medicate, that is, to ease the pain and suffering
associated with depression, family dysfunction, and other problems, many of which are also associated
with suicide risk. However, a review of data on suicides by people of all ages led researchers to conclude
that “the use of alcohol or other drugs might contribute substantially to suicides overall” (CDC, 2006).
Others have come to similar conclusions, speculating that alcohol and drugs promote suicide by
diminishing critical thinking skills and inhibitions (Makhija and Sher, 2007; Esposito-Smythers and
Spirito, 2004). The effect on inhibition may also play a role in the choice of the lethality of the means of
suicide. Young people who die by suicide are more likely to have used alcohol or drugs prior to their
suicidal act than are young people who attempted suicide but did not die (DeJong et al., 2010). It is also
important to understand that almost 96 percent of drug-related suicide attempts by adolescents ages 12–17
who are seen in emergency departments involved prescription drugs (SAMSHA, 2010).
Implications for Prevention
Substance abuse and suicidality can be addressed with common strategies including (1) identifying
students suffering from suicidality, substance abuse, or depression and ensuring that they receive help and
(2) enhancing overarching protective factors, such as connectedness, which can also improve the school
environment and enhance academic achievement. It is also important to educate school staff, students, and
parents about the role of alcohol and drugs—including prescription drugs—in adolescent suicide, as well
as the relationship among substance abuse, suicide, and depression.
REFERENCES
Centers for Disease Control and Prevention (CDC). (2006). Editorial note. Morbidity and Mortality
Weekly Report, 55, 1247–1248.
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DeJong, T., Overholser, J., & Stockmeier, C. (2010). Apples to oranges?: A direct comparison between
suicide attempters and suicide completers. Journal of Affective Disorders, 124(1–2), 90–97.
Dunn, M., Goodrow, B., Givens, C., & Austin, S. (2008). Substance use behavior and suicide indicators
among rural middle school students. Journal of School Health, 78(1), 26–31.
Esposito-Smythers, C., & Goldston, D. (2008). Challenges and opportunities in the treatment of
adolescents with substance use disorder and suicidal behavior. Substance Abuse, 29(2), 5–17.
Esposito-Smythers, C., & Spirito, A. (2004). Adolescent substance use and suicidal behavior: A review
with implications for treatment research. Alcoholism Clinical and Experimental Research, 28, 77S–88S.
Goldsmith, S., Pellmar, T., Kleinman, A., & Bunney, W. (Eds.). (2002). Reducing suicide: A national
imperative. Washington, DC: National Academies Press.
Makhija, N., & Sher, L. (2007). Preventing suicide in adolescents with alcohol use disorders.
International Journal of Adolescent Medicine and Health, 19(1), 53–59.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2002).
Substance use and the risk of suicide among youths. The NSDUH Report. Retrieved from:
http://www.oas.samhsa.gov/2k2/suicide/suicide.htm
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2010). The
DAWN report: Emergency department visits for drug-related suicide attempts by adolescents: 2008.
Rockville, MD. Retrieved from:http://www.oas.samhsa.gov/2k10/DAWN001/SuicideAttemptsHTML.pdf
U.S. Department of Health and Human Services (DHHS). (n.d.). HHS frequent questions: Does alcohol
and other drug abuse increase the risk for suicide? HHS.gov. Retrieved from http://answers.hhs.gov/
questions/3176
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Tool 1.G: Suicide and Bullying Information Sheet
Bullying is the ongoing physical or emotional victimization of a person by another person or group of
people. Cyberbullying is an emerging problem in which people use new communication technologies,
such as social media and texting, to harass and cause emotional harm to their victims.
Thirty-two percent of the Nation’s students (ages 12–18) reported being bullied during the 2007–2008
school year (Dinkes, Kemp, & Baum, 2009). Lesbian, gay, bisexual, and transgender (LGBT) youth
experience more bullying (including physical violence and injury) at school than their heterosexual peers
(Garofalo, Wolf, & Kessel, 1998; Bontempo & D’Augelli, 2002; Berlan, Corliss, Field, Goodman, &
Austin, 2010).
Both victims and perpetrators of bullying are at higher risk of suicide than their peers. Children who are
both victims and perpetrators of bullying are at highest risk (Kim and Leventhal, 2008; Hay and
Meldrum, 2010; Kaminski and Fang, 2009).
Young people who are the victims of bullying are at increased risk for suicide (Kim, Leventhal, Koh, &
Boyce, 2009) as well as increased risk for depression and other problems associated with suicide (Gini
and Pozzoli, 2009; Fekkes, Pipers, and Verloove-Vanhorcik, 2004).
Many children who are bullied have personal characteristics that increase their risk of victimization
(Arseneault, Bowes, & Shakoor, 2010). These characteristics include:
Internalizing problems (including withdrawal, anxiety, and depression)
Low self-esteem
Low assertiveness
Aggressiveness in early childhood (which can lead to rejection by peers and social isolation)
Many of these characteristics are also risk factors for suicidal behavior and ideation. The authors of the
study cited above suggest that the same personal risk factors that can contribute to a child’s risk of
suicidal behavior can also increase the child’s risk of being bullied. Being bullied further heightens the
child’s risk for suicide (as well as for anxiety, depression, and other problems associated with suicidal
behavior). These personal risk factors do not cause bullying, but they act in combination with other risk
factors associated with:
The family, including child maltreatment, domestic violence, and parental depression (Arseneault,
Bowes, & Shakoor, 2010)
The school environment, including a lack of adequate adult supervision (which can be a result of
the physical layout of a school), a school climate characterized by conict, a lack of consistent
and effective discipline (Swearer, Espelage, Vaillancourt, & Hymel, 2010), and school size
(Bowes, Arseneault, Maughan, Taylor, Caspi, & Moftt, 2009)
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The effects of bullying (especially chronic bullying) on suicidal behavior and mental health are long term
and may persist into adulthood (Arseneault, Bowes, and Shakoor, 2010).
Implications for Prevention
Although there is little research on this issue, it would seem that the three areas in which prevention
strategies could affect both bullying and suicide are 1) the school environment, 2) family outreach, and
3) identifying and providing appropriate services to students with personal characteristics that increase
their risk of being bullied, bullying others, or suicidal behavior. At the same time, attempts to find and
use overarching prevention strategies should not ignore the need for interventions that specifically
target each problem.
For additional information and resources, see the following:
StopBullying.gov at http://www.stopbullying.gov/
Stop Bullying Now at http://www.ask.hrsa.gov/results_materials.cfm?type=stopbully
REFERENCES
Arseneault, L., Bowes, L., & Shakoor, S. (2010). Bullying victimization in youths and mental health
problems: ‘Much ado about nothing’? Psychological Medicine, 40, 717-729.
Berlan, E., Corliss, H., Field, A., Goodman, E., & Austin, S. (2010). Sexual orientation and bullying
among adolescents in the Growing Up Today Study. Journal of Adolescent Health, 46(4), 366–71.
Bontempo, D., & D’Augelli, A. (2002). Effects of at-school victimization and sexual orientation on
lesbian, gay, or bisexual youths’ health risk behavior. Journal of Adolescent Health, 30, 364–374.
Bowes, L., Arseneault, L., Maughan, B., Taylor, A., Caspi, A., & Moffitt, T., (2009). School,
neighborhood, and family factors associated with children’s bullying involvement: A nationally
representative longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry,
48(5), 545-553.
Dinkes, R., Kemp, J., & Baum, K. (2009). Indicators of School Crime and Safety: 2009 (NCES 2010–
012/NCJ 228478). National Center for Education Statistics, Institute of Education Sciences, U.S.
Department of Education, and Bureau of Justice Statistics, Office of Justice Programs, U.S. Department
of Justice. Washington, DC.
Fekkes, M., Pipers, F., & Verloove-Vanhorick, V. (2004). Bullying behavior and associations with
psychosomatic complaints and depression in victims. Journal of Pediatrics, 144, 17–22.
Garofalo, R., Wolf, R., Kessel, S., Palfrey S. J., & DuRant, R.H. (1998). The association between health
risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics, 101(5),
895–902.
Gini, G., & Pozzoli, T. (2009). Association between bullying and psychosomatic problems: A meta-
analysis. Pediatrics, 123(3), 1059–1065.
Hay, C., & Meldrum, R. (2010). Bullying victimization and adolescent self-harm: Testing hypotheses
from general strain theory. Journal of Youth and Adolescence, 39, 466–459.
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Kaminski, J., & Fang, X. (2009). Victimization by peers and adolescent suicide in three US samples.
Journal of Pediatrics, 155(5), 683–8.
Kim, Y., & Leventhal, B. (2008). Bullying and suicide: A review. International Journal of Adolescent
Medicine and Health, 20(2), 133–54.
Kim, Y., Leventhal, B., Koh, Y., & Boyce, W. (2009). Bullying increased suicide risk: Prospective study
of Korean adolescents. Archives of Suicide Research, 13, 15–30.
Swearer, S., Espelage, D., Vailancourt, T., & Shelley, H. (2010). What can be done about school bullying?
Linking research to educational practice. Educational Researcher, 39(1), 38–47.
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Tool 1.H: The Implications of Culture on Suicide Prevention
Information Sheet
Understanding the cultural context of suicidal behavior is essential for effective prevention. The American
Psychological Association defines culture as “belief systems and value orientations that influence
customs, norms, practices, and social institutions” of a group (APA, 2002). Culture profoundly influences
how people think about suicide, death, and mental illness; how they display emotions or distress; and how
they ask for or accept help. Additionally, culture is complex. The cultures of groups sharing common
histories and/or heritages are not adequately described by categories such as “Hispanic,” “American
Indian/Alaska Native,” “disabled,” “rural,” “southern,” or “LGBT.” Nor is culture static: Cultures change
over time.
Creating an effective suicide prevention program requires understanding the cultures of your students and
their families. Gaining this understanding entails working with students, families, community leaders, and
“cultural mediators” or “cultural brokers.” They can provide insight into how you can design and
implement culturally competent suicide prevention activities.
This information sheet draws upon one of the few comprehensive reviews of the research on the impact of
culture on suicide and suicide prevention (Goldston, et al., 2008) to provide guidance on how you can
work to ensure your suicide prevention activities will be appropriate and effective for the cultural context
in which they will take place.
Goldston’s review of the literature pointed out the impact of culture upon the following:
Risk and protective factors. For example, family support may be a strong protective factor in
immigrant families. But such protection can weaken as families become “Americanized” and
young people grow more independent.
The precipitants of suicidal behavior. Culture inuences how young people respond to events
that escalate risk and trigger suicide attempts. In cultures in which peer inuence is strong, for
example, the suicide of a friend or schoolmate may provoke a “copycat” suicide. This may not
happen in cultures where family inuence is stronger than peer inuence. In those cultures, a
suicide attempt might be triggered if a vulnerable young person fails to meet family expectations
in academic achievement.
The understanding and expression of the warning signs of suicide. Culture inuences how
people display (or refrain from displaying) emotional distress. Some cultures may promote a
stoicism that makes seeing warning signs difcult. Young people from other cultures may be
reluctant to talk about their problems; rather they express them through behavior or demeanor.
Help-seeking behaviors. Culture plays a large role in determining who (if anyone) young
people turn to for emotional support. Young people from some cultures may prefer to consult
family members or religious leaders rather than mental health professionals or other “outsiders.”
Other cultures may value self-reliance and regard any help-seeking (even within the family) as
a weakness.
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Trust. Young people and families from groups with histories of victimization, oppression,
sectarian violence, or other forms of trauma may fear people who represent authority (including
school and mental health personnel) or are from cultural groups other than their own.
Recommendations for ensuring that suicide prevention activities effectively respond to the cultures of
your student population include the following:
Actively show an understanding of and respect for the cultures of students and their families.
Create culturally sensitive services that build on a culture’s strengths and protective factors.
Engage families as active participants in guaranteeing a young person’s safety as well as in the
therapeutic process.
Respect and build upon the religious and spiritual heritage of students. Some families may
seek the permission of spiritual or traditional leaders before they turn to mental health service
providers or may want to offer both types of support to their children.
Tailor prevention programs, especially gatekeeper programs and assessment services, to how
cultures display—or conceal—distress.
Be sensitive to stigma around issues of suicide, help-seeking, and mental health services. It may
be useful to offer services in settings not associated with mental health treatment.
Creating culturally competent suicide prevention activities is inherently collaborative. It requires the input
of school staff, students, families, mental health service providers, and others. What staff and mental
health providers learn about the culture of students and families, and what students and families learn
about suicide and mental health, may challenge their beliefs. But working together to bring the insights of
both science and culture to bear upon suicide is the key to providing culturally competent and
effective prevention.
REFERENCES
American Psychological Association (APA). (2002). Guidelines on multicultural education, training,
research, practice, and organizational change for psychologists. Washington, DC: Author.
Goldston, D., Molock, S., Whitbeck, L., Murakami, J., Zayas, L., & Hall, G. (2008). Cultural
considerations in adolescent suicide prevention and psychosocial treatment. American Psychologist,
63(1), 14–31.
For additional information on cultural competence, please see:
Substance Abuse and Mental Health Services Administration. (2009). Culture Card: A guide to build
cultural awareness: American Indian and Alaska Native (DHHS Publication No. SMA-08-4354).
Rockville, MD: Author. Available at http://store.samhsa.gov/product/American-Indian-and-Alaska-
Native-Culture-Card/SMA08-4354
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Tool 1.I: Checklist of Suicide Prevention Activities
Suicide Prevention Activities Yes No
Not
Sure
If no or not sure
Protocols for helping students at risk of
suicide
We have a written protocol for helping students
who may be at risk of suicide that is consistent
with the guidelines in Chapter 2 of this toolkit.
Review and implement
steps in Chapter 2
We have a written protocol for responding to
students who attempt suicide at school that is
consistent with the guidelines in Chapter 2 of this
toolkit.
Review and implement
steps in Chapter 2
We have established agreements with outside
providers to provide effective and timely mental
health services to our students.
Review and implement
steps in Chapter 2
Protocols for after a suicide
We have a written protocol for responding to the
suicide of a student or other member of the school
community that is consistent with the guidelines in
Chapter 3 of this toolkit.
Review and implement
steps in Chapter 3
Staff who will implement the suicide response
protocol are familiar with this protocol and the tools
that will help them fulll their responsibilities.
Review and implement
steps in Chapter 3
We have identied community partners to help us
in the event of a suicide.
Review and implement
steps in Chapter 3
Staff education and training
All professional and support staff have received
information about the importance of school-based
suicide prevention efforts, as described in Chapter
4 of this toolkit.
Review and implement
steps in Chapter 4
All professional and support staff have been
trained to recognize and respond appropriately
to students who may be at risk of suicide, as
described in Chapter 4 of this toolkit.
Review and consider
implementing steps in
Chapter 4
Our school has staff who have been trained to
assess, refer, and follow up with students identied
as at risk of suicide, as described in Chapter 4 of
this toolkit.
Review and consider
implementing steps in
Chapter 4
Parent/guardian education and outreach
We educate the parents of our students about
suicide and related mental health issues, as
described in Chapter 5 of this toolkit.
Review and consider
implementing steps in
Chapter 5
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Suicide Prevention Activities Yes No
Not
Sure
If no or not sure
We have a sufcient level of participation in our
programs to educate parents about suicide.
Review and consider
implementing steps in
Chapter 5
Student education
We have implemented at least one type of
program to engage students in suicide prevention.
Review and consider
implementing steps in
Chapter 6
Suicide prevention is integrated into other student
health/mental health courses and initiatives.
Review and consider
implementing steps in
Chapter 6
Screening
We have implemented a suicide screening
program, as described in Chapter 7 of this toolkit.
Review and consider
implementing steps in
Chapter 7
We have the support of parents, school staff, and
community mental health providers for our suicide
screening program.
Review and consider
implementing steps in
Chapter 7
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Tool 1.J: Matrix of School-Based Suicide Prevention Programs
This matrix lists all of the school-based suicide prevention programs that are in either the National
Registry of Evidence-Based Prevention Practices (NREPP) or the Best Practices Registry (BPR) as of
October 2010. The criteria for NREPP and BPR are different. See Tool 1.K: Suicide Prevention Registries
Information Sheet.
The matrix also indicates the primary and secondary components of each program. The primary
component of the program is the one around which the program is built. In most cases, the primary
component is education and training for staff or students. Secondary components are included in some of
the programs to strengthen the primary component and/or to create a more comprehensive program. For
each of the types of components listed, there is a separate chapter in this toolkit.
SCHOOL-BASED SUICIDE PREVENTION PROGRAMS
Program Primary Component Secondary Components
Programs in NREPP
American Indian Life Skills Development/
Zuni Life Skills Development
Student Program
Coping and Support Training (CAST) Student Program
Lifelines Student Program – Protocols
– Staff Education and Training
– Parent Education
Reconnecting Youth Student Program
SOS Signs of Suicide Student Program – Screening
– Staff Education and Training
– Parent Education
TeenScreen Schools and Communities Screening
Programs in BPR
Applied Suicide Intervention Skills
Training (ASIST)
Staff Education and Training
Ask 4 Help! Suicide Prevention for Youth Student Program
Assessing and Managing Suicide Risk
(AMSR)
Staff Education and Training
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Program Primary Component Secondary Components
Be A Link! Suicide Prevention
Gatekeeper Training
Staff Education and Training
Gatekeeper Suicide Prevention
Program: A High School Curriculum
Student Program – Staff Education and Training
– Parent Education
Healthy Education for Life Student Program
Helping Every Living Person (HELP)
Depression and Suicide Prevention
Curriculum
Student Program
LEADS for Youth: Linking Education
and Awareness of Depression and
Suicide
Student Program – Protocols
Making Educators Partners in Youth
Suicide Prevention
Staff Education and Training
More Than Sad: Suicide Prevention
Education for Teachers and Other
School Personnel
Staff Education and Training
Question, Persuade, Refer (QPR)
Gatekeeper Training
Staff Education and Training
QPRT Suicide Risk Assessment and
Risk Management Training Program
Staff Education and Training
Recognizing and Responding to
Suicide Risk (RRSR)
Staff Education and Training
RESPONSE: A Comprehensive High
School-Based Suicide Awareness
Program
Student Program – Protocols
– Staff Education and Training
– Parent Education
School Suicide Prevention
Accreditation Program
Staff Education and Training
Sources of Strength Student Program
Suicide Alertness for Everyone
(safeTALK)
Staff Education and Training
Youth Suicide Prevention School-
Based Guide Checklists
Protocols
Youth Suicide Prevention, Intervention,
and Postvention Guidelines: A
Resource for School Personnel
Protocols
For additional information on the programs in this matrix, see the “Resources” section at the end of the toolkit.
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Tool 1.K: Suicide Prevention Registries Information Sheet
Many of the chapters in this toolkit contain a matrix with information on school-based suicide prevention
programs that have been developed by experts in the field. All of these programs are included in either the
National Registry of Evidence-Based Programs and Practices (NREPP) or the Best Practices
Registry (BPR).
SAMHSAs National Registry of Evidence-based Programs and Practices (NREPP) rates programs whose
developers have published research demonstrating that the program has achieved one or more positive
behavioral outcomes. NREPP rates these programs on both of the following criteria:
1. The quality of the research demonstrating that the programs result in positive outcomes
2. The availability and quality of materials to help people use the program (e.g., training materials)
The Suicide Prevention Resource Centers Best Practices Registry (BPR) includes programs and practices
that meet standards set by experts in suicide prevention.
Both of these registries are periodically updated. Check the Web sites for the most current listings.
NREPP (Section I: Evidence-Based
Programs): http://www.sprc.org/bpr/section-i-evidence-based-programs
BPR (Section III: Adherence to
Standards): http://www.sprc.org/bpr/section-iii-adherence-standards
There may be effective programs and practices that are not included in NREPP or BPR because:
The programs’ developers have not submitted their programs to either registry
The programs are still being rated
In the case of NREPP, developers are completing their evaluation research
CHAPTER 2
Protocols for Helping
Students at Risk of Suicide
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PROTOCOLS
FOR HELPING
STUDENTS
AT RISK
FOR SUICIDE
The steps in Chapter 2 will answer these questions:
Who should develop protocols to meet the needs of students at risk of suicide?
What outside sources of help will you need?
What are essential steps in a protocol to help students who have been identied as
possibly at risk of suicide?
What are essential steps in a protocol to respond to a suicide attempt on campus?
How can you prepare for a student’s return to school after a suicide attempt?
How can you educate your staff about these protocols?
WHY IS IT IMPORTANT TO BE PREPARED TO HELP STUDENTS AT RISK OF
SUICIDE?
Many high school students reported that they had seriously considered suicide in the past
year, and 1 out of 53 will make an attempt serious enough to require medical attention
(CDC, 2010a). Helping these young people lower their suicide risk is essential if schools
are going to:
Maintain a safe and secure school environment
Promote the behavioral health of students, which enhances their
academic performance
Avoid liability related to suicides or suicide attempts by students
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How schools can identify young people who may be at risk of suicide (or suffering from
related problems, including substance abuse, depression, or bullying) will be discussed
elsewhere in this toolkit. But before a school implements activities to identify students at
risk of suicide, it must be prepared to:
Help students at risk for suicide preserve their safety and access behavioral
health services
Respond to the infrequent event in which a student tries to take his or her own
life in the school or on the campus
Plan for the return of students after an absence related to suicide risk (including
a suicide attempt or a hospitalization for the treatment of a mental health issue
related to suicide risk)
Notifying Parents/Guardians
Parents or guardians of a young person identified as being at risk of suicide should be
notified by the school and must be involved in consequent actions. Schools should comply
with local, State, and Federal policies and laws regarding parental notification. If the school
suspects the student’s risk status is the result of abuse or neglect, school staff must notify the
appropriate authorities.
STEPS TO DEVELOP PROTOCOLS TO HELP STUDENTS AT RISK OF
SUICIDE
Step 1: Convene a group to create protocols for helping students at risk of
suicide.
This group should include staff that would normally be involved in the care of at-risk
students, including your school’s mental health professionals: counselors, social workers,
and school psychologists. The group should also include administrators, resource officers,
teachers, and a member of the school Crisis Response Team. Tribal communities should
include the Tribal Behavioral Health and Tribal Court representatives for children and
families. If your school already has a process for identifying students at risk of suicide,
you should include staff familiar with that process.
Tool 1.B: Chart of School Staff Responsibilities (see Chapter 1) will help you identify
and record the names of members of the school staff who should be involved in
this effort.
Step 2: Identify the suicide risk response coordinator.
Subsequent chapters in this guide will describe programs that schools can implement to
increase the likelihood that students, staff members, and parents will be able to identify a
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student at risk for suicide. Everyone in the school should know that he or she must take
suicidal behavior seriously and should know to whom to turn if he or she has a concern.
Your planning group should take the following steps:
Clearly designate at least one individual and one alternate who will serve as the
points of contact for anyone in the building who is concerned that a student may
be at risk. In this guide, the term “suicide risk response coordinator” refers to this
point of contact.
Make sure all staff know who the suicide risk response coordinator and the
alternate are. Keep the list of contacts updated.
Let all members of the school community know that anyone who has a concern
should take immediate action to inform the school administrator, who will locate
the suicide risk response coordinator or alternate. Also, let everyone know
that a staff person should stay with the student until the suicide risk response
coordinator arrives.
Step 3: Identify and involve mental health service providers to whom
students can be referred.
Many schools cannot directly provide appropriate mental health services for students at
risk of suicide. It is important for these schools to identify mental health service providers
to whom students can be referred and to involve these service providers while developing
these protocols. These service providers may include:
Hospitals, especially emergency departments and psychiatric units
Psychiatric hospitals
Community mental health centers
Individual mental health service providers, including psychiatrists, psychologists,
and social workers in both the public and private sectors
Primary care providers
Spiritual leaders or traditional healers to which members of some cultures may
turn when confronted with behavioral health issues
In tribal communities, the hospitals, community mental health centers, and primary care
providers may be part of the Indian Health Service (IHS). In this toolkit the general terms
“hospitals,” “community mental health centers,” and “primary care providers,” should be
understood to include IHS services and Tribal Behavioral Health and Social
Service programs.
Tool 1.C: Chart of Community Partners (see Chapter 1) can help you identify and record
names of mental health service providers.
Tool 2.A: Questions for Mental Health Providers includes questions you can ask to
determine if a provider can meet the needs of students at risk of suicide.
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Step 4: Develop a protocol to help students at risk for suicide.
It is critical to have a protocol in place for helping students who have been identified as
being at potential risk of suicide, as described in Step 2. All staff should be aware of the
protocol and follow it when appropriate.
The protocol should include provisions for:
Assessing suicide risk
Notifying parents
Referring to a mental health service provider
Documenting the process
Tool 2.B: Protocol for Helping a Student at Risk of Suicide is a worksheet that you can
use to create a protocol with the four steps listed above.
Tools 2.B.1—2.B.6 are additional tools to help you take these steps. In each of the steps,
consider the cultural backgrounds of the students to ensure their needs are met in an
effective and appropriate way.
Assessing suicide risk.
School staff should make sure that all students who are identified potentially at risk for
suicide are subsequently assessed for suicide risk. Suicide risk assessment is the process
of determining an individual’s level of risk, i.e., low, medium, or high. Such an
assessment is critical to developing an individualized plan for ensuring the safety of the
student and providing support and treatment. It should only be done by mental health
professionals who have been trained to assess risk using a scientifically validated process.
There are several ways that school staff can ensure that students at risk for suicide are
appropriately assessed:
School mental health staff who have been trained in suicide risk assessment can
conduct the assessment.
The student can be referred to a mental health provider who has been trained in
suicide assessment.
The school can contact a mental health provider or the National Lifeline to
identify a local provider who can conduct a suicide risk assessment.
Tool 2.B.1: Suicide Risk Assessment Resources lists several suicide assessment trainings
you can offer to your mental health staff and some of the assessment tools used by trained
providers.
Tool 2.B.2: Self-Injury and Suicide Risk Information Sheet provides some background
information and additional resources on the problem of self-injury and its relationship to
suicidal behavior.
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Notifying parents.
Parents or guardians (including guardians appointed by a Tribal Court) must always be
notified when there appears to be any risk that a student may harm himself or herself,
unless doing so would exacerbate the situation. Keep in mind that you will need to be
prepared for a range of responses and emotions.
Tool 2.B.3: Guidelines for Notifying Parents provides a list of topics to discuss with
parents of children who are at risk of suicide. It includes suggestions for ways that staff
can provide support to parents and engage them as partners in helping the student.
Tool 2.B.4: Parent Contact Acknowledgement Form is a form to be signed by the parents,
acknowledging that they were notified about their child’s suicide risk.
Referring the student to a community provider.
Students at risk for suicide may need to be referred to community resources. If your
school already has a policy addressing referrals to health and mental health service
providers, your referral procedure for suicide risk should be consistent with this policy, as
well as any district, State, tribal, Bureau of Indian Education, or Federal policies
and laws.
Tool 2.B.5: Guidelines for Student Referrals provides a description of the information that
should be given to a mental health service provider to facilitate a referral.
Documenting the process.
It is essential to document each step in the process by which a student is identified as
possibly being at risk for suicide and assessed for suicide risk. This will help preserve the
safety of the student and ensure communication among school staff, parents, and service
providers.
Tool 2.B.6: Student Suicide Risk Documentation Form is a form you can adapt for your
documentation needs.
Supporting Parents
Parents may experience a complex set of conflicting emotions when they are told their child
may be suicidal, such as shock, anxiety, fear, confusion, embarrassment, anger, belligerence,
and denial. They may experience some or all of these reactions. Parents usually need
support and/or assistance to come to terms with their child’s risk and their reaction to this
risk, as well as the need to get professional help for their child and possibly for themselves.
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Using Referral Data to Understand Your Students’ Needs
The data included on referral forms can also be used to guide your suicide prevention
efforts. One school district studies and patterns data from its mental health referral forms,
including student information related to grade, race, gender, the month/year the referral was
generated, and the specific problems or risk factors presented. By analyzing data over a
10-year period, they were able to identify the months with the greatest number of referrals
for depressive symptoms and the specific grade levels with the highest referral rates. These
data are allowing the school district and its mental health service partners to prepare and
plan for this annual increase in referrals.
Maintaining Condentiality
Student information needs to be kept confidential for both ethical and legal reasons,
including a parent’s or student’s right to privacy under FERPA. This can be challenging.
Here are some suggestions for ensuring confidentiality:
Classroom discussions about particular incidents and students should be avoided
entirely because they violate a student’s right to condentiality.
Gossip about particular incidents and students should also be discouraged.
If a student who has attempted suicide wishes to talk about his or her experience
with other students in class, the teacher and a mental health professional or
administrator should meet with the student to discuss what he or she would like to
disclose and the possible risks of doing so.
Staff should be provided with the information necessary to work with the student
and preserve the young person’s safety. Staff do not need clinical information about
the student or a detailed history of his or her suicidal risk or behavior. Discussion
among staff should be restricted to the student’s treatment and support needs.
Step 5: Develop a protocol for responding to a suicide attempt in the
school or on the school campus.
Although students infrequently attempt suicide in schools or on a high school campus,
such incidents do occur. Schools need to be prepared for such an event.
Tool 2.C: Protocol for Responding to a Student Suicide Attempt outlines the actions to be
taken and people to be contacted when a student attempts suicide on a school campus.
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Step 6: Plan for managing a student’s return to school.
Schools should be prepared to facilitate the reentry of students who have missed school
because of a suicide attempt or related behavioral health issue. Returning to school can be
difficult for these young people:
They may worry about the reactions of their peers and teachers.
They may have problems catching up on their school work.
They may be taking medications that can interfere with their academics.
These problems can create additional stress for students who are already under significant
emotional strain. They need considerable support and monitoring, especially during the
first several months they are back at school, during any school crisis, or near the
anniversary of their attempt or mental health crisis.
A staff member should be assigned to facilitate the student’s return to the school. This
might be a teacher or other staff member particularly trusted by the student and his or her
family. Or it might be a school psychologist, social worker, or counselor. This staff
member will be the primary point of contact for parents, hospital staff, clinicians, and
school staff while the student is out of school, and he or she will oversee the student’s
reentry. Parents should be engaged in every step of this process. A reentry plan should be
developed through consensus of the family, school, and providers.
Tool 2.D: Guidelines for Facilitating a Student’s Return to School will provide you with
specific steps you should take to make sure that these high-risk students get the help they
need in preparing to return to school after a suicide attempt or mental health crisis.
Step 7: Help staff understand the protocols.
All staff members need to be familiar with the protocols for helping students at risk of
suicide in case they are called upon to participate in implementing the procedures
outlined in the protocols. Briefing school staff about these protocols will also educate
them about suicide risk and the problems experienced by students returning to school
after a suicide attempt or mental health crisis.
The protocols should be revisited every year. It is important to determine whether any
staff member responsible for a specific activity has left his or her job. If so, his or her
protocol responsibility should be assigned to someone else. It is also important to ensure
that all new staff become familiar with these procedures.
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Suggestions for Educating Staff about Your School’s Protocols
Educate staff about the protocols during staff meetings or in-service trainings.
Educate new staff about the protocols as part of their orientation.
Remind staff about protocols in newsletters or communications on related issues.
Include copies of the protocols in teacher handbooks and the school crisis plan.
For additional resources on developing protocols for responding to students who
attempt suicide at school or who are at risk of suicide, see the Crisis Response/
Postvention section in the “Resources” section at the end of the toolkit.
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CHAPTER 2: PROTOCOLS FOR HELPING
STUDENTS AT RISK OF SUICIDE TOOLS
Tool 2.A: Questions for Mental Health Providers
Tool 2.B: Protocol for Helping a Student at Risk of Suicide
Tool 2.B.1: Suicide Risk Assessment Resources
Tool 2.B.2: Self-Injury and Suicide Risk Information Sheet
Tool 2.B.3: Guidelines for Notifying Parents
Tool 2.B.4: Parent Contact Acknowledgement Form
Tool 2.B.5: Guidelines for Student Referrals
Tool 2.B.6: Student Suicide Risk Documentation Form
Tool 2.C: Protocol for Responding to a Student Suicide Attempt
Tool 2.D: Guidelines for Facilitating a Student’s Return to School
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Tool 2.A: Questions for Mental Health Providers
Asking the following questions of a mental health provider can help determine if he or she can meet the
needs of students at risk of suicide.
1. Are you able to provide services to people of high school age?
2. What types of services can you provide to high school students?
3. What are your major clinical skills and interests? Do you have any expertise in assessing and
treating young people who are at risk of suicide?
4. What experience and capacity do you have for providing services to LGBT youth and to the
specic ethnic groups that make up your school’s student body?
5. Where are you located?
6. What process do you follow after being called with a referral?
7. What process do you follow in the event of a suicide crisis?
8. Would you be able to come to our school to see a student if necessary?
9. How long might it take for you to see a student with urgent problems? With non-urgent problems?
10. What kind of follow-up can you provide students and the school?
11. Do you offer support groups for students or parents?
12. What insurance plans do you accept?
13. Do you have a sliding fee scale for people who pay out-of-pocket? What is the range of the
fee scale?
14. What are your procedures for ensuring student condentiality?
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Tool 2.B: Protocol for Helping a Student at Risk of Suicide
Suicide Risk Response Coordinator: _____________________________________
Backup to Coordinator: ____________________________________________
Actions Contacts Supporting materials
Conduct a suicide risk
assessment.
Who conducts assessment:
T
Tool 2.B.1: Suicide Risk
Assessment Resources
ool 2.B.2: Self-Injury and
Suicide Risk Information Sheet
Notify parents/guardians Who noties parents/guardians: Tool 2.B.3: Guidelines for
Notifying Parents
Tool 2.B.4: Parent Contact
Acknowledgement Form
Refer for services if needed. Community mental health services
provider:
Tool 2.B.5: Guidelines for
Student Referrals
Document the process Who completes the documentation
form:
Tool 2.B.6: Student Suicide
Risk Documentation Form
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Tool 2.B.1: Suicide Risk Assessment Resources
(TO BE USED WITH TOOL 2.B)
Advanced Training in Suicide Risk Assessment
There are a variety of advanced training programs that may be used to teach appropriate professionals
to assess suicide risk. They include:
Applied Suicide Intervention Skills Training (ASIST)
Assessing and Managing Suicide Risk (AMSR)
Recognizing and Responding to Suicide Risk (RRSR)
QPRT Suicide Risk Assessment and Risk Management Training Program
For more information about these training programs, see Chapter 4 and the “Resources” section in
this toolkit.
Assessment Tools
There are a variety of assessment tools that qualified mental health professionals can use to assess student
suicide risk. They include:
Beck Scale for Suicide Ideation (Pearson,
http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8018-
443&Mode=summary)
Suicide Ideation Questionnaire (PAR,
http://www4.parinc.com/Products/Product.aspx?ProductID=SIQ)
Suicide Ideation Questionnaire–JR (SIQ–JR) (PAR,
http://www4.parinc.com/Products/Product.aspx?ProductID=SIQ)
Suicide Probability Scale (Western Psychological Services,
http://portal.wpspublish.com/portal/page?_pageid=53,69317&_dad=portal&_schema=PORTAL)
Inventory of Suicide Orientation—30 (Pearson,
http://psychcorp.pearsonassessments.com/haiweb/cultures/en-us/productdetail.
htm?pid=PAg126&Community=CA_Psych_AI_Behavior)
All of these tools are published, validated by research, have been used with adolescents, and take about 10
minutes to complete. The Beck Scale is also available in Spanish.
The Suicide Prevention Unit of the Los Angeles Unified School District uses a simpler assessment for
students who may be at risk for suicide
(http://notebook.lausd.net/pls/ptl/docs/PAGE/CA_LAUSD/FLDR_ORGANIZATIONS/STUDENT_
HEALTH_HUMAN_SERVICES/SHHS/MENTAL/SMH_SUICIDE_PREVENTION/SMH_SUICIDE_
PREVENTION_RESOURCE/INTERVENING%20WITH%20SUICIDAL%20YOUTH%202009.PDF).
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Tool 2.B.2: Self-Injury and Suicide Risk Information Sheet
(TO BE USED WITH TOOL 2.B)
Self-injury (also known as self-mutilation or deliberate self-harm) is defined as intentionally and often
repetitively inflicting socially unacceptable bodily harm to oneself without the intent to die. Self-injury
includes a wide variety of behaviors, such as cutting, burning, head banging, picking or interfering with
healing of wounds, and hair pulling.
The relationship between self-injury and suicide is complicated. Researchers believe self-injury is a
behavior separate and distinct from suicide and the result of a very complex interaction among cognitive,
affective, behavioral, environmental, biological, and psychological factors. However, in some people the
self-destructive nature of self-injury may lead to suicide.
Students who injure themselves intentionally should be taken seriously and treated with compassion.
Teachers or other staff who become aware of a student who is intentionally injuring himself or herself
should refer the student to the school counselor, psychologist, social worker, or nurse. Staff should offer
to accompany the student to the proper office and help broach the issue with the relevant mental
health professional.
School mental health staff should:
Assess the student for both self-injury and risk of suicide
Notify and involve the parents/guardians
Design appropriate treatment for the student’s current behaviors or refer the student to a mental
health provider in the community for treatment
The following resources can be used to understand and prepare to respond to self-injury by students:
Prevention Researcher. February 2010, Vol. 17, No.1 focuses on adolescent
self-injury: http://www.tpronline.org/issue.cfm/Adolescent_Self_Injury
Self-Injurious Behavior Webcast. October 2006, 1 hour, includes an interview with Dr. Janice
Whitlock: http://www.albany.edu/sph/coned/t2b2injurious.htm
Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults. Web site
contains numerous informational materials:
http://www.crpsib.com
[Developed in consultation with Richard Lieberman M.A., NCSP, School Psychologist/Coordinator, Los Angeles
Unified School District, Suicide Prevention Unit]
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Tool 2.B.3 Guidelines for Notifying Parents
(TO BE USED WITH TOOL 2.B)
Notifying Parents and Guardians
Parents or guardians should be contacted as soon as possible after a student has been identified as being at
risk for suicide. The person who contacts the family is typically the principal, school psychologist, or a staff
member with a special relationship with the student or family. Staff need to be sensitive toward the family’s
culture, including attitudes towards suicide, mental health, privacy, and help-seeking.
1. Notify the parents about the situation and ask that they come to the school immediately.
2. When the parents arrive at the school, explain why you think their child is at risk for suicide.
3. Explain the importance of removing from the home (or locking up) rearms and other dangerous
items, including over-the-counter and prescription medications and alcohol.
4. If the student is at a low or moderate suicide risk and does not need to be hospitalized, discuss
available options for individual and/or family therapy. Provide the parents with the contact
information of mental health service providers in the community. If possible, call and make an
appointment while the parents are with you.
5. Ask the parents to sign the Parent Contact Acknowledgement Form conrming that they were
notied of their child’s risk and received referrals to treatment.
6. Tell the parents that you will follow up with them in a few days. If this followup conversation
reveals that the parent has not contacted a mental health provider:
Stress the importance of getting the child help
Discuss why they have not contacted a provider and offer to assist with the process
7. If the student does not need to be hospitalized, release the student to the parents.
8. If the parents refuse to seek services for a child under the age of 18 who you believe is in danger
of self-harm, you may need to notify child protective services that the child is being neglected.
9. Document all contacts with the parents.
Supporting Parents through Their Child’s Suicidal Crisis
Family Support is Critical. When an adolescent experiences a suicidal crisis, the whole family is in
crisis. If at all possible, it is important to reach out to the family for two very important reasons:
First, the family may very well be left without professional support or guidance in what is often a state of
acute personal shock or distress. Many people do not seek help—they don’t know where to turn.
Second, informed parents are probably the most valuable prevention resource available to the
suicidal adolescent.
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Remember, a prior attempt is the strongest predictor of suicide. The goal of extending support to the
parents is to help them to a place where they can intervene appropriately to prevent this young person
from attempting suicide again. Education and information are vitally important to family members and
close friends who find themselves in a position to observe the at-risk individual.
The following steps can help support and engage parents:
1. Invite the parents’ perspective. State what you have noticed in their child’s behavior (rather than
the results of your assessment) and ask how that ts with what they have observed.
2. Advise parents to remove lethal means from the home while the child is possibly suicidal, just as
you would advise taking car keys from a youth who had been drinking.
3. Comment on how scary this behavior is and how it complicates the life of everyone who cares
about this young person.
4. Acknowledge the parents’ emotional state, including anger, if present.
5. Acknowledge that no one can do this alone—appreciate their presence.
6. Listen for myths of suicide that may be blocking the parent from taking action.
7. Explore reluctance to accept a mental health referral, address those issues, explain what to expect.
8. Align yourself with the parent if possible…explore how and where youth get this idea…without
in any way minimizing the behavior.
[Adapted from DiCara, C., O’Halloran, S., Williams, L., & Canty-Brooks, C. (2009). Youth suicide prevention,
intervention & postvention guidelines. Augusta, ME: Maine Youth Suicide Prevention Program. Retrieved
from http://www.maine.gov/suicide/docs/Guidelines%2010-2009--w%20discl.pdf]
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Tool 2.B.4: Parent Contact Acknowledgement Form
(TO BE USED WITH TOOL 2.B)
This form is an example that can be used to verify that the parents have been advised of a student’s
suicide risk.
Parent Contact Acknowledgement Form
School ________________________________________________
This is to verify that I have spoken with school staff member ___________________________________
___ on __________________________ (date), concerning my child’s suicidal risk. I have been advised to
seek the services of a mental health agency or therapist immediately.
I understand that _________________________________ (name of staff) will follow up with me, my
child, and the agency to whom my child has been referred for services within two weeks.
Parent Signature: __________________________________ Date: ___________
DateFaculty Member Signature: ____________________________ : ___________
[From DiCara, C., O’Halloran, S., Williams, L., & Canty-Brooks, C. (2009). Youth suicide prevention, intervention
& postvention guidelines (p. 45). Augusta, ME: Maine Youth Suicide Prevention Program. Retrieved
from http://www.maine.gov/suicide/docs/Guidelines%2010-2009--w%20discl.pdf]
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Tool 2.B.5: Guidelines for Student Referrals
(TO BE USED WITH TOOL 2.B)
Schools should be prepared to give the following information to providers. Note: Parents’ permission may
be required to share this information.
1. Basic student information (age, grade, race/ethnicity, and parents’ or guardians’ names, addresses,
and phone numbers).
2. How did the school rst become aware of the student’s potential risk for suicide?*
3. Why is the school making the referral?
4. What is the student’s current mental status?
5. Are the student and parents/guardians willing or reluctant to meet with a mental health
service provider?
6. What other agencies are involved (names and information)?
7. Who pays for the referral and possible treatment?
8. Where is the best place to meet with the student (e.g., school, student’s home, therapist’s ofce,
emergency room)?
*Be sure that parental consent meets the requirements of FERPA as follows:
1. Specify the records that may be disclosed.
2. State the purpose of the disclosure.
3. Identify the party or class of parties to whom the disclosure may be made.
See 34 CFR § 99.30.
Tool 2.B.6: Student Suicide Risk Documentation Form
(TO BE USED WITH TOOL 2.B)
This form is
an example that can be used to document the school’s response to a student who has been
identified at risk for suicide. It includes the results of a suicide risk assessment and the actions taken on
the students behalf.
Put this form on your school’s letterhead. Consider adapting it for your school’s policies, procedures, and
student population.
Student information
Date
student
was
identified
as
possibly
at
risk:
Name
of
student:
If
Native
American,
tribal
status:
Name
of
school:
Birth
date:
Gender:
Grade:
Name
of
Parent/Guardian/Tribal
Court
appointed
guardian:
Parent/Guardian
s
telephone
number(s):
(1) (2)
Tribal Court appointed guardian’s telephone number: OR
Directions
to
residence:
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SUICIDE:
A
HIGH SCHOOL
T
OOLKIT
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IDENTIFICATION OF RISK
Who identified student as being at risk:
Self
Parent
Teacher
Other staff:
Student/friend
Other:
Reason for concern:
ASSESSMENT
Action
taken to assess for suicide risk:
School staff [name ] conducted
assessment
Outside provider [name ] conducted
assessment
Other:
Date of assessment:
Type of assessment conducted:
Results of assessment:
NOTIFICATION OF PARENT/GUARDIAN
Staff who notified parent/guardian/Tribal Court appointed guardian:
Date notified:
Parent acknowledgement form signed: Yes No If no, reason:
REFERRAL
Type of referral
School personnel:
Outsider provider:
Hospital:
Other:
Date of referral:
Follow-up scheduled:
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SOURCES:
DiCara, C., O’Halloran, S., Williams, L., & Canty-Brooks, C. (2009). Youth suicide prevention,
intervention & postvention guidelines. Augusta, ME: Maine Youth Suicide Prevention Program. Retrieved
from http://www.maine.gov/suicide/docs/Guidelines%2010-2009--w%20discl.pdf. From the following
forms: Report of Risk, p. 44 and Student Record of Actions Taken, p. 47.
Suicide Prevention Unit, Los Angeles Unified School District, School Mental Health—Suicide Prevention.
(n.d.). Risk assessment referral data. Retrieved August 27, 2010 from http://notebook.lausd.net/pls/ptl/docs/
PAGE/CA_LAUSD/FLDR_ORGANIZATIONS/STUDENT_HEALTH_HUMAN_SERVICES/SHHS/
MENTAL/SMH_SUICIDE_PREVENTION/SMH_SUICIDE_PREVENTION_RESOURCE/RISK%20
ASSESMENT%20REFERRAL%20DATA%20FINAL.PDF
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Tool 2.C: Protocol for Responding to a Student Suicide Attempt
The first adult to reach the student should:
1. Stay with the student or designate one or more other adults to stay with the student. Never leave the
student alone.
2. Call 9-1-1 or your local emergency service provider.
3. Contact the Student Risk Response Coordinator.
The Student Risk Response Coordinator should:
1. Contact additional personnel as necessary. These may include community crisis service providers,
law enforcement, the school superintendent and other administrators, the school nurse, guidance
counselor, social worker, psychologist, and other school staff.
2. Contact the student’s parents to tell them what has occurred with their child. Make arrangements to
meet at the appropriate location, for example, the school psychologist’s ofce or the emergency room
of the local hospital.
3. Contact emergency medical services if needed.
4. After the immediate crisis, make a plan to follow up with the parents and student regarding
arrangements for medical and/or mental health services.
The Response Team includes:
Suicide Risk Response Coordinator(s):
_______________________________________________
Backup Coordinator(s): ___________________________________________________________
Emergency Medical Services: ______________________________________________________
[Compiled from the DiCara, C., O’Halloran, S., Williams, L., & Canty-Brooks, C. (2009). Youth suicide prevention,
intervention & postvention guidelines. Augusta, ME: Maine Youth Suicide Prevention Program. Retrieved
from http://www.maine.gov/suicide/docs/Guidelines%2010-2009--w%20discl.pdf]
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Tool 2.D: Guidelines for Facilitating a Student’s Return to School
These guidelines will help staff plan for a student’s return to school after a suicide attempt or mental
health crisis. In addition to meeting regularly with the student, the staff member facilitating the student’s
return should do the following:
1. Become familiar with the basic information about the case, including:
How the student’s risk status was identied
What precipitated the student’s high-risk status or suicide attempt
What medication(s) the student is taking
2. With the family’s agreement, serve as the school’s primary link to the parents and maintain
regular contact with the family:
Call or meet frequently with the family.
Facilitate referral of the family for family counseling, if appropriate.
Meet with the student and his or her family and relevant school staff (e.g., the school
psychologist or social worker) about what services the student will need upon returning
to school.
3. Serve as liaison to other teachers and staff members, with permission of the family, regarding the
student, which could involve the following:
Ask the student about his or her academic concerns and discuss potential options.
Educate teachers and other relevant staff members about warning signs of another
suicide crisis.
Meet with appropriate staff to create an individualized reentry plan prior to the student’s
return and discuss possible arrangements for services the student needs.
Modify the student’s schedule and course load to relieve stress, if necessary.
Arrange tutoring from peers or teachers, if necessary.
Work with teachers to allow makeup work to be extended without penalty.
Monitor the student’s progress.
Inform teachers and other relevant staff members about the possible side effects of the
medication(s) being taken by the student and the procedures for notifying the appropriate
staff member (e.g., the school nurse, psychologist, or social worker) if these side effects
are observed. When sharing information about medical treatment, you need to comply with
FERPA (dened in the Introduction to this toolkit) and HIPAA (which protects release of an
individual’s health information).
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4. Follow up behavioral and/or attendance problems of the student by:
Meet with teachers to help them understand appropriate limits and consequences of behavior
Discuss concerns and options with the student
Consult with the school’s discipline administrator
Consult with the student’s mental health service provider to understand whether, for example,
these behaviors could be associated with medication being taken by the student
Monitor daily attendance by placing the student on a sign-in/sign-out attendance sheet to be
signed by the classroom teachers and returned to the attendance ofce at the end of the school
day
Make home visits or have regularly scheduled parent conferences to review attendance and
discipline record
Facilitate counseling for the student specic to these problems at school
5. If the student is hospitalized, obtain the family’s agreement to consult with the hospital staff
regarding issues such as:
Deliver classwork assignments to be completed in the hospital or at home, as appropriate
Allow a representative from school to visit the student in the hospital or at home with the
permission of the parents
Attend treatment planning meetings and the hospital discharge conference with the
permission of the parents
6. Establish a plan for periodic contact with the student while he or she is away from school.
7. If the student is unable to attend school for an extended period of time, determine how to help
him or her complete course requirements.
[Compiled with information from DiCara, C., O’Halloran, S., Williams, L., & Canty-Brooks, C. (2009). Youth
suicide prevention, intervention & postvention guidelines. Augusta, ME: Maine Youth Suicide Prevention Program.
Retrieved from http://www.maine.gov/suicide/docs/Guidelines%2010-2009--w%20discl.pdf]
CHAPTER 3
After a Suicide
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AFTER A SUICIDE
The steps in Chapter 3 will answer these questions:
Who in our school and our community needs to be involved in developing our
protocols for responding to a suicide?
What are the key components of immediate and long-term suicide
response protocols?
How should we inform all staff about the protocols?
POSTVENTION, SURVIVORS, AND CONTAGION
The terms “postvention,” “survivors,” and “contagion” are commonly used by suicide
prevention experts and practitioners when discussing the aftermath of suicide. As they
may be unfamiliar to most people, definitions are given below:
A survivor (or suicide survivor) is a person who has experienced the suicide of a family
member, friend, or colleague. A person who attempts suicide but does not die is an
attempt survivor.
Postvention refers to programs and interventions for survivors following a death by
suicide. These activities help alleviate the suffering and emotional distress of suicide
survivors and help prevent suicide contagion.
Suicide contagion is “a process by which the suicide or suicidal behavior of one or more
persons influences others to commit or attempt suicide” (Davidson and Gould, 1989).
WHY IS IT IMPORTANT TO DEVELOP PROTOCOLS FOR RESPONDING TO
A SUICIDE?
Any death can have a profound effect on young people, especially the unexpected death
of a peer or someone they know:
The death of someone their own age can threaten the adolescent sense
of invulnerability.
The death of a role model can produce conicting feelings, including loss
and betrayal.
The suicide death of someone they know can leave them susceptible to
suicide contagion.
The suicide death may make it difcult for students to focus on their academics
and other regular activities.
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Schools need to prepare to do the following:
Help students cope in the short term by creating a protocol that describes specic
steps to take after a suicide
Continue helping students cope over the long term, since the emotional fallout
from a suicide can continue for months, and even years, after the event
A High School Principal Talks about the Need to Be Prepared
We didn’t have a suicide prevention plan. The superintendent didn’t think it was critical.
There was a mindset of “it doesn’t happen here.” We had a crisis plan for when a student
died in an automobile collision or a staff member got cancer, but suicide just wasn’t on our
agenda. When it happened, it just blew us out of the water because we weren’t ready for it.
An effective response to a suicide can also avoid the infrequent but very real phenomenon
of suicide contagion. Adolescents are more susceptible to suicide contagion than people
of other ages (Gould, Jamieson, & Romer, 2003b).
Groups of related suicides, called suicide clusters, are approximately 1–2 percent of all
adolescent suicides in the United States (Gould, et al., 1990). While clusters can include
students in the same school, it is not necessary for young people to have direct contact
with one another to be part of a suicide cluster. A suicide by a celebrity or a person whom
teens see as a role model can raise vulnerable teens’ risk for suicide, as can widely
publicized suicides by other adolescents.
How a school responds to a suicide (as well as the way in which the media reports on a
suicide) can help prevent—or promote—suicide contagion (sometimes called “copycat
suicides”). Unintentionally glamorizing a youth who died by suicide, suggesting that the
death was caused by a single problem (such as breaking up with a girlfriend or
boyfriend), or providing a detailed description of how a youth died can raise suicide risk
among other vulnerable young people. It is important to work with the press to ensure
that the public’s right to know is balanced with the damage that inappropriate reporting
can cause. The campus needs to be managed for safety. Reporters and other outsiders
should not be allowed free access to the campus and your students.
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Many teens use the Internet and social media to keep in touch with friends, obtain news
and information, and otherwise exchange information with those in the larger world.
Social media include blogs, Internet bulletin boards, wikis (Web sites that allow any user
to add and edit content), and social networking sites of different types.
Keep informed of the types of information—and misinformation—students may
be sharing in the wake of a suicide or attempted suicide. Responses may include
posting comments that dispel rumors, reinforcing important information such as
the connection between mental illness and suicide, and offering resources such as
for mental health care (American Foundation for Suicide Prevention (AFSP) and
Suicide Prevention Resource Center (SPRC), 2011).
Identify students who may need help in coming to terms with the event.
To the extent possible, social media sites that should be monitored include the following:
Online condolence pages that many funeral homes provide to clients
Blogs that many newspapers use to display readers’ comments on their stories
Social networking sites (including the deceased student’s page)
Schools Use Social Media to Prevent Suicide and Contagion
After a suicide, one school district monitored its students’ use of social media to prevent
additional tragedies. The school had access to a Facebook page as well as a young writer’s Web
site monitored by the project’s coordinator through which students could express their feelings.
The local funeral home also had an online condolence page that students used. The writer’s
project coordinator, funeral home director, and school counseling director all maintained close
contact and closely followed the emotional outpouring of students through the sites. The school
counselors and administrators, along with the community mental health crisis coordinator,
watched these social media channels closely to identify youth who might be at risk of suicide or
need additional support.
Another district provided students with hotline numbers and other information that they
could post on their personal Facebook pages.
A suicide will also profoundly affect staff. Staff members will experience their own grief
as well as the stress of responding to the emotional pain of students, parents, and other
members of the community. Staff members may feel a deep sense of guilt if they think
that they could have done something to prevent the death. It is essential to provide
resources that support the emotional health of the staff, especially those responsible for
responding to the suicide, as they may be under intense emotional pressure.
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STEPS TO DEVELOP PROTOCOLS FOR RESPONDING TO A SUICIDE
Step 1: Convene a group to create the protocols.
The protocol planning group should include:
Staff members who know the school personnel and their roles, skills, and
personalities and the community partners who will be involved in responding to a
suicide (see Step 2 below)
An administrator
Mental health professionals, such as the counselor, social worker, or school
psychologist (if your school has one on staff)
A member of your school’s Crisis Response Team
Tool 1.B: Chart of School Staff Responsibilities (see Chapter 1) will help you identify and
record the names of members of the school staff who should be involved in this effort.
Step 2: Identify community partners who can help.
Schools may need the help of other individuals, agencies, and organizations in the
community while responding to the suicide of a student. They may, for example, need the
help of a local mental health center to address the emotional needs of students and staff,
and the local police department (including Tribal and Bureau of Indian Affairs Law
Enforcement agencies in tribal communities) to get information about the death or secure
the campus. It is also important to involve representatives of the cultural and religious
communities represented by your students when preparing these protocols. These
representatives can provide essential insight into the grieving traditions of these
communities. These partners should be involved in the planning process so that they can
inform the process and be ready and willing to participate should a tragedy occur.
Tool 1.C: Chart of Community Partners (see Chapter 1) can help you identify and record
names of mental health service providers.
Step 3: Create a protocol for your school’s immediate response to a
suicide.
Before beginning the process of creating a protocol for your school, first investigate what
is already in place:
Are there any State, district, Bureau of Indian Education, or tribal protocols or
procedures to which your protocol and activities must conform?
If so, are they recommended or mandated, and how appropriate are they for the
needs of your school?
Does your school have a crisis response plan, and if so, does the plan include
procedures for responding to a suicide?
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If you determine that you need to create a protocol or modify an existing protocol, it is
important to include the following:
A Suicide Response Coordinator, who will be responsible for contacting
the members of the Suicide Response Team in the event of a suicide and for
coordinating the work of the team. A backup coordinator should be designated for
times when the coordinator is unavailable.
A procedure for deciding when to implement the protocol, as well as what
aspects of the protocol to implement, based on the nature of the event. The
decision will probably be made by the principal in consultation with the suicide
response coordinator.
The actions the school needs to take immediately after a suicide, the person
responsible for each action, and a backup person to undertake these tasks if
the lead person is not available. Although one individual, such as the principal,
may be responsible for several actions, it is important not to assign too many
responsibilities to a single staff member, since this could interfere with his or her
ability to complete these tasks. Avoid assigning tasks to individuals who will not
be able to function effectively in a highly emotional environment.
Contact information for people and agencies you may need to notify, such as
the police or a grief counselor. The community partners you identied in Step
2 may be able to help you determine which agencies and individuals need to be
involved. You should conrm with these individuals and organizations that they
are the appropriate parties to contact and that they consent to being identied in
the school’s suicide response protocol as parties to contact if a suicide occurs.
Resources that your staff need to implement the protocol, such as a letter to send
to parents or guidelines for talking to the media. The sample materials included
in this toolkit may be used as is or modied to t your needs.
Tool 3.A: Immediate Response Protocol is a worksheet that you can use or adapt to create
an Immediate Response Protocol for your school. Tools 3.A.1–3.A.9 are additional tools
to help you implement the Immediate Response Protocol.
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When to Use the Immediate Response Protocol
Whether you use some or all of the steps in the Immediate Response Protocol will depend
on the situation. Some events might warrant implementing selected activities rather than the
entire protocol. Consider these examples:
The suicide of a student that occurs at the beginning of a long school vacation or
over the summer. School staff need to be made aware that students’ emotions may
resurface when they return to school.
The suicide of a person to whom many students have a strong emotional attachment,
such as an actor, musician, or athlete, or the suicide of a young person which
receives substantial media coverage. School staff need to be sensitive to the
sometimes emotional response of young people to the death of someone they did
not know.
The Suicide Response Coordinator (in consultation with other members of the Suicide
Response Team, if appropriate) should decide on the level of implementation warranted by
the incident at hand.
Step 4: Include the Immediate Response Protocol in your school’s crisis
response plan.
Many districts and schools have crisis response plans. These plans often include protocols
for responding to a natural disaster, medical emergency, and serious violence. Your
suicide response protocols should be included in your school’s crisis response plan.
Step 5: Create a protocol for the long-term response to a suicide.
The suicide of a member of the school community, especially of a student, has
consequences that will continue long after the event. You should also create a protocol
that describes actions to take in the weeks, months, and years after a suicide. These
actions include:
Appropriately memorializing the deceased in the yearbook and at graduation
Preparing for the anniversary of the death or the birthday of the deceased in ways
that do not increase the likelihood of creating suicide contagion
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The Long-Term Response Protocol, like the Immediate Response Protocol, specifies the
actions to take, who is responsible for each action, and relevant contacts and resources.
Tool 3.B: Long-Term Response Protocol is a worksheet that you can use or adapt to create
a long-term response protocol. Tool 3.B.1 provides guidance on dealing with
anniversaries of a death.
Step 6: Help staff understand the protocols.
The people responsible for implementing the protocols, including those in a backup role,
should be familiar with the protocols and their specific duties. They should be asked if
they feel they can carry out these assignments. Some members of your staff may have
had experiences that may make it emotionally difficult for them to undertake particular
responsibilities. Once responsibilities have been assigned, provide each staff member
with copies of the protocols and any resources they may need. All school personnel
should be briefed about the protocols.
Step 7: Update the protocols.
The protocols may need to be periodically updated, for example, to recruit new members
of the Suicide Response Team if team members retire, leave their jobs, or take sabbaticals
or parental leave. Changes in the community—such as the closing of a mental health
center—may also require changes to the protocol. Someone (perhaps the Suicide
Response Coordinator) should:
Periodically review the protocol
Decide whether the protocol needs to be updated
Convene a small group (perhaps the original planning team) to update
the protocol
For additional resources on developing protocols after a suicide, see the section Crisis
Response/Postvention in the “Resources” section at the end of the toolkit.
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CHAPTER 3. AFTER A SUICIDE TOOLS
School staff need to remember that postvention helps prevent additional suicides by mitigating the effect
that a suicide has on vulnerable students.
Tool 3.A: Immediate Response Protocol
Tool 3.A.1: Sample Script for Office Staff
Tool 3.A.2: Sources of Postvention Consultation
Tool 3.A.3: Guidelines for Working with the Family
Tool 3.A.4: Guidelines for Notifying Staff
Tool 3.A.5: Sample Announcements
Tool 3.A.6: Sample Letter to Families
Tool 3.A.7: Talking Points for Students and Staff after a Suicide
Tool 3.A.8: Guidelines for Memorialization
Tool 3.A.9: Guidelines for Working with the Media
Tool 3.B: Long-Term Response Protocol
Tool 3.B.1: Guidelines for Anniversaries of a Death
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Tool 3.A: Immediate Response Protocol
Use this worksheet to:
1. Understand the steps your school will need to take in the event of a suicide. The steps will
not necessarily be taken in the order outlined on this worksheet. Some of them will need to be
implemented simultaneously.
2. Assign members of the school staff to be responsible for each task.
3. Record the names and telephone numbers of people and agencies who will be called in the event
of a suicide.
4. Understand and, if necessary, modify the resources that will be used in implementing
the protocol.
Ensure the following:
Each member of the Suicide Response Team has a copy of the completed protocol.
Each person who has lead or backup responsibility for a particular step has the tools necessary
to complete this task. As soon as these roles are assigned, the individuals should read the tools
(and modify if necessary) so that they will be prepared to respond immediately in the event of
a suicide.
The approaches you use are appropriate to the cultural and spiritual traditions of the students in
your school.
Suicide Response Coordinator—responsible for contacting the Suicide Response Team in the event of a
suicide and coordinating the work of the team:
Name_____________________________________
Backup Suicide Response Coordinator—responsible for contacting and coordinating the team if the
Suicide Response Coordinator is unavailable:
Name_____________________________________
Steps to Take in
Immediate Aftermath
Staff Responsible
External Contacts
(Phone Numbers)
Tools
Notify key individuals
1. Verify death Lead:
Backup:
Police:
Medical examiner:
2. Ensure that staff know Lead: Tool 3.A.1:
how to respond to Sample Script
inquiries and manage the
Backup:
for Ofce Staff
campus for safety
3. Notify superintendent’s
ofce
Lead:
Backup:
Superintendent :
.
Backup/weekends:
4. Notify district crisis team* Lead:
Backup:
District crisis team:
Weekend/vacation/late
night contacts:
5. Notify schools attended
by family members of the
deceased
Lead:
Backup:
Other schools in district:
.
6. Contact and coordinate
with external mental
health professionals
Lead:
Backup:
Community mental health
providers:
External crisis response
professionals:
Tool 3.A.2:
Sources of
Postvention
Consultation
7. Reach out to and work
with the family of the
deceased
Lead:
Backup:
Tool 3.A.3:
Guidelines for
Working with the
Family
*In tribal communities, Bureau of Indian Education schools notify the main office and tribal schools notify
the principal.
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Steps to Take in
Immediate Aftermath
Staff Responsible
External Contacts
(Phone Numbers)
Tools
Notify school community
8. Notify all faculty and staff Lead:
Backup:
Tool 3.A.4:
Guidelines for
Notifying Staff
9. Coordinate notifying
students about the deaths
Lead:
Backup:
Tool 3.A.5:
Sample
Announcements
10. Notify families of students
about the death and the
school’s response
Lead:
Backup:
Tool 3.A.6:
Sample Letter to
Families
Support students and staff
11. Provide staff with
guidance in talking to
students
Lead:
Backup:
Tool 3.A.7:
Talking Points
for Students
and Staff After a
Suicide
12. Provide support to staff Lead:
Backup:
Community mental health
professionals:
13. Identify, monitor, and
support students who
may be at risk
Lead:
Backup:
14. Implement steps to help
students with emotional
regulation
Lead:
Backup:
15. Participate in and/or
advise on appropriate
memorialization in the
immediate aftermath
Lead:
Backup:
Tool 3.A.8:
Guidelines for
Memorialization
Minimize risk of contagion through the media
16. Work with press/media Lead:
Backup:
Local media contact(s): Tool 3.A.9:
Guidelines for
Working with the
Media
17. Monitor social media Lead:
Backup:
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Tool 3.A.1: Sample Script for Ofce Staff
(USE WITH TOOL 3.A)
This script can help receptionists or other people who answer the telephone to respond appropriately to
telephone calls received in the early stages of the crisis.
Hello, _______________ School. May I help you?
Take messages on non-crisis-related calls.
For crisis-related calls, use the following general schema:
Police or other security professionals—Immediate transfer to principal.
Family members of deceased—Immediate transfer to principal or anyone else they want to reach
at the school. If principal is not available immediately, ask if they would like to speak to a school
psychologist or social worker.
Other school administrators—Give out basic information on death and crisis response and offer
to transfer call to principal or others.
Parents regarding their child’s immediate safety—Reassure parents if you know their child
was not involved and outline how children are being served and supported. If child may have
been involved, transfer to a crisis team member who may have more information.
Persons who call with information about others at risk—Take down information and get it
to a crisis team member. Take a phone number where the person can be called back by a crisis
team member.
Media—Take messages and refer to principal.
Parents generally wanting to know how to respond—Explain that children and staff are
being supported. Take messages to give to Student Services staff from parents needing more
detailed information.
Where to send parents who arrive unannounced on the scene—Set aside a space for parents
to wait and get information. Any person removing a student from school must be on the annual
registration form as the parent or guardian. Records must be kept of who removed the child
and when.
[From Madison Metropolitan School District. (Revised 2005). Sudden death-suicide-critical incident: Crisis
response procedures for principals and student services staff. Retrieved from
http://www.mhawisconsin.org/Data/Sites/1/media/gls/gls_madisoncrisisplan.pdf]
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Tool 3.A.2: Sources of Postvention Consultation
(USE WITH TOOL 3.A)
There are local resources that can provide consultation on postvention in the event of a school suicide.
Since the availability of these resources varies depending on a school’s location, you should investigate
the resources in your area as part of your planning.
Some valuable sources of such consultation are organizations and agencies that receive Garrett Lee Smith
Memorial Grant funding. To identify Garrett Lee Smith grantees in your area, see the Suicide Prevention
Resource Center Web site.
For State grantees: http://www.sprc.org/states/all/contacts
For tribal grantees: http://www.sprc.org/grantees/listing
The following are national organizations that provide consultation for developing a postvention response
or that can put you in touch with other experts.
National Association of School Psychologists (NASP): NASP sponsors a National Emergency Assistance
Team (NEAT) that provides consultation to schools and, in some cases, makes site visits. NEAT members
are listed with their contact information at http://www.nasponline.org/resources/crisis_safety/neat.aspx.
Schools may also contact NASP during business hours at 301-657-0270 and ask for the NASP
Executive Director.
National Institute for Trauma and Loss: The National Institute for Trauma and Loss sponsors the TLC
Referral Directory of Certified Trauma and Loss Specialists, School Specialists, Consultants, and
Consultant Supervisors. The directory is accessible to TLC members only. Membership is automatic after
completing requirements for Level-1 Certification as a Certified Trauma Specialist. Schools are
encouraged to assign a representative to receive certification training as a School Specialist (Level-1) in
order to access the directory or as a Consultant (Level-2) to acquire expertise as a local crisis consultant.
Level-1 Certification requires a 3-day TLC training and completion of online courses and an essay exam.
Directory: http://www.starrtraining.org/tlc
Certification details: http://www.starrtraining.org/certification
To access listings outside of the United States and Canada, call 877-306-5256 or 586-263-4232.
Suicide Prevention Resource Center (SPRC) State pages: Consult the State pages on the Suicide
Prevention Resource Center Web site for the contact and organizations working to prevent suicide in your
State. They may be able to assist you in identifying expert consultants for postvention support.
SPRC State Pages: http://www.sprc.org/states
National Suicide Prevention Lifeline Crisis Center Locator: Through this locator, you can find your
local crisis center, which may be able to provide postvention support for schools.
See http://www.suicidepreventionlifeline.org/CrisisCenters/Locator.aspx
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Tool 3.A.3: Guidelines for Working with the Family
(USE WITH TOOL 3.A)
It is important to work with the family of a student who died by suicide. They will often appreciate the
support of the school community, and their cooperation can be valuable for effective postvention. The
principal or a representative of the school should request to visit the family in their home. It may be useful
for a pair of representatives to visit together so that they can support one another during the visit. It is
important to respect the cultural and religious traditions of the family related to suicide, death, grieving,
and funeral ceremonies.
The school representative(s) should:
Offer the condolences of the school.
Inquire about funeral arrangements. Ask if the funeral will be private or if the family will allow
students to attend.
Ask if the parents know of any of their child’s friends who may be especially upset.
Provide the parents with information about grief counseling.
Ask the family if they would like their child’s personal belongings returned. These could include
belongings found in the student’s locker and desk as well as papers and projects they may want
to keep.
Briey explain to the parents what the school is doing to respond to the death.
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Tool 3.A.4: Guidelines for Notifying Staff
(USE WITH TOOL 3.A)
These preparations should be made by the individual responsible for notifying faculty and staff about a
suicide so that a system will be in place in the event of a death.
Create two telephone trees:
(1) To notify the Suicide Response Team
(2) To notify all staff members of a suicide that occurs during non-school hours
Hold a staff meeting before school opens to review the postvention process. Provide staff with
any information they may need to address the situation when the students arrive.
Identify which Suicide Response Team members will be responsible for notifying staff if news
of a suicide arrives while school is in session. These people should be provided with completed
copies of a suicide death announcement (samples of which can be found in Tool 3.A.5).
Announcements should always be made in classrooms. They should never be made over the
school’s public address system or in assemblies. In classrooms, school staff familiar to the students
can make the announcements and then assess students’ reactions, respond to students’ concerns,
provide support, and identify those who may need additional help. This will help students cope
with intense emotions they may experience. The toolkit After a Suicide: A Toolkit for Schools,
developed by SPRC/AFSP, is available online at http://www.sprc.org/sites/sprc.org/les/library/
AfteraSuicideToolkitforSchools.pdf and http://www.afsp.org/les/Surviving/toolkit.pdf
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Tool 3.A.5: Sample Announcements
(USE WITH TOOL 3.A)
Sample Announcements for Use with Students after a (Possible) Suicide
1. After the school’s Suicide Response Team has been mobilized, it is critical for administration
and/or crisis team members to prepare a statement about the death for release to faculty
and students. The announcement should include the facts as they have been ofcially
communicated to the school. Announcements should not overstate or assume facts not in
evidence. If the ofcial cause of death has not as yet been ruled suicide, avoid making that
assumption. There are also many instances when family members insist that a death that may
appear to be suicide was, in fact, accidental.
2. The Suicide Response Team should either visit all classrooms to give the announcement to
staff or present the announcement at a meeting of all staff called by the building administrator
as soon as possible following the death. If a meeting is held, the building administrator and
a member of the Suicide Response Team could facilitate the meeting. The goals of such a
meeting are to inform the faculty, acknowledge their grief and loss, and prepare them to
respond to the needs of the students. Faculty will then read the announcement to their students
in their homerooms (or other small group) so that students get the same information at the same
time from someone they know.
3. The sample announcements in this section are straightforward and are designed for use with
faculty, students, and parents, as appropriate. Directing your announcement to the grade level of
the students is also important, especially in primary or middle schools. A written announcement
should be sent home to parents with additional information about common student reactions to
suicide and how to respond, as well as suicide prevention information.
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Day 1
Sample Announcement for When a Suicide has Occurred, Morning, Day 1
This morning we heard the extremely sad news that _________________________ took his/her life last
night. I know we are all saddened by his/her death and send our condolences to his/her family and
friends. Crisis stations will be located throughout the school today for students who wish to talk to a
counselor. Information about the funeral will be provided when it is available, and students may attend
with parental permission.
Sample Announcement for a Suspicious Death Not Declared Suicide: Morning, Day 1
This morning we heard the extremely sad news that _________________________ died last night from a
gunshot wound. This is the only information we have officially received on the circumstances surrounding
the event. I know we are all saddened by __________________________________’s death and send our
condolences to his/her family and friends. Crisis stations will be located throughout the school today for
students who wish to talk to a counselor. Information about the funeral will be provided when it is
available; students may attend with parental permission.
Sample Announcement, End of Day 1
At the end of the first day, another announcement to the whole school prior to dismissal can serve to join
the whole school in their grieving in a simple, non-sensationalized way. In this case, it is appropriate for
the building administrator to make an announcement similar to the following over the loud speaker:
Today has been a sad day for all of us. We encourage you to talk about ___________________________
________’s death with your friends, your family, and whoever else gives you support. We will have
special staff here for you tomorrow to help in dealing with our loss. Let us end the day by having the
whole school offer a moment of silence for ____________________________________________.
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Day 2
Sample Announcement, Day 2
On the second day following the death, many schools have found it helpful to start the day with another
homeroom announcement. This announcement can include additional verified information, re-emphasize
the continuing availability of in-school resources, and provide information to facilitate grief. Here’s a
sample of how this announcement might be handled:
We know that ________________________________’s death has been declared a suicide. Even though
we might try to understand the reasons for his/her doing this, we can never really know what was going
on that made him/her take his/her life. One thing that’s important to remember is that there is never just
one reason for a suicide. There are always many reasons or causes, and we will never be able to figure
them all out.
Today we begin the process of returning to a normal schedule in school. This may be hard for some of us
to do. Counselors are still available in school to help us deal with our feelings. If you feel the need to
speak to a counselor, either alone or with a friend, tell a teacher, the principal, or the school nurse, and
they will help make the arrangements.
We also have information about the visitation and funeral. The visitation will be held tomorrow evening at
the ______________________________ Funeral Home from 7 to 9 p.m. There will be a funeral Mass
Friday morning at 10:00 a.m. at ____________________________________ Church. In order to be
excused from school to attend the funeral, you will need to be accompanied by a parent or relative, or
have your parent’s permission to attend. We also encourage you to ask your parents to go with you to the
funeral home.
[Reprinted from Underwood, M., & Dunne-Maxim, K. (1997). Managing sudden traumatic loss in the schools.
Piscataway, N.J.: University of Medicine and Dentistry of New Jersey.]
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Tool 3.A.6: Sample Letter to Families
(USE WITH TOOL 3.A)
Dear Parents,
I am writing this letter with great sadness to inform you that one of our sophomore students took his life
last evening. Our thoughts and sympathies go out to his family and friends.
All of the students were given the news of the death by their teacher in homeroom this morning. I have
included a copy of the announcement that was read to them. Members of our crisis team met with students
individually and in groups today and will be available to the students over the next days and weeks to
help them cope with the death of their peer.
Information about funeral services will be given to the students once it has been made available to us.
Students will be released to attend services only with parental permission and pick up, and we strongly
encourage you to accompany your child to any services.
I am including information about suicide and some talking points that can be helpful to you in discussing
this issue with your teen. I am also including a list of school and community resources should you feel
your child is in need of additional assistance. If you need immediate assistance, call the National Suicide
Prevention Lifeline at 1-800-273-TALK (8255).
Please do not hesitate to call me or one of the counselors if you have questions or concerns.
Sincerely,
(Principal)
[Adapted from AFSP. After a suicide: A toolkit for schools. Newton, MA: Education Development Center, Inc. Available
online at http://www.sprc.org/sites/sprc.org/files/library/AfteraSuicideToolkitforSchools.pdf
and http://www.afsp.org/files/Surviving/toolkit.pdf]
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Tool 3.A.7: Talking Points for Students and Staff after a Suicide
(USE WITH TOOL 3.A)
Talking Points What to Say
Give accurate information about suicide.
Suicide is a complicated behavior. Help students
understand the complexities.
“Suicide is not caused by a single event such as
ghting with parents, or a bad grade, or the breakup
of a relationship.”
“In most cases, suicide is caused by mental health
disorders like depression or substance abuse
problems. Mental health disorders affect the way
people feel and prevent them from thinking clearly
and rationally. Having a mental health disorder is
nothing to be ashamed of.”
“There are effective treatments to help people who
have mental health disorders or substance abuse
problems. Suicide is never an answer.”
Address blaming and scapegoating.
It is common to try to answer the question “why”
by blaming others for the suicide.
“Blaming others for the suicide is wrong, and it’s not
fair. Doing that can hurt another person deeply.”
Do not talk about the method.
Talking about the method can create images
that are upsetting, and it may increase the risk
of imitative behavior by vulnerable youth.
“Let’s focus on talking about the feelings we are left
with after _______________’s death and gure out
the best way to manage them.”
Address anger.
Accept expressions of anger at the deceased.
Help students know these feelings are normal.
“It is okay to feel angry. These feelings are
normal, and it doesn’t mean that you didn’t care
about_____. You can be angry at someone’s
behavior and still care deeply about that person.”
Address feelings of responsibility.
Help students understand that the only person
responsible for the suicide is the deceased.
Reassure those who have exaggerated feelings
of responsibility, such as thinking they should
have done something to save the deceased or
seen the signs.
“This death is not your fault. We cannot always see
the signs because a suicidal person may hide them
well.”
“We cannot always predict someone’s behavior.”
Encourage help-seeking.
Encourage students to seek help from a trusted
adult if they or a friend are feeling depressed or
suicidal.
“We are always here to help you through any
problem, no matter what. Who are the people you
would go to if you or a friend were feeling worried,
depressed, or had thoughts of suicide?”
[Adapted from AFSP. After a suicide: A toolkit for schools. Newton, MA: Education Development Center, Inc. Available
online at http://www.sprc.org/sites/sprc.org/files/library/AfteraSuicideToolkitforSchools.pdf
and http://www.afsp.org/files/Surviving/toolkit.pdf]
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Tool 3.A.8: Guidelines for Memorialization
(USE WITH TOOL 3.A)
Memorializing a student who has died by suicide can be a difficult process. Faculty, students, and the
family of the deceased may have different ideas of what is appropriate, inappropriate, or useful. It is important
to be prepared to respond to and channel the need of people to grieve into activities that will not raise the
suicide risk of vulnerable students or escalate the emotional crisis. The following guidelines will help you
prepare to face these challenges:
1. Establish a policy on memorialization for all deaths (including suicide). This policy should
address the issues below. The family should be consulted in each case.
Flags: Flags should not be own at half-staff. Only the President or a governor has the
authority to order ags to be own at half-staff.
Memorials: Spontaneous memorials (such as collections of objects and notes) should not be
encouraged and should be respectfully removed within a very short time. A memorial can be
an upsetting reminder of a suicide and/or romanticize the deceased in a way that increases
risk for suicide imitation or contagion.
Assemblies: Large memorial assemblies should not be convened as the emotions generated at
such a gathering can be difcult to control.
Graduations: Acknowledge a death at graduation but do not glamorize the death or let the
acknowledgement overwhelm the event. Acknowledge a death toward the beginning of an
event and then move on.
Funerals: Do not hold funerals at the school. This can forever associate the room in which
services are held with the death.
2. Consult with the family about memorials. The person designated as the liaison with the family
needs to be prepared to explain the memorialization policy to the family while respecting their
wishes as well as the grieving traditions associated with their culture and religion.
3. Solicit ideas to memorialize the deceased in positive ways that do not put other students at risk
or contribute to the emotional crisis that occurs after a death. Consult with the family before
implementing any of the following ideas:
Invite students to write personal and lasting remembrances in a memory book located in the
guidance ofce, which will ultimately be given to the family.
Encourage students to engage in service projects, such as organizing a community service
day, sponsoring behavioral health awareness programs, or becoming involved in a peer
counseling program.
Invite students to make donations to the library or to a scholarship fund in memory of
the deceased.
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4. Be prepared to address the unique aspects of a suicide death:
Use the opportunity to educate students, families, and the community about suicide.
Monitor social media sites for signs of risk to other students.
SOURCES:
Adapted from AFSP. After a suicide: A toolkit for schools. Newton, MA: Education Development Center,
Inc. Available online at http://www.sprc.org/sites/sprc.org/files/library/AfteraSuicideToolkitforSchools.
pdf and http://www.afsp.org/files/Surviving/toolkit.pdf
Kerr, M., Brent, D., McKain, B., & McCommons, P. (2003). Postvention standards manual: A guide for a
school’s response in the aftermath of sudden death (4th ed.). Pittsburgh: University of Pittsburgh/Western
Psychiatric Institute and Clinic.
Underwood, M., Fell, F. T., & Spinazzola, N. A. (2010). Lifelines postvention: Responding to suicide and
other traumatic death. Center City, MN: Hazelden Publishing.
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Tool 3.A.9: Guidelines for Working with the Media
(USE WITH TOOL 3.A)
The staff person responsible for working with the media should prepare a written statement for release to
those media representatives who request it. The statement should include the following:
A very brief statement acknowledging the death of the student that does not include details about
the death
An expression of the school’s sympathy to the survivors of the deceased
Information about the school’s postvention policy and program
All other staff (including school board members) should:
Refrain from making any comments to or responding to requests from the media
Refer all requests from the media to the person responsible for working with the media
Media representatives should:
Not be permitted to conduct interviews on the school grounds
Not be allowed to attend parent and student group meetings in order to protect information shared
by parents who are concerned about their children
Be provided with a copy of SPRC’s information sheet “At-a-Glance: Safe Reporting on Suicide,”
which can be found at http://www.sprc.org/library/at_a_glance.pdf
[Adapted from Kerr, M., Brent, D., McKain, B., & McCommons, P. (2003). Postvention standards manual: A guide
for a school’s response in the aftermath of sudden death (4th ed.). Pittsburgh: University of Pittsburgh/Western
Psychiatric Institute and Clinic.]
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Tool 3.B: Long-Term Response Protocol
Steps to Take in Long-
Term Aftermath
Staff Responsible Relevant Contacts Resources
1. Coordinate
implementation of long-
term response protocol
Lead:
Backup:
2. Monitor and assist
vulnerable students
Lead:
Backup:
Community mental
health professionals:
3. Prepare for
anniversaries of the
death
Lead:
Backup:
Tool 3.B.1:
Guidelines for
Anniversaries
of a Death
4. Prepare for long-term
memorials
Lead:
Backup:
5. Prepare to provide
support to siblings of
the deceased who may
be enrolling in the high
school
Lead:
Backup:
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Tool 3.B.1: Guidelines for Anniversaries of a Death
(USE WITH TOOL 3.B)
A revisiting of grief feelings can resurface on or near the anniversary date of a tragic loss. In some
cultures there is a memorial ceremony held about one year after a death. Faculty and staff, if reminded of
the anniversary, can be prepared to monitor and support students at that time. Adults are not immune to
this, and so staff members may also revisit the loss. The postvention team may consider a follow-up
program on the anniversary date. The school should be prepared for grief and emotions associated with
the death that may also occur on other occasions, such as:
The birthday of the person who died
Holidays
Athletic or other events in which the deceased would have participated
The start of a school year
Proms
Graduation
The following actions can help a school prepare for such an anniversary:
Remind staff to be aware that students may experience emotional reactions
Educate staff about the warning signs of suicide and how to recognize and respond to students
who may be at risk or experience severe emotions
Remind staff that they may also experience an emotional reaction on this date
Have grief counselors or mental health professionals on call
[Adapted from Kerr, M., Brent, D., McKain, B., & McCommons, P. (2003). Postvention standards manual: A guide
for a school’s response in the aftermath of sudden death (4th ed.). Pittsburgh: University of Pittsburgh/Western
Psychiatric Institute and Clinic.]
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CHAPTER 4
Staff Education and Training
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STAFF EDUCATION
AND TRAINING
The steps in Chapter 4 will answer these questions:
Who needs to be involved in developing the plan to educate and train staff?
What suicide-related information do all staff need to know?
What is “gatekeeper training,” and who needs it?
What type of suicide assessment training is recommended and should the staff
receive it?
WHY IS IT IMPORTANT THAT SCHOOL STAFF RECEIVE EDUCATION AND
TRAINING?
Raising staff awareness about suicide and training staff to take steps that prevent it are
important components of any school suicide prevention program:
All staff should be made aware that suicide poses a risk to their students and that
the school is taking steps to reduce this risk.
All staff should be trained to recognize the warning signs of suicide in young
people and to take appropriate action if they become aware of a student who
displays these warning signs.
Appropriate mental health professionals should be trained to assess the suicide
risk of individual students.
STEPS FOR CHOOSING AND IMPLEMENTING SUICIDE PREVENTION
EDUCATION AND TRAINING FOR STAFF
Step 1: Convene a group to assess your staff’s education and training needs.
For additional resources, see Staff Education and Training in the “Resources” section
at the end of the toolkit.
Tool 1.B: Chart of School Staff Responsibilities (see Chapter 1) will help you identify and
record the names of members of the school staff who should be involved in this effort.
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Step 2: Provide all staff with information and awareness about suicide and
the school’s role in suicide prevention.
All school staff should understand that suicide poses a risk to students and that the school
is taking steps to reduce this risk. The staff should be made aware that the school’s
mission includes providing a safe environment in which education can take place and that
the mental health of students affects their academic performance.
You may want to combine suicide awareness education with information about your
school’s suicide prevention activities (i.e., the activities described in Chapters 2–7 of this
toolkit). It may be less intimidating for staff to learn about the risk that suicide poses to
students if, at the same time, they hear that the school is taking steps to reduce this risk.
And, understanding the risk that suicide poses to their students will motivate the staff to
support the school’s suicide prevention activities.
Tool 1.A: Suicide Prevention: Facts for Schools (see Chapter 1) includes an overview of
the problem of adolescent suicide and the role schools can play in preventing suicide.
Tool 1.D: Risk and Protective Factors and Warning Signs Factsheets (see Chapter 1)
describes the factors that increase the risk of adolescent suicide as well as those that
protect against it. The factsheets also detail warning signs that a young person may be at
immediate risk.
The Getting Started part of the “Resources” section contains a number of publications
and factsheets that may be used to educate staff about suicide and suicide prevention.
Step 3. Train staff to identify suicide risk factors and warning signs among
students and to take appropriate action.
Training all school staff—faculty; administrators; office staff; staff in the athletic
facilities, cafeteria, and transportation departments; and classroom volunteers from the
community—to recognize and respond appropriately to students who may be at risk of
suicide can save lives because:
Staff see students on a daily basis and thus are in a position to recognize changes
in personality, appearance, and performance that may indicate a student is at risk
for suicide
Students may turn to a trusted staff member for help
Students may conde in a trusted adult at school if they are worried about a
friend or classmate
In addition to the type of suicide awareness education described under Step 2 (above),
specialized training programs are available that teach staff to:
Identify individuals who may be at risk for suicide (by recognizing warning signs
and understanding risk factors)
Verify this risk by talking with the individual
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Refer the individual to mental health services that will help reduce their risk
Many, but not all, of these programs describe themselves as “gatekeeper training.”
Some gatekeeper trainings teach people additional skills, including how to do
the following:
Reduce a person’s suicide risk by talking with them
Keep a person at imminent risk of suicide safe until additional help can be found
Facilitate referrals and increase the likelihood a person at risk will receive
professional help
Schools that implement gatekeeper training programs may experience an increase in the
number of students who seek help for behavioral health problems, including those related
to suicide. Therefore, schools should put in place the components described in Chapters
1–3 in this toolkit before implementing gatekeeper training. These components include
protocols to respond to students at risk and in crisis.
Select a gatekeeper training program.
There are a number of gatekeeper training programs available from commercial and
nonprofit sources. These vary greatly in length and format and include:
Brief online or video trainings
Curricula for training that schools can implement themselves
Single or multi-day workshops by certied trainers
Before selecting a gatekeeper training program, check whether your State has any
requirements about training high school staff on suicide prevention. State policies on
suicide prevention in schools are listed on the State Information pages of the Suicide
Prevention Resource Center Web site: (http://www.sprc.org/stateinformation/index.asp).
The SPAN USA Web site has updates on all suicide-related State legislation: http://www.
afsp.org/index.cfm?fuseaction=home.viewPage&page_id=DDB4817F-AFFD-AB5B-
65FFA5FF8FD4DDCC.
The most effective gatekeeper training programs include opportunities for the participants
to practice their skills during role-playing and other interactive activities. Training
programs that do not provide these opportunities can still be useful to educate and raise
the awareness of staff about suicide and suicide prevention (discussed in Step 1 above).
The training appropriate for your school will depend on a number of factors, including
the cost and the time staff have to devote to a training, as well as the cultural groups
represented in your student body.
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The three sources below can help you choose the program(s) that is/are best for
your needs:
1. Tool 4.A: Matrix of Staff Education and Training Programs lists the programs
that are in the National Registry of Evidence-Based Programs and Practices
(NREPP) or the Best Practices Registry (BPR). The matrix contains basic
information to help you determine which program(s) to choose.
2. The Staff Education and Training: Identifying Suicide Risk part of the
“Resources” section in this toolkit provides additional information about these
programs.
3. The guide To Live To See the Great Day That Dawns describes the applicability
of some of the staff education/training programs to American Indian
and Alaska Native communities. See pages 76–83 of this guide, located
at http://www.sprc.org/library/Suicide_Prevention_Guide.pdf.
Adapt gatekeeper training for your school.
How students display the warning signs of suicide can differ by culture, as can student
attitudes about suicide and sharing personal information, speaking with adults, or seeking
help. Staff attitudes towards suicide, their role in suicide prevention, and how trainings
should be implemented can also vary by culture.
You may want to adapt a gatekeeper training program for the culture(s) of your students
and staff. Note that any adaptation made for cultural reasons should take into account the
diverse cultures of all students within the school or district and should not rely on
stereotypes or overly broad generalizations about a culture. It is very important to avoid
changing a training program in any way that would undermine its effectiveness. The
developer of the gatekeeper program you choose may be able to:
Tell you what aspects of the program may be changed without damaging
program effectiveness
Identify schools or organizations that have successfully adapted their training for
schools with a student population similar to that of your school
If you think a training program might need to be adapted for your school, you should
explore this issue of adaptation before finalizing your choice. You should contact the
developer of the training program to discuss the adaptation.
click to sign
signature
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Cultural Competency and Gatekeeper Training
It can be invaluable to involve knowledgeable representatives from local cultural groups to
help your staff understand how young people from their communities think about suicide,
mental illness, and help-seeking and then adapt your training to be effective with these groups.
The Maine Youth Suicide Prevention Program is modifying its gatekeeper training program
so that it is more appropriate for identifying suicide risk among tribal youth and adults.
Program staff are being advised by members of the Penobscot Nation Prevention Coalition
on how to adapt the program to be appropriate to their cultures. The team has been advised
to add information to the training on specific culturally relevant risk factors, such as
hopelessness caused by generational trauma and racism, the difficulty of transitioning from
a middle school on a reservation to an off-reservation high school, and prescription drug
abuse. Similarly, tribal leaders emphasized the importance of protective factors, such as
cultural practices and connections to community-based service providers, families, and
elders. The trainers were advised to add opening and closing ceremonies and small talking
circles that would allow participants to discuss information they received at the end of the
training day. Program staff noted that is important to make cultural adaptation an iterative
process that responds to the needs of specific cultural groups as these needs become evident
during training activities.
The QPR Institute, working with the National Organization of People of Color Against
Suicide and the Aberdeen Area Indian Health Service, developed culturally relevant
versions of the QPR gatekeeper training’s introductory video for African Americans and
Native Americans. A version of the QPR slides was also developed for Native Americans.
QPR has certified instructors who can provide QPR training in Spanish and other languages
and has created training materials in Spanish and other languages.
Step 4. Train selected mental health staff to assess suicide risk in
individual students.
Students can exhibit a range of suicide-related behaviors, including ambiguous statements
that may indicate risk. Although most gatekeeper programs, as well as many suicide
awareness programs, teach people to recognize the warning signs indicating that a student
may be at risk for suicide, they usually do not train staff to assess the level of risk beyond
recognizing when a young person may be at immediate risk of suicide and should not be left
alone. Only a mental health professional should be trained to assess student suicide risk.
The availability of mental health staff who have been trained to assess suicide risk in
individual students is an important component of a comprehensive suicide
prevention program.
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Increasing Participation in Staff Trainings
There are a number of strategies you can use to increase participation in staff trainings,
including the following:
Use professional development funds to pay for staff training.
Make sure that suicide prevention training counts as professional development time.
Find out if CEUs are available for suicide prevention staff trainings.
When staff at one school did not show up for trainings in suicide prevention during the
summer after a suicide attempt by an incoming freshman, the school decided to hold the
trainings during the day because that worked best for the staff, pay the staff to attend, and
count the training as part of that years professional development requirement. Another
school provided suicide awareness training during the school’s regularly scheduled
professional learning group meetings.
Determine whether you have staff qualified to be trained to do suicide risk assessments.
Only professionals with some background in mental health assessments should be trained
to assess suicide risk. You may have staff in your school with these qualifications, for
example, a school psychologist, social worker, nurse, or counselor.
If your school staff does not include a mental health professional who can be trained to
assess suicide risk, check if there is one at the school district level. If not, then contract
with a mental health professional in the community to perform these assessments.
However, not all mental health professionals have been trained to assess suicide risk. It is
important to determine whether any of the mental health service providers available in
the community have staff trained to assess suicide risk and, if not, whether they are
willing to have their staff trained to conduct these assessments, using one of the training
programs described in Tool 4.A: Matrix of Staff Education and Training Programs in the
section on training programs to assess suicide risk.
Select a training program.
The two sources below can help you choose the program(s) that is/are best for
your needs:
Tool 4.A: Matrix of Staff Education and Training Programs lists programs that
provide training in assessing suicide risk and are included in the Best Practices
Registry (BPR).
The Staff Education and Training: Assessing Suicide Risk part of the “Resources”
section in this toolkit provides additional information about these programs.
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CHAPTER 4: STAFF EDUCATION AND
TRAINING TOOLS
Tool 4.A: Matrix of Staff Education and Training Programs
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Tool 4.A: Matrix of Staff Education and Training Programs
This matrix lists all of the Staff Education and Training Programs that are in either the National Registry
of Evidence-Based Prevention Practices (NREPP) or the Best Practices Registry (BPR), as of October
2010. The criteria for NREPP and BPR are different. See Tool 1.K: Suicide Prevention Registries
Information Sheet.
The first section of the matrix lists gatekeeper training programs, and the second section lists programs
that train professional staff to assess suicide risk. Several of the gatekeeper trainings center on a student
curriculum but contain other components to create a more comprehensive program. For those programs,
the matrix lists the other components, each of which is discussed in a separate chapter in this toolkit.
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STAFF EDUCATION AND TRAINING PROGRAMS
Program Registry
School
Focused
Number &
Length of
Sessions
Facilitator
& Location
Other
Components
Notes
Gatekeeper Training Programs
Be A Link!
Suicide
Prevention
Gatekeeper
Training
BPR No One 2-hour
session
Teachers who
take a 2-day
facilitator
training or
Yellow Ribbon
representatives.
Provided at
Yellow Ribbon
sites or local
locations.
Often used
with Yellow
Ribbon’s
student
program
Ask 4 Help!
Gatekeeper
Suicide
Prevention
Program: A
High School
Curriculum
BPR Yes Different
types of
training
ranging from
1 hour to 2
days
Facilitators
must be
trained by
Gryphon Place.
Delivered
onsite.
Student
Programs
Parent
Education
Mainly
available in
Michigan.
Lifelines NREPP Yes One 45–60
minute
presentation,
but up
to 1.5–2
hours with
participant
discussion
School Crisis
Response
Team member
(social worker,
psychologist,
counselor,
health teacher).
Information
on giving the
training is in
the training
materials.
Protocols
Student
Programs
Parent
Education
A 2-day,
onsite
training
on how to
implement
all the
program
components
is available
through
Hazelden
Publishing.
Making
Educators
Partners in
Youth Suicide
Prevention
BPR Yes 5 modules;
total time 2
hours
None; self-
directed online
training. Fifth
module allows
users to e-mail
questions to
a panel of
experts.
More Than
Sad: Suicide
Prevention
Education for
Teachers and
Other School
Personnel
BPR Yes 2 hours School staff. Also
suitable for
parents and
other adults
who care for
or work with
youth.
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Program Registry
School
Focused
Number &
Length of
Sessions
Facilitator
& Location
Other
Components
Notes
Question,
Persuade,
Refer (QPR)
Gatekeeper
Training
BPR No One session
of 1–2 hours
None for
online version.
Certied QPR
gatekeeper
instructors
teach the
in-person
training onsite
and at other
local locations.
Training of
trainers by QPR
available onsite
or online.
Online and
in-person
versions
are adapted
for Native
Americans
and African
Americans.
In-person
versions
available
in Spanish
and other
languages.
Response: A
Comprehensive
High School-
Based Suicide
Awareness
Program
BPR Yes One 2-hour
session
School staff.
Training for
providing
staff training
is included in
the school kit.
RESPONSE
staff will provide
training if
requested.
Protocols
Student
Programs
Parent
Education
Suicide
Alertness for
Everyone
(safeTALK)
BPR No One 3-hour
session
Trainers who
are trained and
certied by
LivingWorks.
Training
available onsite.
1-day and
2-day train-the-
trainer sessions
available for
local facilitators.
Training Programs to Assess Suicide Risk
Applied
Suicide
Intervention
Skills Training
(ASIST)
BPR No 2 days Trainers must
be trained and
certied by
LivingWorks.
Training
available onsite.
5-day train-the-
trainer sessions
available for
local facilitators.
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Program Registry
School
Focused
Number &
Length of
Sessions
Facilitator
& Location
Other
Components
Notes
Assessing
and Managing
Suicide Risk
(AMSR)
BPR No 1 day Training must
be given by
the program’s
developer.
Onsite and
other local
locations
available.
QPRT
Suicide Risk
Assessment
and Risk
Management
Training
Program
BPR No 8 hours in
classroom
or 10 hours
online
Training must
be given by
trainers certied
and licensed
to teach this
program. Onsite
and other
local locations
available.
Online and
in-person
versions
are adapted
for Native
Americans.
Recognizing
and
Responding to
Suicide Risk
(RRSR)
BPR No 2 days Training must
be given by
the program’s
developer.
Onsite and
other local
locations
available.
School Suicide
Prevention
Accreditation
Program
BPR Yes Online, self-
paced
None; self-
directed online
training.
For additional resources, see Staff Education and Training in the “Resources” section at the end of the toolkit.
CHAPTER 5
Parent/Guardian
Education and Outreach
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PARENT/GUARDIAN
EDUCATION AND
OUTREACH
The steps in Chapter 5 will answer these questions:
Who should plan and implement your school’s parent outreach program?
What kinds of parent outreach programs are available, and how do you decide
which to use?
How can you engage parents in suicide prevention?
Can suicide prevention be integrated into other programs for parents?
IMPORTANT: Schools that implement programs to educate parents about suicide may
experience an increase in the number of students who seek help for behavioral health and
suicide-related problems. Schools should put in place the components described in
Chapters 1–4, before implementing parent programs. These components include:
Protocols to respond to students at risk and in crisis
Suicide prevention education and training for all school staff
This chapter discusses parent education and outreach activities—that is, activities
designed to educate parents about suicide and related mental health issues. Several of the
other chapters describe how parents and guardians should be involved in other aspects of
a school’s suicide prevention efforts.
The word “parents” will be used in this toolkit as a shorthand term for parents; legal
guardians, including Tribal Court appointed guardians; and other primary caretakers
of students.
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WHY IS IT IMPORTANT TO PROVIDE SUICIDE PREVENTION EDUCATION
TO PARENTS AND GUARDIANS?
Providing parents with specific suicide prevention education is important for the
following reasons:
The information may help parents identify and get help for children who may be
at risk (Smith, T., Smith, V., Lazear, Roggenbaum, & Doan, 2003).
Suicide prevention education for students is more effective when it is reinforced
by the same information and messages at home (Smith et al., 2003).
Involving parents is an important way to ensure that your efforts appropriately
target the needs of your community and enhance the cultural competency of
your efforts.
What Parents Need to Know
Although parents may be aware that children die by suicide, they often do not think it could
happen to their child or in their community (Schwartz, Pyle, Dows, & Sheehan, 2010).
Parents need information about:
The prevalence of suicide and suicide attempts among youth
The warning signs of suicide
How to respond when they recognize their child or another youth is at risk
Where to turn for help in the community
STEPS FOR DEVELOPING SUICIDE PREVENTION EDUCATION AND
OUTREACH FOR PARENTS
Step 1: Convene a group to plan and implement parent education and
outreach activities.
Use Tool 1.B: Chart of School Staff Responsibilities and Tool 1.C: Chart of Community
Partners (see Chapter 1) to help you identify and record the names of staff, individuals,
and organizations that can help with your outreach activities.
Your community may have a suicide prevention coalition or group that can help develop
and implement outreach activities. Community partners—including parent groups and
representatives of the faiths, cultures, and tribes of your students—can be important to
the success of outreach activities.
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Step 2: Select or develop parent education and outreach programs.
Select or develop parent education and outreach programs that are appropriate for your
community and parents’ needs, concerns, and cultures. Remember to consider practical
issues such as cost, time, and staff availability.
You may want to use the parent education and outreach component of a packaged
program, especially if your school is already using other parts of the program. Several
programs in the Best Practices Registry (BPR) and the National Registry of Evidence-
Based Prevention Programs and Practices (NREPP) include materials for parents. The
matrix in Tool 5.A: Matrix of Parent/Guardian Education and Outreach Programs
includes some information about these materials. Additional information is available
under Parent/Guardian Education and Outreach in the “Resources” section of this toolkit.
Some things that schools should consider when designing and implementing parent
outreach and education activities include the following:
Engage parents in a variety of ways, for example, at freshman orientation,
health and safety events at the school, senior transition activities, and
other regularly scheduled events for parents. Do not limit your efforts to a
one-time event.
Select appropriate formats for outreach, such as written materials (e.g.,
newsletters, cards, emails, posters) or presentations (by school staff, a
professional from the community, or a national expert). Outreach should occur
in formats that are easily understandable, including for families of English
Language Learners.
Use existing factsheets or resources to communicate your messages. Tool
5.B: Suicide Prevention and Schools: Facts for Parents may be used in your
parent outreach efforts. Additional materials are described under Parent/Guardian
Education and Outreach in the “Resources” section of this toolkit.
Get input from people who are not a part of your planning group, but who
may have insight into reaching parents, such as bus drivers, lunch staff, or school
administrators.
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Two Successful Parent Events
A high school held a parent forum that integrated suicide prevention education
with information about the problems 12th graders face as they transition from high
school to the next stage of their lives. The forum described the behavioral health
issues students might experience during this transition, such as anxiety, depression,
and risk of suicide. There were also college counselors at the forum to offer insight
to parents about services and supports for students going away to school. The
publicity for the event did not mention suicide prevention but emphasized a focus
on “supporting your children with the transition from 12th grade.” The outreach was
a collaborative effort between the school and its parent organization, relying upon
the parents to recruit their friends and peers for what proved to be a well-attended
and successful event.
Another high school held a two-hour event for parents of high school students
called “Parent to Parent Courageous Conversation: If your child is approaching
overload—What you can do about it!” The event featured three speakers: (1)
a doctor who talked about community-based treatment programs for anxiety,
depression, and suicidal behavior; (2) a representative of a school-based suicide
prevention program; and (3) a parent advocate whose son had struggled with
behavioral health issues when he attended the high school. The presentations were
followed by a one-hour question and discussion session.
Step 3: Identify ways to increase participation among parents at events and
activities.
It can be challenging to recruit parents for suicide prevention events. Parents may be
reluctant or unable to attend these events. Effective parent education programs need to
target parents’ needs, concerns, and cultures. Some ways to increase parent participation
include the following:
Give parents what they need: Find out what the parents in your community
need to help a teen who may be at risk of suicide. For example, if parents do
not know where to get professional help for their child, provide them with
information on community resources.
Accommodate language, culture, religion, and economic status: Consider
whether the parent outreach materials and events need to be translated into
languages other than English. It may be helpful to use a cultural mediator—a
respected community member who is bilingual and bicultural. He or she can help
you design culturally appropriate materials and events, as well as help parents
understand why their participation is important to their family.
Do not use the word “suicide” in the title of the event: Parents may not attend
events if they are framed as “suicide prevention.” They may be frightened by the
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idea that their child may be at risk. Or they may come from a culture in which
suicide is never addressed directly. Schools have had greater parental support and
turnout at events when they were publicized not as suicide prevention activities,
but as efforts to:
» Promote behavioral health and wellness
» Support your child with the transition from 8th grade or 12th grade
» Learn how to keep your teenager safe
Go to parents. Don’t expect parents to come to you: If accommodating
parents’ needs does not increase the turnout at your events, you may need to
reach parents in other places, such as churches, pediatricians’ ofces, their
children’s sporting events, and continuing education classes. Ask the pastor,
pediatrician, and sports coach to collaborate with your school to educate parents
about suicide prevention.
Clarify privacy issues: Parents may be reluctant to participate because of a fear
that their private family matters will become public. You may need to explain that
schools are required to protect student and family privacy unless it conicts with
protecting the safety of a child.
Engaging Diverse Communities
A school in a predominantly Native American and Latino community successfully engaged
parents in their outreach activities by considering cultural issues while developing outreach
events. The outreach coordinator was a well-respected, long-time Latina resident who knew
many people in the community. She engaged students in presenting at the outreach events.
Because the students were excited about giving the presentation and conveyed that to their
parents, their parents were inspired to come to the event.
Other students greeted participants as they arrived and handed out flyers. Siblings of all
ages were invited to attend. Food and door prizes were provided so that the event had the
feeling of a celebration.
Step 4: Integrate parent education into existing programs.
Parent education and outreach can complement other suicide prevention activities at your
school and in your community. Educating parents about suicide may be integrated into
existing programs and activities, such as freshman orientation, parent events, and
community education programs.
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Including Suicide Prevention in Other Efforts to Reach Parents
Schools have integrated suicide prevention outreach into other activities by:
Holding a parents’ night about student safety that included suicide prevention
Sponsoring events for the parents of 8th graders or 12th graders that focused
on their children’s upcoming transition and addressing issues such as anxiety,
depression, substance use, and bullying, in addition to suicide
Sending material—sometimes in the form of a card that ts into a wallet or purse
or can be put on the family bulletin board—to the parents of every middle and high
school student with information about how to help a child in crisis
Including suicide awareness as part of freshman orientation, safety days, or other
health events at the school that involve parents
Including suicide prevention in parenting classes
Presenting suicide prevention education at a PTO meeting
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CHAPTER 5: PARENT/GUARDIAN EDUCATION
AND OUTREACH TOOLS
Tool 5.A: Matrix of Parent/Guardian Education and Outreach Programs
Tool 5.B: Suicide Prevention and Schools: Facts for Parents
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Tool 5.A: Parent/Guardian Education and Outreach Programs
The matrix on the next page lists all of the Parent/Guardian Education and Outreach Programs that are in
either the National Registry of Evidence-Based Prevention Practices (NREPP) or the Best Practices
Registry (BPR), as of October 2010. The criteria for NREPP and BPR are different. See Tool 1.K: Suicide
Prevention Registries Information Sheet.
In this matrix, all of the listings are secondary components to a student curriculum except the video “Not
My Kid.” The primary component of the program is the one around which the program is built. Secondary
components are included to strengthen the primary component and/or to create a more comprehensive
program. For each of the types of components listed, there is a separate chapter in this toolkit.
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PARENT/GUARDIAN EDUCATION AND OUTREACH PROGRAMS
Program Registry
Number &
Length of
Sessions
Leader
Other
Components
Notes
Gatekeeper
Suicide
Prevention
Program: A
High School
Curriculum
BPR 1.5-hour
workshop
Facilitators must be
trained by Gryphon
Place. Delivered
onsite.
- Staff Training
- Student
Program
Mainly
provided just in
Michigan.
Lifelines NREPP One 45–60
minute
presentation,
but up
to 1–1.5
hours with
participant
discussion
School Crisis
Response Team
members (social
worker, psychologist,
counseling staff,
health teacher).
Information on giving
the training is in the
training materials.
- Protocols
- Staff Training
- Student
Program
A 2-day, onsite
training on how
to implement
all the program
components
is available
through
Hazelden
Publishing.
Not My Kid BPR 17-minute
video online
None
Response: A
Comprehensive
High School-
Based Suicide
Awareness
Program
BPR 1-hour
workshop
School staff. Training
for providing parent
education is included
in the school kit.
RESPONSE staff
will provide training if
requested.
- Staff Training
- Student
Program
Parent training
is separate
from the main
school kit.
For additional resources, see Parent/Guardian Education and Outreach in the “Resources” section at the end of
the toolkit.
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Tool 5.B: Suicide Prevention and Schools: Facts for Parents
This factsheet is designed to educate and gain the support of parents for implementing suicide prevention
initiatives in high schools. It includes an overview of the problem of adolescent suicide, explains why it is
important to address suicide risk among students, and discusses the roles that parents and schools can play
in prevention.
This factsheet can also be found in the “Handouts” section of this Toolkit, which begins on page 209.
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SUICIDE PREVENTION: FACTS FOR PARENTS
HIGH SCHOOL STUDENTS EXPERIENCE UNIQUE CHALLENGES
High school can be a rewarding time for young people. But for some students, it can also be emotionally
difficult, especially in 9th grade during the transition to high school and again in 12th grade during the
transition out of high school.
The stresses of high school and the mental and emotional stage of adolescence can combine with risk
factors for suicide, such as depression, and increase the risk of suicide for some teens. Parents and school
staff can help identify students at risk of suicide and help them get treatment before a tragedy occurs.
Many high school students reported that they had seriously considered
suicide in the past year.
One out of every 53 high school students (1.9 percent) reported having made a
suicide attempt that was serious enough to be treated by a doctor or a nurse.
Suicide is the third leading cause of death among teenagers.
The toll among some groups, such as Native Americans, is even higher.
Source: Centers for Disease Control and Prevention (CDC)
WHY HIGH SCHOOLS ADDRESS SUICIDE
Administrators and staff care about the well-being of their students.
Maintaining a safe and secure school environment is part of a school’s overall mission.
Depression and other mental health issues can interfere with children’s ability to learn and affect
their academic performance.
Although few suicides take place on high school campuses, students spend much of the day in school.
This puts high schools in a position to identify and help students who may be at risk for suicide and
related behavioral health issues.
PREVENTING SUICIDE CAN PREVENT OTHER BEHAVIOR PROBLEMS
Students at risk of suicide may also be at risk of other problem behaviors, such as violence and bullying,
and substance abuse. Reducing the risk of suicide can help reduce the likelihood of these other behaviors.
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Parents can help protect their children from suicide risk by:
Maintaining a supportive and involved relationship with their sons and daughters
Understanding the warning signs and risk factors for suicide
Knowing where to turn for help
HOW SCHOOLS CAN HELP PREVENT SUICIDE
Experts recommend that schools use an approach to suicide prevention that includes the following:
Identifying students at possible risk of suicide and referring them to appropriate services
Responding appropriately to a suicide death
Providing training and suicide awareness education for staff
Educating parents regarding suicide risk and mental health promotion
Educating and involving students in mental health promotion and suicide prevention efforts
Screening students for suicide risk
You should encourage your high school to implement some or all of these strategies to prevent suicide
and protect the well-being of your children. You can work with the school on these important efforts as
well as use the school as a resource for help with your child’s needs.
CHAPTER 6
Student Programs
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STUDENT
PROGRAMS
The steps in Chapter 6 will answer these questions:
Who should be involved in developing or selecting suicide prevention programs for
your students?
What are the differences among the types of suicide prevention programs:
education, skill-building, and peer leader?
What specic programs are available, and how can you decide which are right for
your school?
How can you make programs culturally appropriate for your student body?
How can you include suicide prevention activities in existing programs?
IMPORTANT: Schools implementing student programs that address suicide may
experience an increase in the number of students who seek help for behavioral health and
suicide-related problems. Schools should put in place the components described in
Chapters 1–4, before implementing student programs. These components include:
Protocols to respond to students at risk and in crisis
Suicide prevention education and training for all school staff
WHY ARE STUDENT PROGRAMS THAT ADDRESS SUICIDE IMPORTANT?
Research indicates that most youth who are suicidal talk with peers about their concerns
rather than with adults, yet as few as 25 percent of peer confidants tell an adult about
their suicidal peer (Kalafat, 2003).
Student programs that address suicide can play a significant role in reducing risk for
suicide when they are used in conjunction with other strategies, such as protocols and
staff training. There are three types of student programs, each with different objectives.
They are as follows:
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Curricula for all students
» Provide information about suicide prevention
» Promote positive attitudes
» Increase students’ ability to recognize if they or their peers are at risk for
suicide
» Encourage students to seek help for themselves or their peers
Skill-building programs for at-risk students
» Help protect at-risk students from suicide by building their coping, problem-
solving, and cognitive skills
» Address problems that can lead to suicide, such as depression and other
mental health issues, anger, and drug use
Peer leader programs
» Teach selected students skills needed to help students at risk
» Empower selected students so that they can take action to improve the school
environment
STEPS TO DEVELOP OR SELECT STUDENT PROGRAMS
Step 1: Convene a group to plan and implement student programs.
Determine which individuals will take the lead in developing and implementing student
programs. Use Tool 1.B: Chart of School Staff Responsibilities (see Chapter 1) to help
you identify and record the names of the individuals who should be a part of this group.
Step 2: Determine which type(s) of student program(s) will t the needs of
your school.
The types of student education programs that you may want to implement will depend
upon the needs of your students as well as the resources available in your school. Some
schools may have the need and the resources to implement all three types of programs.
Other schools may find it more appropriate and possible to only implement programs
representing one or two of the program types.
Tool 6.A: Types of Student Programs Information Sheet will help you decide which types
of programs are appropriate for your school based on their objectives, content, format, and
target audience, and whether they address health education standards.
Step 3: Choose or develop the specic program(s) you want to implement
at your school.
Choose the specific program(s) that meet the needs of your students and school and that
fit with the resources you have available. Be sure to take into consideration the cultural
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backgrounds of your students. Keep in mind that every suicide prevention strategy or
program has its own strengths and limitations. The sources below can help you choose
the program(s) that is/are best for your needs.
Tool 6.B: Matrix of Student Programs lists the programs that are in the National Registry
of Evidence-Based Programs and Practices (NREPP) or the Best Practices Registry
(BPR). The matrix contains basic information to help you determine which program(s)
to choose.
The Student Education and Skill-Building part of the “Resources” section in this toolkit
provides additional information about these programs.
The guide To Live To See the Great Day That Dawns describes the applicability of some
of the student programs to American Indian and Alaska Native communities. See pages
76–87 of the guide, located at http://www.sprc.org/library/Suicide_Prevention_Guide.pdf.
You should consider using the Health Curriculum Analysis Tool (HECAT) to help you
decide which program to use. The HECAT provides guidance in using evidence-based
health education standards and population-specific information (e.g., was the curriculum
deemed effective for a population similar to your population?) to determine which
curriculum is the most appropriate. Suicide is included in the violence prevention section.
For more information on HECAT,
see: http://www.cdc.gov/healthyyouth/HECAT/index.htm.
One of the goals of any student program is to increase the likelihood that a student will
identify a peer who may be at risk of suicide and refer him or her to an appropriate adult.
Therefore, when implementing any of these programs, staff should let students know that
they should turn to a trusted adult with a concern. They can also let students know that
the school has a designated suicide risk response coordinator and procedures for making
referrals, as described in Chapter 2.
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Examples of Peer Leader Programs
Although there is only one peer leader program in the Best Practices Registry (Sources of
Strength), some organizations and schools have developed or adapted other peer leader
programs, including those listed below, as part of their suicide prevention efforts. These
programs provide examples of other innovative approaches, but none of them have applied
to the BPR. More information on these programs can be found in the Student Education and
Skill-Building part of the “Resources” section in this toolkit.
Students for Students: A Youth-Centered Suicide Prevention Program: Students are
recruited to apply for this program. Once selected, the peer leaders are trained to work
directly with clinicians to identify and assist other students with getting services, support, or
clinical help. Peer leaders also increase awareness of behavioral health issues and improve
the school environment by talking with students, teaching classes, and organizing events.
Natural Helpers: Students selected by other students are trained to help their peers with a
wide variety of youth issues by listening to them and assisting them in getting help from
adults. They also help improve the school environment and increase the connections
between students and staff. Although Natural Helpers is not focused on suicide prevention,
some schools have given their peer leaders in this program specific training on suicide
prevention and included this program in their suicide prevention efforts.
Native H.O.P.E. (Helping Our People Endure): Focused on suicide prevention, this
program is specifically designed for Native American youth by incorporating Native
American culture, traditions, spirituality, ceremonies, and humor. The youth develop and
carry out a strategic action plan to implement prevention activities related to suicide,
depression, trauma, violence, and substance abuse. They also provide support to their peers
and assist them with getting help for behavioral health issues.
Curricula for Transition Grades
A small number of curricula are available that integrate suicide prevention with preparing
students for the transition into or out of high school. Typically for 8th and 12th graders,
these lessons cover the specific issues surrounding their transition and address suicide
prevention in that context. A few schools have developed their own lessons, and the SOS
(Signs of Suicide) program has developed a lesson for 11th and 12th graders.
Step 4: Adapt student programs for your school community.
Student programs sometimes need to be adapted for a school’s students. There may be
cultural differences in how students display the warning signs of suicide and in their
attitudes about suicide, as well as in how they feel about sharing personal information,
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speaking with adults, or seeking help. Note that any adaptation made for cultural reasons
should take into account the diverse cultures of all students within the school or district
and should not rely on stereotypes or overly broad generalizations about a culture.
Knowledgeable representatives from cultural groups and organizations serving LGBT
youth and youth with disabilities in your community can help you understand how young
people from your community think about mental health, help-seeking, and suicide.
A major concern with adapting an evidence-based program is maintaining its integrity
so that the positive outcomes will still be attained. If you think a program might need to
be adapted for your school, you should explore the issue of adaptation before choosing
a program.
The developer of a program may be able to:
Tell you what aspects of the program may be changed without
impacting effectiveness
Identify schools or organizations that have successfully adapted the program for a
student population similar to yours
Adding to SOS to Make It More Relevant for Native American Youth
The Gallup, New Mexico, schools wanted to make the SOS (Signs of Suicide) program
relevant for their Native American students while still maintaining fidelity in the
implementation of the program. Peer leaders from the school’s Natural Helpers program
created 2–3-minute video vignettes based on the content of the SOS video but using Native
American youth, reservation language, and issues familiar to the youth in that community.
These vignettes were shown in class after the SOS video. The changes made a difference.
According to Norma Vazquez, the State of New Mexico Youth Suicide Prevention
Coordinator, “When students saw a reflection of themselves and their experience in the
videos, it increased the power of the message for them.”
The Natural Helpers students also created laminated business cards and flyers listing local,
culturally appropriate sources of help for mental health issues.
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Video for Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ)
Youth
To address the issue of suicide among LGBTQ youth, the OUTLoud Project of the Youth
Suicide Prevention Program in Washington State produced the video “You Are Not Alone:
LGBTQ Youth and Suicide,” featuring three LGBTQ youth speaking from their personal
experiences with depression, self-harm, and being suicidal. The video also educates youth
about the risk and protective factors for suicide that are specific to LGBTQ youth and how
to intervene when they think a friend is contemplating suicide. The video was written and
produced by LGBTQ youth working with an adult advisor. It can be used as part of a suicide
prevention program for all students.
To view the video, go to
http://www.youtube.com/watch?v=b3OLfTjOxYs&feature=play er_embedded
A Program Tailored for Latina Adolescents
Comunilife, a nonprofit organization in New York City providing health, behavioral health,
and social services to a largely Latino population, created an innovative mental health and
youth development program that serves the needs of Latina adolescents in a culturally
appropriate way. Its purpose is to decrease suicide risk in girls who are currently receiving
clinical services. From their experience working with this population and through convening
a focus group of teens and their families, the staff of Comunilife learned that Latina girls
and their families often find traditional mental health services intrusive, not responsive to
their needs, and not effective. In addition, girls often do not talk with their parents about
their problems because they are afraid everyone in their family will find out.
Comunilife’s Life is Precious program is designed to respond to the girls’ desire to have a
place to go where they can be themselves, be involved in activities, have fun, and have
someone available to talk with if they want to talk. The girls can go to the program every
day after school until 7:30 p.m. and for several hours on Saturday. They can have a snack,
get help with homework, use the Internet, participate in creative art therapy groups, and/or
talk with the adult staff or a counselor at any time. Parents can also drop by if they want to
talk about their problems. On Saturdays, there are group discussions where the girls and
their parents discuss together cultural, school, and parenting issues to help them understand
each other better and strengthen the parent/child relationships.
This program works because it takes into account the girls’ culture and needs. It provides an
informal setting that is available almost every day for the girls to visit without the time limit
of a set appointment or requirement to talk with a provider. The girls can obtain help when
they feel the need for it. In its two years of operation, Life is Precious participants and their
families have reported decreases in suicidal ideations, improvement in academic
performance, and better relationships and communication with family and peers.
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Step 5: Integrate suicide prevention programs into other initiatives to
improve behavioral health.
There are a variety of ways to integrate suicide prevention into other initiatives for
students. Suicide prevention is often incorporated into a health class or other health
programs, such as a health and safety day. Skill-building programs for students at risk
usually address suicide in the context of other issues, such as depression, anger, substance
abuse, and violence prevention.
Some schools offer a peer leadership program that includes training for the peer leaders
about suicide prevention, behavioral health, and other related issues such as dating
violence. Some schools also use activities that build a culture in which students look out
for each other and learn how to help a peer in distress.
Adding Suicide Prevention to Existing Programs
Two districts addressed suicide as part of their Federal Safe Schools/Healthy Students grant,
which focuses on violence prevention (bullying) and mental health awareness and
promotion. Another school planned a study hall with freshman on technology and
cyberbullying. At one school, the SADD group emphasized that “friends help friends,”
which was a theme connected to the suicide prevention classroom curricula used by
the school.
Using Social Media for Suicide Prevention in a School-Based Program
Here are some examples of how students in the peer leader program Sources of Strength use
social media for suicide prevention:
Suicide prevention materials are given to students to post on their Facebook pages.
Students are building a team to make videos and create stories of sources of strength
that they will put out through their social networks on Facebook and the Web.
When peer leaders read suicide-related comments in text messages or on Facebook,
they pass them on to their trusted adults or the adult advisors in the program so that
the adults can intervene and help the suicidal youth.
When peer leaders read harassing text in text messages or online, they interrupt it
with a simple comment such as “not cool” and/or provide support to the individual
being harassed.
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Connecting Students to a Suicide Prevention Web Site that Uses Social Media
Reach Out is a Web site (http://us.reachout.com/) for high school students to find
information about suicide prevention and other behavioral health issues, share their stories,
discuss issues of concern, ask questions, support peers, and connect with support services. It
is part of the WeCanHelpUs Campaign. The content, which is researched and written by
young people, is delivered through blogs, MySpace, video games, Short Message Service
(SMS), Podcasts, digital storytelling, and moderated discussions via online communities.
Schools can encourage students to use Reach Out by displaying posters and Web site
banners with information about the Web site.
The posters may be ordered by phone at 1-877-SAMHSA-7 or online at http://store.samhsa.
gov/product/We-Can-Help-Us/ADC10-SUICIDEP.
The Web site banners may be ordered at http://psacentral.adcouncil.org.
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CHAPTER 6: STUDENT PROGRAMS TOOLS
Tool 6.A: Types of Student Programs Information Sheet
Tool 6.B: Matrix of Student Programs
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Tool 6.A: Types of Student Programs Information Sheet
CURRICULA FOR ALL STUDENTS
Purpose: These curricula:
Provide information about suicide prevention
Promote positive attitudes
Increase students’ ability to recognize if they or their peers are at risk for suicide
Encourage students to seek help for themselves and their peers
Content: Typical content includes:
Basic information about depression and suicide
Warning signs that indicate a student may be in imminent danger of suicide
Underlying factors that place a student at higher risk of suicide
Appropriate responses when someone is depressed or suicidal
Help-seeking skills and resources
Participants: These curricula are usually offered to all students in a class or a grade. Some programs,
schools, districts, and funders require consent from parents for their child to participate. The children of
parents who do not give consent are provided with an alternative activity.
Format: These curricula are typically given in one to four class periods of 45–60 minutes each. They are
often given as part of a class, such as a health, family life, or life skills class, which addresses related
topics (e.g., mental health issues, substance abuse, bullying, and other violence). This enables the
connections between the issues to be highlighted. Sometimes they are implemented during other classes,
such as English.
Heath education standards: Almost all of the curricula address at least some, if not most, of the National
Health Education Standards. Some states have their own standards. State standards are typically aligned
with the national standards.
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SKILL-BUILDING PROGRAMS FOR STUDENTS AT RISK OF SUICIDE
Purpose: These programs help protect at-risk students from suicide by:
Building their coping, problem-solving, and cognitive skills
Addressing related problems such as depression and other mental health issues, anger, and
substance abuse
Content: Typical content includes exercises and activities to:
Increase problem-solving and coping skills
Improve resilience and interpersonal relationships
Prevent or reduce self-destructive behavior
Format: These programs fit into regular class periods and are given as a separate class. They typically last
from 12 weeks to a semester.
PEER LEADER PROGRAMS
Purpose: Peer leader programs teach selected students skills to identify and help peers who may be at risk.
Some programs teach peer leaders to build connectedness among students and also between students and
staff, which improves the school environment.
Format: These programs are usually held outside of class time.
Peer leader roles: Roles vary greatly by program and may include:
Listening to and supporting peers, educating them about mental health problems, and encouraging
them to seek help, as well as talking with adults about students possibly at risk for suicide and other
mental health problems
Presenting lessons to their peers in high school classes, to middle school students, and/or to youth
in the community
Developing and promoting messages to change the school environment through public service
announcements, posters, videos, Web sites, and text messaging
Peer leader training: The training varies according to the roles taken on by the peer leaders. Basic
components of these trainings include:
Teaching about the risk factors and warning signs of suicide
Dispelling myths about suicide
Destigmatizing mental illness and seeking help
Learning about other health and behavioral health problems, as well as other common issues
teenagers face
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Tool 6.B: Matrix of Student Programs
This matrix lists all of the Student Programs that are in either the National Registry of Evidence-Based
Prevention Practices (NREPP) or the Best Practices Registry (BPR) as of October 2010. The criteria for
NREPP and BPR are different. See Tool 1.K: Suicide Prevention Registries Information Sheet.
All of the programs in this matrix are the primary or sole component of the program. The primary
component of the program is the one around which the program is built. Secondary components are included
in some of the programs to strengthen the primary component and/or to create a more comprehensive
program. For each of the types of components listed, there is a separate chapter in this toolkit.
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STUDENT PROGRAMS
Program Type Grades
Number
& Length
of
Sessions
Facilitator
Other
Components
Notes
Programs in NREPP
American
Indian
Life Skills
Development/
Zuni Life Skills
Development
Curriculum
for all
students
9–12 28–56
lesson
plans
delivered
over 30
weeks.
Teachers, with
input from
community
members
for cultural
relevance.
Teachers
must have a
3-day training
that may be
delivered
onsite.
Culturally
tailored to
American
Indian youth.
CAST (Coping
and Support
Training)
Skill-
building
for at-risk
students
9–12 Twelve
55-minute
group
sessions.
Teacher,
counselor,
nurse, or other
mental health
staff person
experienced
with high-risk
youth. Training
is given by
developer
and may be
delivered
onsite.
Similar to
Reconnecting
Youth
but fewer
sessions
over fewer
weeks with a
group of 6–8
students.
Lifelines Curriculum
for all
students
8–10 Four
45-minute
lessons.
Teachers.
Information on
teaching the
curriculum is
included with
the curriculum
materials, and
a 1-day, onsite
training is
also available
through
Hazelden
Publishing.
- Protocols
- Staff Training
- Parent
Education
All the other
components
must be
implemented
before the
student
lessons. A
2-day, onsite
training
on how to
implement all
the program
components
is available
through
Hazelden
Publishing.
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Program Type Grades
Number
& Length
of
Sessions
Facilitator
Other
Components
Notes
Reconnecting
Youth
Skill-
building
for at-risk
students
9–12 75 classes
delivered
in one
semester.
Teacher,
counselor,
nurse, or other
mental health
staff person
experienced
with at-risk
youth. Training
is given by
developer
and may be
delivered
onsite.
Similar
to CAST
but more
sessions over
more weeks
with a group
of 10–12
students.
SOS (Signs of
Suicide)
Curriculum
for all
students
8–12 Three
lessons;
often only
the rst is
given, and
it includes
a short
student
screening.
Teachers.
Training for
teachers is
included in
curriculum
materials.
Technical
assistance is
also available.
- Screening
- Staff Training
- Parent
Education
Schools
can decide
if they want
to provide
the student
screening
along with
the lesson(s).
Also included
is a version of
the screening
tool for
parents to
complete
about their
child.
Programs in BPR
Ask 4 Help!
Suicide
Prevention for
Youth
Curriculum
for all
students
9–12 1 hour. Teachers or
Yellow Ribbon
representatives.
Requires a
2-day training
for facilitators
provided by
Yellow Ribbon,
either at the
school or local
locations.
Usually used
with Yellow
Ribbon’s adult
gatekeeper
program Be A
Link!
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Program Type Grades
Number
& Length
of
Sessions
Facilitator
Other
Components
Notes
Gatekeeper
Suicide
Prevention
Program: A
High School
Curriculum
Curriculum
for all
students
7 and 9 Three
50–60
minute
lessons
for 7th
grade and
four for
9th grade.
Facilitators
must be trained
by Gryphon
Place. Training
is delivered
onsite.
- Staff Training
- Parent
Education
Mainly
provided just
in Michigan.
Healthy
Education for
Life Program
(HELP)
Curriculum
for all
students
9–12+ One 45–
55 minute
session.
Facilitators
must be
volunteers
trained by
HELP. Training
is delivered
onsite.
Only available
in Oklahoma.
Helping Every
Living Person
(HELP)
Depression
and Suicide
Prevention
Curriculum
Curriculum
for all
students
9–11 Four
45-minute
lessons.
Teachers must
be trained by
developer.
Teacher
training may be
delivered onsite
or by phone.
LEADS for
Youth: Linking
Education and
Awareness of
Depression
and Suicide
Curriculum
for all
students
9–12 Three
1-hour
sessions.
Teachers.
Training for
teachers is
included in
curriculum
materials.
Technical
assistance also
available.
- Protocols Includes the
planning
tool School-
Based Crisis
Management
Recommen-
dations on
Suicide.
Response:
A Compre-
hensive High
School-Based
Suicide
Awareness
Program
Curriculum
for all
students
9–12 Four
1-hour
sessions.
Teachers.
Training for
teachers is
included in
the school kit.
RESPONSE
staff will
provide training
if requested.
- Protocols
- Staff Training
- Parent
Education
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Program Type Grades
Number
& Length
of
Sessions
Facilitator
Other
Components
Notes
Sources of
Strength
Peer
leader
program
6–12 3–6-month
program;
advisors
contribute
40 hours
and peer
leaders
15–50
hours.
Advisors
receive a
3–6 hour
orientation;
peer
leaders
receive
a 4-hour
training.
Team of 2–5
adult advisors
(from school,
community,
or families)
and 10–50
peer leaders.
Training by
Sources of
Strength
trainers
required.
Will come to
the school.
Technical
assistance is
also available.
Peer leaders
recruit
students
to develop
and deliver
a campaign.
Initially
implemented
in rural/tribal
areas, now
expanded to
all high school
students.
For additional resources, see the Student Programs in the “Resources” section at the end of the toolkit.
CHAPTER 7
Screening
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SCREENING
The steps in Chapter 7 will answer these questions:
Who should be involved in planning and implementing a screening program in
your school?
How can you enlist the support of school administrators and staff?
How do you prepare for the increased need for mental health referrals?
What types of screening programs are available, and how do you decide which
to use?
How do you involve families?
IMPORTANT: Schools that implement screening programs may experience an increase
in the number of students who seek help for behavioral health and suicide-related
problems. Schools should put in place the components described in Chapters 1–4, before
implementing screening. These components include:
Protocols to respond to students at risk and in crisis
Suicide prevention training for all school staff
WHY IS SCREENING IMPORTANT?
The purpose of screening is to identify students at risk for suicide, suicidal behaviors, and
suicidal ideation. Parents and teachers may not be able to tell that youth are suicidal (Smith
et al., 2003; Scott, et al., 2009), and youth may not step forward on their own to get help.
The results from a screening indicate which students may need evaluation so that the school
and their parents can help them receive evaluation and treatment, if needed. Treatment can
prevent suicide as well as improve the student’s behavioral health, school performance,
social development, and future productivity (Center for Mental Health in Schools at
UCLA, 2007).
Schools can screen individual students who are thought to be at risk for suicide and/or
other behavioral health problems or implement screening programs to screen large
numbers of students. This chapter will focus on screening programs.
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Are Screening Programs Cost-Effective?
Screening programs in schools are cost-effective because they reach a large number of
students quickly and at less cost than through community screening programs (Center for
Mental Health in Schools at UCLA, 2007). Screening can catch problems early and avoid
the intensive treatment that might be needed if students’ problems are not identified until
they become more severe.
BASIC INFORMATION ABOUT SCREENING PROGRAMS
Format: Typically, a brief questionnaire is given to each student. If the screening is given
in a group setting, pay special attention to ensuring that the questionnaires the students
fill out are kept completely confidential. Those who screen positive are given a
confidential interview as soon as possible by a mental health provider to assess whether
they need a referral for more in-depth evaluation or treatment. Students who need help
are referred to appropriate services.
Support of parents: Parents should be informed about the screening program, its purpose,
and its value in order to gain their support, since schools often need a parent’s consent
before screening their child. In addition, parents need to be involved if a referral is
indicated. Parent support can make a major difference in whether a child receives
treatment. In tribal communities it may also be important to gain the support of tribal
leaders and programs.
Support of school administrators and staff: School administrators and staff may resist
screening programs because of the cost and logistics as well as a concern that the school
will not be able to handle the number of students identified as at risk. They need to be
made aware that screening programs can have significant benefits for students who are at
risk, and for the school environment.
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Screening Programs: Positive Experiences
Signs of Suicide (SOS): In Chemung County High Schools, New York
Chemung County in New York, which includes the city of Elmira and surrounding rural
areas, has found the SOS high school student education and screening program to be a
valuable tool in identifying students at risk of suicide. Three suicide deaths by high school
students in the 2004–2005 school year motivated school staff to implement a broad array of
suicide prevention initiatives, including the SOS program.
Nearly 1,800 students were screened the first year, and over 3 percent were referred for
mental health care who were not already receiving it. According to Pat Breux, program
coordinator, “We’re convinced the screening found students who otherwise would not have
received help. The response in our school has been very positive. The guidance counselors
told me that the screening helped them connect with students who they did not know were
struggling. Student evaluations of SOS indicated our young people found the screening
process to be very valuable, and they now have a better idea of how to help a friend, a
family member, or themselves.”
Signs of Suicide (SOS): From a School Mental Health Clinician, Washington, DC
“I have identified four students already, all of them Latinos, two boys and two girls (and I
have only done three groups of SOS). One of the boys identified, who seemed to be a tough
boy, gave the test back and I saw that he answered ‘yes’ to one of the questions. I sat down
with him and reviewed all the questions thinking he may have not understood the question
well, but he did. I was sort-of shocked because I would have never thought of this boy
having suicidal ideation. One of the girls identified was basically screaming for help. She
could have easily been badly poisoned if she had not participated in SOS and I was not able
to stop the plan she had.”
TeenScreen: At Moultonborough Academy, New Hampshire
Moultonborough Academy, a very small public high school in central New Hampshire,
decided to implement TeenScreen without having had a suicide attempt or death simply
because they thought mental health screening was important.
During the four years the program has been conducted, about 150 students have been
screened. Of these, about 10 students have screened positive—students whom the staff
would not have otherwise identified. In addition, they give every student who participates a
directory of local mental health services and encourage them to use it if they or their friends
ever need help. According to Peter Whelley, the district school psychologist, “This program
has been successful b