Published August 2016
Resource links updated August 2016
Casey A. Barrio Minton and Sharon L. Bruner,
University of Tennessee, Knoxville
Suicide is the third leading cause of death among youth 10–24 years of age. In 2014, suicide accounted for 5,504 deaths among young people and almost 157,000 hospital visits for self-inflicted injuries were documented (Centers for Disease Control [CDC], 2015). Although death by suicide is relatively infrequent, depression and thoughts of suicide are disturbingly common among high school youth and have increased over the last five years. In 2013, 29.9% of high school students felt so sad or hopeless every day for two or more weeks that they stopped doing some usual activities, 17.0% seriously considered suicide, 13.6% made a suicide plan, 8.0% attempted suicide, and 2.7% sought medical treatment for a suicide attempt (Kann et al., 2014). Risk to youth varies by gender and ethnicity; for example, thoughts of suicide were nearly double among females compared to males, but males accounted for four out of five deaths by suicide among young people. Youth who identified as American Indian/ Alaskan Native were at increased risk of death and Hispanic/Latino(a) youth were at increased risk of suicidal thoughts (CDC, 2015).
Because suicide is so complex and the stakes are so high, there is risk in trying to identify a “profile” of a youth at risk for suicide out of fear of missing someone who does not fit the profile. Social support, ability to cope with stressful events, high self-esteem, stable home environment, and engagement in the community are considered protective factors against thoughts of suicide (World Health Organization, 2014). Personal or parental mental health concerns, unstable or conflictual home environments, exposure to violence, and poverty are associated with increased risk of suicidal thoughts and actions (Hankin & Abela, 2011). Compared to youths who “only” thought about suicide, youths with suicide attempts in the past year were more likely to report dating violence victimization, mental health concerns, running away from home, and self-injurious behavior (Taliaferro & Muehlenkamp, 2014). Multiple risk factors, as opposed to any single risk factor, were important for identifying youth at risk of suicide (Roberts, Roberts, & Zing, 2010).
In Fall 2015, a panel of suicide experts conducted a comprehensive review of the literature and released a set of consensus suicide warning signs specific to youth up to age 24 years. In contrast to risk factors, warning signs indicate likelihood for suicidal behavior in the very near future. Available to the public at www.youthsuicidewarningsigns.org, these warning signs include
• Talking about or making plans for suicide
• Expressing hopelessness about the future
• Displaying severe/overwhelming emotional pain or distress
• Showing worrisome behavioral cues or marked changes in behavior, particularly in the presence of the warning signs above. Specifically, this includes significant:
• Withdrawal from or changes in social connections/situations
• Changes in sleep (increased or decreased)
• Anger or hostility that seems out of character or out of context
• Recent increased agitation or irritability
• American Foundation for Suicide Prevention www.afsp.org
• Centers for Disease Control http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
• National Center for the Prevention of Youth Suicide www.suicidology.org/ncpys
• Society for the Prevention of Teen Suicide http://www.sptsusa.org/educators
• Suicide Prevention Resource Center www.sprc.org
• Trevor Project http://www.thetrevorproject.org/
Professional school counselors are likely to be interested in both suicide screening and assessment (Suicide Prevention Resource Center [SPRC], 2014). Screening activities are focused on identification of youth who are at risk of thoughts of suicide and may include activity with an entire student body or a subgroup of individuals believed to be at higher risk (e.g., youth who identify as Lesbian, Gay, Bisexual, or Transgender). Assessment activities are focused on evaluating risk and ensuring appropriate treatment for specific students who show warning signs related to suicide. Although dated, Goldston (2000) presented a comprehensive summary of screening and assessment tools for assessing child and adolescent suicidal behaviors and risk.
The Substance Abuse and Mental Health Services Administration (SAMHSA) Lessons Learned Working Group recommended that school-based screening programs be developed only after sufficient training, referral, and follow-up care procedures are implemented so that the system is prepared to respond to individuals identified as at risk for suicide in a timely and effective manner (SPRC, 2014). Broad-scale screening may have limited utility in the school setting because it produces a large number of false positives (O’Connor et al., 2013a; O’Connor et al., 2013b; SPRC, 2014). In fact, the U.S. Preventative Services Task Force concluded “the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in a primary care setting” (LeFevre, 2014, p. 719).
Despite controversy and lack of precision, Horowitz, Ballard, and Pao (2009) evaluated two screening instruments as possibly useful for school settings in which there are both a comprehensive suicide prevention program and adequate resources for timely follow-up. The Columbia Suicide Screen (CSS) (Shaffer et al., 2004) includes 11-items embedded within a broader self-report measure and assesses lifetime history of suicide attempt, suicidal ideation within past three months, and other factors related to suicide risk. Approximately 30% of youth screen positive on the instrument, half of whom have thoughts of suicide (Horowitz et al., 2009). Thus, the CSS must be used in context of a more complex suicide prevention program; recent adaptations to the CSS may make it more appropriate for school-based screening (Scott et al., 2010). The Suicide Risk Screen (SRS) (Hallfors et al., 2006) is a 20-item self-report tool designed to identify high school students at risk for suicide. In a high school setting, the instrument identified 29% of students as at risk for suicide and in need of timely follow-up care, a level of demand researchers identified as not feasible for responsible follow-up.
When students are believed to be at risk of suicide, school counselors can conduct suicide assessment activities within current district structure and policy. Although Goldston (2000) outlined a number of formal suicide assessment tools, the clinical interview remains the primary assessment tool used in practice. A strong clinical assessment will incorporate essential counseling skills and include focused attention to the presence and nature of suicidal thoughts, other suicide warning signs, risk factors, and protective factors. SAMHSA (2009) offers a free Suicide Assessment Five-step Evaluation and Triage (SAFE-T) resource card and mobile app which includes guidance to: identify risk factors, identify protective factors, conduct suicide inquiry, determine risk level/intervention, and document actions. In addition, school counselors may use the Columbia-Suicide Severity Rating Scale (C-SSRS), a semi-structured interview designed to help distinguish suicidal ideation and behavior (Posner et al., 2011). The C-SSRS includes two questions asked of all individuals, four follow-up domains, and recommended triage points. Individuals who wish to use the C-SSRS should first view the training video listed in the resources.
Additional Identification/Assessment Resources:
• Columbia Suicide Severity Rating Scale http://www.cssrs.columbia.edu/ and C-SSRS Training Videohttp://www.youtube.com/watch?v=01P6id9wvig&feature=youtu.be
• SAFE-T http://www.integration.samhsa.gov/images/res/SAFE_T.pdf
• SPRC Suicide Screening and Assessment http://www.sprc.org/sites/default/files/migrate/library/RS_suicide%20screening_91814%20final.pdfscreening_91814%20final.pdf
• Assessment of Suicidal Behaviors and Risk among Children and Adolescents http://www.sprc.org/sites/default/files/migrate/library/GoldstonAssessmentSuicidalBehaviorsRiskChildrenAdolescents.pdf
• Recommendations for School-Based Suicide Prevention Screening http://www.sprc.org/resources-programs/recommendations-school-based-suicide-prevention-screening
School-based suicide intervention includes attention to three primary considerations: prevention and preparation, intervention with at-risk students, and postvention. Although there is a relative lack of evidence-based intervention strategies focused specifically on immediate response to students at risk of suicide, there is a plethora of research-informed practice guidelines for each step of the process. The Youth Suicide Prevention School-Based Guide (Lazear, Roggenbaum, & Blasé, 2012) provides a series of issue briefs focused on each element of creating a suicide prevention and intervention plan in schools. These include attention to messaging, development of supportive community frameworks, and composition of crisis response teams.
Prevention & Preparation
Prevention and preparation activities may be targeted toward enhancing coping and resourcefulness among students or preparing staff and students to respond to students showing warning signs for suicidal behavior. The National Registry of Evidence-Based Programs and Practices (NREPP), a service of SAMHSA identified seven evidence-based interventions appropriate for children and adolescents in school settings and focused on suicide.
• Officially classified as a prevention program, CAST (Coping and Support Training) is a group-based program designed to provide support for high school students identified as at significant risk for suicide. The program includes attention to mood, school performance, and substance risk and has demonstrated outcomes related to suicide risk factors, depression, hopelessness, anxiety, anger, drug involvement, personal control, and coping skills.
• LEADS: For Youth (Linking Education and Awareness of Depression and Suicide) is a school-based suicide awareness program in which high school youth learn about depression and suicide in efforts to empower help-seeking. The three-hour program can be implemented by teachers and has demonstrated outcomes related to knowledge and attitudes related to depression and suicide and knowledge of resources.
• Lifelines is a comprehensive prevention program designed for use in middle and high schools, and it is focused on opening pathways to help seeking and ensuring students and staff are able to respond appropriately to students at risk. The three-hour curriculum has been demonstrated to increase knowledge about suicide and promote positive attitudes related to suicide intervention, seeking adult help, and helping a friend get help.
• Kognito At-Risk for High School Educators is an one-hour, online program in which school staff members learn how to identify, approach, and refer students at risk of suicide. The program includes role-play interactions that help teachers motivate students to accept support. Participants who complete Kognito have shown greater ability to recognize, approach, and refer students, and they are more likely to do so than control groups.
• SOS (Signs of Suicide) is designed to help high school students identify and respond to signs of depression and suicide by acknowledging the program, expressing care, and telling a trusted adult. The program has demonstrated effectiveness in reducing suicide attempts and increasing knowledge and attitudes regarding depression and suicide.
• Sources of Strength is a high-school-based suicide prevention program in which peer leaders provide messaging and programming to affect change on a systemic level. Program outcomes include improving attitudes and knowledge regarding seeking adult help, rejection of codes of silence, and increased referrals for peers.
• QPR (Question, Persuade, and Refer) Gatekeeper Training for Suicide Prevention is a 1–2 hour education program conducted in person or online in which participants, often school staff members, learn how to ask about suicide, persuade students at risk to seek help, and refer to qualified helpers. Program outcomes include knowledge about suicide and prevention resources, self-efficacy, and gatekeeper skills.
The second type of school suicide intervention is focused on providing care to students who expressed thoughts of suicide or engage in suicide behavior. There are few evidence-based suggestions for responding to thoughts of suicide, and specific protocols will vary according to district policy.
The Applied Suicide Intervention Skills Training (ASIST) is an evidence-based program rated as promising within the most recent NREPP standards. The ASIST intervention is divided into three phases: connecting, understanding, and assisting. During the first two phases, the emphasis in on listening to personal at risk experiences with a specific focus on risk factors and motivations. In the final phase, caregivers assist clients in creating a safe plan that specifically addresses each of the issues identified during the first two phases. Training to become an ASIST caregiver takes place over two consecutive days and encourages the recognition of a direct connection between current struggles, suicidal thoughts, and potential supports (Gould, Cross, Pisani, Munfakh, & Kleinman, 2013). A randomized control trial focused on the National Suicide Prevention Lifeline revealed that ASIST-trained counselors showed stronger suicide intervention skills include a greater likelihood to explore warning signs, reasons for living, ambivalence about dying, and supports; they also had longer calls, and their callers reported more positive change compared to callers who spoke to other counselors. Similarly, school counselors who learned ASIST reported increases in suicide intervention skills, knowledge about suicide, and helpful attitudes related to suicide (Shannonhouse & Lin, in press).
After a student dies by suicide or engages in suicide-related behavior, professional school counselors are responsible for providing supportive services to the community, actions that then become part of the suicide prevention efforts. The American Foundation for Suicide Prevention and SPRC (2011) offer a free resource called After a Suicide: A Toolkit for Schools which outlines step-by-step resources for responding to student suicide in ways that align with best practice.
Systematic evaluation of school based postvention programs has yielded limited evidence of effectiveness. One strategy demonstrated to be helpful is immediate and appropriate response by authority figures in the school. Crisis intervention training of gatekeepers within the school setting may help decrease depression and suicide rates following a suicide death by equipping teachers and administrators to appropriately respond to a crisis (Szumilas & Kutcher, 2011). Ultimately, quick and accurate informing of students by a classroom teacher and subsequent informing of parents can help to decrease confusion and potential contagion (Kerr, Brent, McKain, & McCommons, 2003). There is some evidence that support groups and counseling for students and their families may be effective in supporting students during postvention (Robinson et al., 2013).
Additional Intervention Resources:
• AFSP Model School District Policy on Suicide Prevention https://afsp.org/wp-content/uploads/2016/01/Model-Policy_FINAL.pdf
• AFSP After a Suicide A Toolkit for Schools https://afsp.org/our-work/education/after-a-suicide-a-toolkit-for-schools/
• National Suicide Prevention Lifeline www.suicidepreventionlifeline.org
• SAMHSA National Registry of Evidence Based Programs and Practices http://www.samhsa.gov/nrepp
• SAMHSA Preventing Suicide: A Toolkit for High Schools http://store.samhsa.gov/shin/content/SMA12-4669/SMA12-4669.pdf
• Youth Suicide Prevention School-Based Guide http://theguide.fmhi.usf.edu
• Applied Suicide Intervention Skills Training www.livingworks.net
American Foundation for Suicide Prevention. (2011). After a suicide: A toolkit for schools. Retrieved from https://www.afsp.org/coping-with-suicide-loss/education-training/after-a-suicide-a-toolkit-for-schools
Centers for Disease Control and Prevention. (2015). Youth suicide. Retrieved from http://www.cdc.gov/violenceprevention/suicide/youth_suicide.html
Goldston, D. (2000). Assessment of suicidal behaviors and risk among children and adolescents. Technical report submitted to NIMH under Contract No. 263-MD-909995. Retrieved from http://www.sprc.org/ library _resources/items/assessment-suicidal-behaviors-and-risk-children-and-adolescents
Gould, M. S., Cross, W., Pisani, A. R., Munfakh, J. L., & Kleinman, M. (2013). Impact of applied suicide intervention skills training on the national suicide prevention lifeline. Suicide and Life-Threatening Behavior, 43, 676-691. doi: 10.1111/sltb.12049
Hallfors, D., Brodish, P. H., Khatapoush, S., Sanchez, V., Cho, H., & Steckler, A. (2006). Feasibility of screening adolescents for suicide risk in “real-world” high school settings. American Journal of Public Health, 96, 282-287. doi: 10.2105/AJPH.2004.057281
Hankin, B. L., & Abela, J. R. (2011). Nonsuicidal self-injury in adolescence: Prospective rates and risk factors in a 2½ year longitudinal study. Psychiatry Research, 186(1), 65-70. doi: 10.1016/j.psychres.2010.07.056
Horowitz, L. M., Ballard, E. D., & Pao, M. (2009). Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics, 21, 620-627. doi:10.1097/MOP.0b013e3283307a89.
Kann, L., Kinchen, S., Shanklin, S. L., Flint, K. H., Kawkins, J., Harris, W. A...Whittle, L. (2014). Youth risk behavior surveillance—United States, 2013. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf
Kerr, M. M., Brent, D. A., McKain, B., & McCommons, P. (2003). Postvention standards manual: A guide for a school’s response in the aftermath of sudden death. Retrieved from http://www.sprc.org/library _resources/ items/postvention-standards-manual-guide-schools-response-aftermath-sudden-death
Lazear, K. J., Roggenbaum, S., & Blasé, K. (2012). Youth suicide prevention school-based guide — Overview. Retrieved from http://theguide.fmhi.usf.edu
LeFevre, M. L. (2014). Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 160(10), 719-726.
O’Connor, E., Gaynes, B., Burda, B., Soh, C., & Whitlock, E. P. (2013a). Screening for and treatment of suicide risk relevant to primary care: A systematic review of the U.S. Preventative Services Task Force. Annals of Internal Medicine, 158(10), 741-754. doi: 10.7326/0003-4819-158-10-20135210-00642
O’Connor, E., Gaynes, B., Burda, B. U., Williams, C., & Whitlock, E. P. (2013b). Screening for suicide risk in primary care: a systematic evidence review for the U.S. Preventive Services Task Force (Agency for Healthcare Research and Quality Report No. 13-05188-EF-1). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23678511
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A…Mann, J. J., (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266-1277. doi: 10.1176/appi.ajp.2011.10111704
Roberts, R. E., Roberts, C. R., & Xing, Y. (2010). One-year incidence of suicide attempts and associated risk and protective factors among adolescents. Archives of Suicide Research, 14, 66-78 doi: 10.1080/13811110903479078
Robinson, J., Cox, G., Malone, A., Williamson, M., Baldwin, G., Fletcher, K., & O’Brien, M. (2013). A systematic review of school-based interventions aimed at preventing, treating, and responding to suicide-related behavior in young people. Crisis, 34(3), 165-182. doi: 10.1027/0227-5910/a000168
Scott, M., Wilcox, H., Huo, Y., Turner, B., Fisher, P., & Shaffer, D. (2010). School-based screening for suicide risk: Balancing costs and benefits. American Journal of Public Health, 100, 1648-1652. doi: 10.2105/ AJPH.2009.175224
Shaffer D., Scott M., Wilcox H., Maslow, C., Hicks, R., Lucas, C. P…Greenwald, S. (2004). The Columbia Suicide Screen: Validity and reliability of a screen for youth suicide and depression. Journal of American Academy of Child and Adolescent Psychiatry, 43(1), 71–79.
Shannonhouse, L., & Lin, Y-L. (in press). Suicide intervention training in K–12 schools: A quasi-experimental study on ASIST. Journal of Counseling & Development.
Substance Abuse and Mental Health Services Administration. (2009). Suicide assessment five-step evaluation and triage (safe-t): Pocket card for clinicians. Retrieved from http://store.samhsa.gov/product/Suicide- Assessment-Five-Step-Evaluation-and-Triage-SAFE-T-Pocket-Card-for-Clinicians/SMA09-4432
Suicide Prevention Resource Center. (2014, September). Suicide screening and assessment. Retrieved from http://www.sprc.org/sites/sprc.org/files/library/RS_suicide%20screening_91814%20final.pdf
Szumilas, M., & Kutcher, S. (2011). Post-suicide intervention programs: A systematic review. Canadian Journal of Public Health, 102, 18-29.
Taliaferro, L. A., & Muehlenkamp, J. J. (2014). Risk and protective factors that distinguish adolescents who attempt suicide from those who only consider suicide in the past year. Suicide & Life-Threatening Behavior, 44, 6-22. doi: 10.1111/sltb.12046
World Health Organization. (2014). Preventing suicide: A global imperative. Retrieved from http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/