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If you are thinking of hurting yourself, or if you are concerned that someone else may be suicidal, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

Jocelyn was a high school student referred to the school counselor by her math teacher. Her teacher was concerned because Jocelyn's grades had recently taken a rapid decline, and her behavior in class had changed from quiet and reserved to sarcastic and outspoken.

The school counselor, Mr. Cooper, told Jocelyn why she was referred to him. He asked her if there was anything she could think of that may have caused such a change in her grades and behavior. Jocelyn said that she had not been feeling very well recently and was finding it difficult to concentrate in class. She was also having trouble sleeping. Further probing revealed that Jocelyn's grandmother had recently died and that her mother and her mother's boyfriend were constantly arguing about the disposition of the grandmother's possessions and money. Jocelyn also said that she has an older sister who spends much of her time out of the house.

Mr. Cooper decided to ask Jocelyn if she had ever thought about suicide. Jocelyn emphatically denied ever thinking about harming herself. Mr. Cooper believed Jocelyn and told her so, but he asked her to come see him if she ever did have self-destructive thoughts. He asked Jocelyn if she would like to join a support group for students who are living in homes where there is a lot of conflict. He also suggested that she sign up for the after-school math tutoring program, as it provides the type of one-on-one instruction that may help her concentrate during this difficult period. Jocelyn agreed to try both the support group and the tutoring program and to talk with Mr. Cooper after two weeks to let him know how she was doing. He encouraged her to contact him at any time if she wanted to talk.

After the appointment, Mr. Cooper called the math teacher and, without revealing the exact nature of Jocelyn's difficulties, told her that Jocelyn did not appear to be in any imminent danger and was accepting help to improve her situation.

Not every student with behavioral problems or in emotional distress is at risk of suicide-but some are. And students who have problems but are not in danger of harming themselves also deserve help. Emotional and behavioral problems that affect a student's education can have life-long consequences. School-based clinic staff, school nurses, school psychologists and counselors, and other providers of health care and mental health care in a school setting are especially well placed to help students with emotional problems that can present an imminent risk to their safety or a longer-range risk to their chances of becoming healthy and happy adults.

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The Role of School Health and Mental Health Providers in Preventing Suicide

Suicide is the third leading cause of death among children, teens, and young adults ages 10 to 24. About 4,000 young people die by suicide each year. But this is only the tip of the iceberg. Every year, about 125,000 young people in this age group are brought to emergency rooms to receive treatment for injuries that were self-inflicted in the course of attempting suicide (Centers for Disease Control and Prevention, 2004). The majority of these injuries are to older children. In 2002, the age-adjusted suicide rate for young people ages 15-24 was 9.76/100,000; the rate for those under 15 was .43/100,000. That same year, the rate of "self-harm" injuries for the 15-24 age group was 263.40/100,000; the rate for those under 15 was 44.50 (Centers for Disease Control and Prevention, 2003a). A recent national survey (Centers for Disease Control and Prevention, 2003b) revealed that, in the 12 months preceding the survey:

Very few of these suicides, or suicide attempts, take place in schools. But many young people who are at risk of suicide exhibit warning signs in school, and recognizing and acting on these warning signs could prevent death or injury and reduce emotional suffering. As someone who provides health care or mental health care to young people in schools, you are in a key role to observe students' behavior and to act when you suspect that a student may be at risk of self-harm. You can provide needed expertise, support, and information to school staff, students, and parents who may notice that something is wrong with one of their students, peers, or children, but may not know what to do about it.

The National Association of School Psychologists summarized the school's role as follows (Poland & Lieberman, 2003):

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Recognizing the Warning Signs

Suicide and other self-destructive behaviors rarely occur without some warning signs. You, perhaps more than parents, can assess what is "normal" adolescent behavior and what may be an indication that something is wrong.

Students may describe their emotional problems in terms of physical symptoms, especially to health care professionals. Insomnia, stomachaches, and headaches can be signs of emotional distress. Unexplained injuries can be indications of physical or sexual abuse or self-mutilation.

Here are some signs that a young person may be considering suicide:

Some warning signs of suicide demand immediate action:

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Responding to the Warning Signs

As someone whose concern and responsibilities lay with the health and welfare of students, you have the opportunity to intervene when students are in danger of suicide or other health risks. You also have a responsibility to provide support to teachers who come to you with concerns about students, and to students who come to you with concerns about themselves and their peers. There are a number of steps you can take when you have a concern that a student may be at risk of suicide.

Ask the Tough Questions
Do not be afraid to ask a student if he or she has considered suicide or other self-destructive acts. Research has shown that asking someone if he or she has contemplated self-harm or suicide will not increase that person's risk. Rather, studies have shown that a person in mental distress is often relieved that someone cares enough to inquire about the person's well-being. Your concern can counter the person's sense of hopelessness and helplessness. However, you need to be prepared to ask some very specific and difficult questions in a manner that doesn't judge or threaten the young person you are attempting to help. For example:

Be Persistent
A student may feel threatened by your concern. The student may become upset or deny that he or she is having problems. Be consistent and firm, and make sure that the student gets the help that he or she may need.

Be Prepared to Act
You need to know what to do if you believe that a student is in danger of harming him- or herself. Many schools have procedures for this situation. If your school has such procedures, explain them to the student.

Do Not Leave a Student at Imminent Risk of Suicide Alone
If you have any reason to suspect that a student may attempt suicide or otherwise engage in self-harm, you need to remain with the student (or see that the student is in a secure environment, supervised by caring adults) until professional help can be obtained. The student's well-being supercedes any promises of confidentiality you may have made to the student. Let the student know that you care, that he or she is not alone, and that you are there to help.

Get Help When Needed
If you believe that the student is in imminent danger, you, or another member of the school staff, should call 911 or 1-800-273-TALK (800-273-8255). Tell the dispatcher that you are concerned that the person with you "is a danger to [him- or herself]" or "cannot take care of [him- or herself]." These key phrases will alert the dispatcher to locate immediate care for this person with the help of police. Do not hesitate to make this call if you suspect that someone may be a danger to him- or herself. It could save that person's life.

Use Your School's Support System
School districts typically have crisis policies for responding to any emergency, from a natural disaster to violence in the school community. This policy should include procedures for addressing students who try to harm themselves as well as those who are only contemplating it; students who are not in an acute state of crisis will still need support to stay in school and stay healthy. The plan should also provide some guidance for the role of individual teachers in identifying and responding to potential suicidal or violent behavior in students, as well as how to respond when actual violence takes place.

If your school does not have procedures for responding to a crisis, organize a team to draft some now-don't wait for a crisis situation!

Connect with Parents or Guardians
If a troubled student opens up to you about self-destructive thoughts or actions, contact that student's parents or legal guardian. Do not promise confidentiality to a child when it comes to issues regarding the child's safety-but always talk privately with a student before letting others know of your concerns for the student's safety. If you believe that contacting the parents or guardian may further endanger the child (if, for example, you suspect physical or sexual abuse), contact the proper authorities. In most states, school staff are "mandated reporters" and are required to report suspected child abuse.

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Postvention

"Postvention" is a term used to describe prevention measures implemented after a crisis or traumatic event to reduce the risk to those who have witnessed or been affected by the tragedy. The suicide, or violent or unexpected death, of a student, teacher, or even a celebrity can result in an increased risk of suicide for other vulnerable young people. Although rare, a suicide in the community (or even a remote suicide that receives substantial press coverage) can contribute to an increased risk of suicide. Appropriately responding to a tragedy that may put students at risk is an essential part of any crisis or suicide prevention plan. Postvention includes grief counseling for students and staff; identification of students who may be put at risk by a traumatic incident, and support for those students; support for families; and working with the media to ensure that news coverage of such an event does not lead to additional suicides or emotional trauma.

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School-Based Suicide Prevention Programs

As someone who will play a primary role in responding to a suicide or attempted suicide, it is in your interest (as well in the interest of your students and colleagues) to prevent suicide among your school's students. Important steps you can take to prevent suicide and related behavior in your school include the following:

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References

Centers for Disease Control and Prevention. (2003a). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved March 23, 2005, from www.cdc.gov/ncipc/wisqars/

Centers for Disease Control and Prevention. (2003b). Youth online: Comprehensive results. Retrieved March 23, 2005, from http://apps.nccd.cdc.gov/yrbss/

Centers for Disease Control and Prevention. (2004, June 11). Suicide and attempted suicide. Morbidity and Mortality Weekly Report, 53(22). Retrieved March 23, 2005, from http://www.cdc.gov/mmwr/PDF/wk/mm5322.pdf

Kaltiala-Heino, R., Rimpela, M., Marttunen, M., Rimpela, A., & Rantanen, P. (1999). Bullying, depression, and suicidal ideation in Finnish adolescents: School survey. British Medical Journal, 319(7206), 348-351. Retrieved March 23, 2005, from http://bmj.bmjjournals.com/cgi/content/full/319/7206/348

Poland, S., & Lieberman, R. (2003). Questions and answers: Suicide intervention in the schools. NASP Communiqu, 31(7). Retrieved March 23, 2005, from http://www.nasponline.org/publications/cq317suicideqa.html

Taras, H. L., & American Academy of Pediatrics Committee on School Health. (2004). School-based mental health services. Pediatrics, 113(6), 1839-1845. Retrieved March 23, 2005, from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;
113/6/1839.pdf

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Resources

Resources for School Health and Mental Health Providers

Publications

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 and Adolescent Psychiatry, 42(4), 386-405.
A review of the research on youth suicide, its dramatic decrease over the last 10 years, risk factors for suicide, and promising prevention strategies, including school-based skills training, screening, education of primary care physicians, media education, and lethal-means restriction.

Hawton, K., & van Heeringen, K. (2000). International handbook of suicide and attempted suicide. New York: John Wiley.
Chapters of interest to school staff include Chapter 15. Suicide behavior in children; Chapter 16. Adolescent suicide behavior; and Chapter 37. Suicide prevention in schools.

Jacobs, D. (Ed.). (1999). Harvard Medical School guide to suicide assessment and intervention. San Francisco: Jossey-Bass.
A guide to help clinicians in their assessment and care of suicidal patients.

Kalafat, J. (2003). School approaches to youth suicide prevention. American Behavioral Scientist, 46(9), 1211-1223.
Literature review, discussion, and recommendations on the types and effectiveness of school-based youth suicide prevention programs.

Leenaars, A. (2001). Suicide prevention in schools: Resources for the millennium. In D. Lester (Ed.), Suicide prevention: Resources for the millennium (pp. 213-238). Philadelphia: Brunner-Routledge.
An overview of school-based prevention and an outline of a comprehensive school-based suicide prevention program.

Maris, R., Berman, A., & Silverman, M. M. (Eds.). (2000). Comprehensive textbook of suicidology. New York: Guilford Press.
Chapters of interest to school staff include Suicide, Gender, and Sexuality; Indirect Self-Destructive Behavior; and In the Wake of Suicide: Survivorship and Postvention.

Posner, M. (2000). Preventing school injuries: A comprehensive guide for school administrators, teachers, and staff. New Brunswick, NJ: Rutgers University Press.
This book contains information on implementing suicide prevention, postvention, and crisis preparation activities in the context of a comprehensive school injury prevention program.

Quinnett, P. G. (2000). Counseling suicidal people: A therapy of hope. Spokane, WA: QPR Institute. Retrieved March 18, 2005, from http://www.qprinstitute.com/
This book was written for therapists, mental health workers, physicians, nurses, and others who are not clinical suicide counselors, but who might find themselves counseling people at risk of suicide. It provides a practical set of tools and strategies for risk assessment and intervention. Much of the information on how to talk to a person at risk of suicide will be valuable to a broad range of professionals and paraprofessionals.

Velting, D., & Gould, M. (1997). Suicide contagion. In S. Cavetto, R. Maris, and M. Silverman (Eds.), Review of suicidology (pp. 96-137). New York: Guilford Press.
This chapter reviews the literature on suicide contagion and the influence of media portrayals of suicide.

School-Based Suicide Prevention Programs and Materials

Columbia University TeenScreen Program (http://www.teenscreen.org/). TeenScreen helps schools and communities implement screening programs to identify at-risk teens and pre-teens. It uses simple screening tools that can detect depression, the risk of suicide, and other mental disorders in teens to help schools identify and arrange treatment for youth who are suffering from depression and other undiagnosed mental illness and those who are at risk of suicide.

Guidelines for School-based Suicide Prevention Programs (http://www.suicidology.org/associations/1045/files/School%20guidelines.pdf). This 14-page report, written by the Prevention Division of the American Association of Suicidology in 1999, examines the bases of and requirements for school-based prevention programs in general, as well as for three variations of school-based suicide prevention programs: those for all students, those for groups of at-risk students as identified by research (i.e., incoming high school freshmen), and those for individual students identified through screening. It explores the essential components of and a sample curriculum for a comprehensive school-based suicide prevention program. The report also provides recommendations to ensure the longevity of programs once they are implemented.

Jason Foundation, Inc. (http://www.jasonfoundation.com). The Jason Foundation, Inc., educates young people, parents, teachers, and others who work with young people about youth suicide. The foundation offers programs, seminars, and support materials on suicide awareness and prevention.

SOS Signs of Suicide® (http://www.mentalhealthscreening.org/highschool/index.aspx). The SOS Signs of Suicide program provides school health professionals with the screening and educational materials to teach high school students to recognize the signs and symptoms of suicide and depression in themselves and others and to follow specific action steps to respond to those signs. The program can be incorporated into an existing health curriculum or can be used as a stand-alone program. The program includes educational materials, a training video, screening forms in both English and Spanish languages, and an implementation manual, and can be completed in one or two class periods.

Yellow Ribbon Suicide Prevention Program(http://www.yellowribbon.org/). This organization provides training and resources for school- and community-based suicide prevention programs (including gatekeeping). Chapters in a number of states can provide suicide prevention speakers, materials, and training to schools and other organizations.

Youth Suicide Prevention Intervention and Postvention Guidelines: A Resource For School Personnel (http://www.state.me.us/suicide/guidelines02.pdf). These guidelines were developed by the Maine Youth Suicide Prevention Program and designed for schools to use within existing protocols to assist at-risk students and to intervene appropriately in a suicide-related crisis.

The Youth Suicide Prevention School-Based Guide (http://cfs.fmhi.usf.edu/StateandLocal/suicide_prevention/). This online resource was developed by the Florida Mental Health Institute at the University of South Florida. It provides a framework for schools to assess their existing or proposed suicide prevention efforts (through a series of checklists) and provides resources and information that school administrators can use to enhance or add to their existing program. Information is offered in a series of issue briefs corresponding to a specific checklist. Each brief offers a rationale for the importance of the specific topic together with a brief overview of the key points. The briefs also offer specific strategies that have proven to work in reducing the incidence of suicide, with references that schools can use to explore these issues in greater detail.

Suicide Gatekeeping Programs

Livingworks Education, Inc. (http://www.livingworks.net/). Livingworks provides training and support for their Applied Suicide Intervention Skills Training (ASIST) program, a suicide gatekeeping program. Livingworks also offers shorter presentations on suicide awareness and prevention.

Preventing Youth Suicide Through Gatekeeper Training: A Resource Book for Gatekeepers (http://www.state.me.us/suicide/gkeepbook.pdf). This book was designed for use in youth suicide prevention gatekeeper trainings and to provide basic information about suicide prevention, crisis intervention, support for survivors of suicide, and suicide prevention resources. The book was created for the Maine Youth Suicide Prevention Program.

QPR Institute (http://www.qprinstitute.com). The QPR Institute offers gatekeeper training programs to the general public and to professionals, including teachers.

Crisis Response and Postvention

Brock, S., Sandoval, J., & Lewis, S. (2000). Preparing for crises in the schools: A manual for building school crisis response teams (2nd ed.). San Francisco: Jossey-Bass.
This volume offers advice on preparing for crises, including developing a crisis response policy and crisis preparedness plan, crisis intervention, media relations, security and safety procedures, and emergency medical and health procedures.

Lerner, M., Volpe, J., & Lindell, B. (2003). A practical guide for crisis response in our schools (5th ed.). Commack, NY: American Academy of Experts in Traumatic Stress.
A guide to preparing for and managing crises in schools. This book covers traumatic stress management, responding to suicidal or violent students, grief counseling, and other issues.

National Association of School Psychologists Publications

The National Association of School Psychologists website contains a great deal of valuable information on suicide prevention and crisis response. Much of this material is available online at no cost, for example:

Bullying Prevention Websites

Cyberbully.org (http://www.cyberbully.org/) provides information about "cyberbullying"-the use of the Internet by children and adolescents to harass, intimidate, and socially exclude their peers. Resources on this website include the Educator's Guide to Cyberbullying and the Cyberbullying Needs Assessment Survey.

Stop Bullying Now Campaign (http://www.stopbullyingnow.hrsa.gov/index.asp), sponsored by the U.S. Department of Health and Human Services, offers educational materials for parents, educators, and health professionals.

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General Resources on Suicide and Suicide Prevention

Suicide Prevention Resource Center (http://www.sprc.org/). The Suicide Prevention Resource Center (SPRC) provides prevention support, training, and materials to strengthen suicide prevention efforts. Among the resources found on its website is the SPRC Library Catalog (http://library.sprc.org/), a searchable database containing a wealth of information on suicide and suicide prevention, including publications, peer-reviewed research studies, curricula, and web-based resources. Many of these items are available online.

American Association of Suicidology (http://www.suicidology.org/). The American Association of Suicidology is a nonprofit organization dedicated to the understanding and prevention of suicide. It promotes research, public awareness programs, public education, and training for professionals and volunteers and serves as a national clearinghouse for information on suicide.

American Foundation for Suicide Prevention (http://www.afsp.org). The American Foundation for Suicide Prevention (AFSP) is dedicated to advancing our knowledge of suicide and our ability to prevent it. AFSP's activities include supporting research projects; providing information and education about depression and suicide; promoting professional education for the recognition and treatment of depressed and suicidal individuals; publicizing the magnitude of the problems of depression and suicide and the need for research, prevention, and treatment; and supporting programs for suicide survivor treatment, research, and education.

National Center for Injury Prevention and Control (http://www.cdc.gov/ncipc/). The National Center for Injury Prevention and Control (NCIPC), located at the Centers for Disease Control and Prevention, is a valuable source of information and statistics about suicide, suicide risk, and suicide prevention. To locate information on suicide and suicide prevention, scroll down the left-hand navigation bar on the NCIPC website and click on "Suicide" under the "Violence" heading.

National Suicide Prevention Lifeline (http://www.suicidepreventionlifeline.org/). The National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: 1-800-273-TALK (800-273-8255). Technical assistance, training, and other resources are available to the crisis centers and mental health service providers that participate in the network of services linked to the National Suicide Prevention Lifeline.

Suicide Prevention Action Network USA (http://www.spanusa.org). Suicide Prevention Action Network USA (SPAN USA) is the nation's only suicide prevention organization dedicated to leveraging grassroots support among suicide survivors (those who have lost a loved one to suicide) and others to advance public policies that help prevent suicide.

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This page was modified on October 10, 2008

This effort has been funded in part with Federal funds from the National Institute of Mental Health, National Institutes of Health, under Contract No. N44MH22044.

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