Introduction

Recent media coverage of suicide deaths among high-profile individuals has served to underscore the disturbing reality that suicide is a growing public health concern that does not discriminate on the basis of demographics. In fact, suicide has become the tenth leading cause of death in the US and has recently surpassed the death rate by motor vehicle accidents, homicides, and breast cancer (NYSOMH, 2016). In 2017, over 47,000 individuals died by suicide in the United States, including 1,696 in NY State (CDC, 2019). New York State has one of the lowest suicide rates in the nation, at 8.6 per 100,000 as compared to the 13.4 per 100,000 national rate. However, given the high population, New York is among the top six states for the number of suicide deaths (CDC, 2019). Moreover, deaths by suicide in NYS have increased by 32% in the past decade, in stark contrast to the gradual reductions in the death rate for other diseases such as cancer, heart disease, or stroke (NYSDOH, 2018).

Each year, 4,600 children and teens, age 10-19, die by suicide. The rate of suicide in all age groups has continued to steadily rise in the last decade and the rate of suicide death among children 10 to 14 has doubled in that same time frame. As a result, in 2016, suicide was the second leading cause of death among young people ages 10-19 (CDC, 2018). According to the Centers for Disease Control and Prevention (CDC), among high school students in New York State in 2017, 17.4% seriously considered suicide, and 10.1% have made non-fatal suicide attempts (CDC, 2018).

Addressing the problem of youth suicide requires collaborative action across a variety of community agencies, but schools have logically assumed more of a leadership role in identifying, referring, and aiding youth with mental health needs. Schools also play a critical role in promoting psychosocial competencies that reduce vulnerability to suicide. The importance of schools is best highlighted by the recent adoption of NYSED’s 2018 Mental Health Education Literacy in Schools: Linking to a Continuum of Well-Being Comprehensive Guide. Given that the developmental trajectory for suicide risk can begin early in life, schools are uniquely positioned for building resilience among their students and developing a caring community within a positive school climate and culture necessary for the prevention of suicide. Since protecting the health and well-being of students is a fundamental role of all school staff, it is critically important that school districts develop policies and put procedures in place to reduce and respond effectively to suicide risk.

Given this critical responsibility, the following guidance document outlines best practices for school districts in New York State (NYS), to help protect the health and safety of all students and to guide school districts in developing policies and procedures to prevent, assess the risk of, intervene, and respond to youth suicidal behavior. This document utilized the Multi-Tiered System of Support (MTSS) model, and includes a focus on universal supports, prevention, and a positive school climate (Tier I), targeted supports for at-risk groups and individuals (Tier II), and specialized supports and procedures for students in crisis or high risk (Tier III).

As related to suicide prevention efforts, effectively implementing the MTSS model includes three critical components for school districts:

(1) Developing and implementing policies that include suicide prevention, intervention, and postvention.

(2) Providing ongoing professional development for teachers and school staff on warning signs, risk factors, protective factors, and school prevention, intervention, and postvention procedures.

(3) Implementing educational programming and curriculum that integrates developmentally appropriate, social/emotional, suicide prevention, and mental health education as a basic foundation for health, safety, and wellness for all students.

Understanding Suicide

The CDC defines suicide as “Death caused by self-directed injurious behavior with an intent to die as a result of the behavior.”

The operative word here is “intent.” If someone does something that is risky and dangerous, like drink and drive or take drugs and they die, it will be ruled an accidental death unless there is some evidence that they intended to die as a result of what they did.

There are many situations such as single car accidents with fatalities where there is suspicion of suicide, but because the intent to die was never communicated, it will be ruled accidental. This also can help us understand by behaviors like cutting are called non-suicidal self-injury. Most of the time the self-injury is done with the intention of relieving some type of psychological pain – not dying. There is concern however, that people who cut on multiple occasions lower their threshold for lethal self-injury. In other words, the more they get used to injuring themselves, the easier it might be to fatally injure themselves.

Another definition is sometimes helpful: “Suicide is an attempt to solve a problem of intense emotional pain with impaired problem-solving skills.” This definition captures what is happening to someone who is suicidal: they are experiencing a problem or series of problems which are causing great psychological pain.

For example, if you think about a time in your life when you felt overwhelmed by what you considered to be a terrible problem, you can probably remember that your problem-solving was not at its best. Most suicidal people, including youth, do initially try to figure out how to cope with their problems. When the initial solution does not work and now problems get piled on, their coping skills start to diminish. Usually, there is some type of triggering event that pushes them over the edge.

Understanding suicide from this behavioral perspective can help us appreciate that for most people, the decision to take their life is at the end of a process that has. Been going on for a while. While the final act of suicide may be impulsive, the thought process leading up to it is not. There is a time to intervene and perhaps prevent the suicide if we know what to look for and how important it is to get them help.

Risk and Protective Factors

Risk and protective factors for suicide can be envisioned through the lens of resiliency theory (Zimmerman, 2013), which tells us that suicide is a complex behavior that is influenced by the dynamic interplay of multiple risk and protective factors. These risk and protective factors can be understood as occurring along the social ecology continuum that included individual, relationship, and cultural/environmental factors (WHO, 2014).

This continuum starts at the individual level, encompassing a person’s biology, psychology, and social history. Risk factors on this level include depression, impulsive, or aggressive responses to stress, poor coping skills, substance use, problem gambling, and prior experiences with death and trauma.

Risk is also influenced by a person’s relationships with family, peers, and mentors. These relationship factors include experiences such as interpersonal violence, abuse or sexual assault, bullying, family separations, the loss of an important friend or family member, no access and/or lack of engagement with mentors, or having those close to you not recognize or be aware of your help-seeking attempts/signals.

On the continuum are cultural/environmental factors, including the perception of social acceptability of suicide in popular culture or among a peer group, codes of silence that discourage reaching out to adults for assistance, having access to the means to kill oneself, poor coordination of services, limited access to care, or a lack of social connectedness. The work of prevention is to identify and implement interventions that decrease risk factors or increase protective factors at varying points along the social ecology.

Warning Signs

It is important to remember that most risk factors are common, and in and of themselves are no more predictive of a suicide than risk factors for heart disease predict heart attacks. Risk factors are simply predictors of potential risk, but a percentage of students exhibiting risk factors may start to exhibit suicide warning signs.

Stressful life events or situations can serve as triggering events for suicidal behavior. For young people, these precipitants may include events like getting in a fight with a friend or family member, getting in trouble at school, a bullying incident, family separation, illness or death in the family, or loss of a friend or opportunity. Real or perceived losses, and upcoming events for which a student feels unprepared and overwhelmed, can also be precipitating events. When stressful life events are coupled with multiple or significant risk factors, it is important that school staff can recognize warning signs for suicide. Warning signs are observable signals that tell us to stop and pay immediate attention to a particular student because they may be at risk for imminent suicidal behavior. The word FACTS serves as a helpful acronym for identifying the most commonly recognized warning signs of suicide.

F is for FEELINGS. Hopelessness, worthlessness, despair about the future, or excessive worry.

A denotes ACTIONS. Actions include trying to gain access to a gun or pills, behaving recklessly or increasing alcohol or drug use. Actions can also include showing aggressive behavior that is inconsistent with the student’s previous demeanor, self-harming behaviors, or being involved in bullying or looking online for ways to die.

C indicates CHANGES. This is a very important category because it means we are looking for changes from the student’s previous attitude, moods, or behaviors which have been noticeable for at least a couple of weeks. For example, students who were active may become withdrawn, quit athletic teams, stop paying attention to personal appearance, daydream or even fall asleep in the classroom. It would be impossible to list all the potential behaviors you might see, so simply concentrating on recognition of changes from previous behaviors is a real key to making assessments in this category.

T represents the THREATS that some students make or hint at. These can be specific statements of intent like “I’m done with living” or “I’m thinking of killing myself” or worrisome innuendos in writing or other class assignments like “People would be better off without me”. Threats may also be posted on social media sites. Whether specific or vague, threats tell us the student is thinking about death or suicide, and this escalates the level of concern.

S refers to SITUATIONS that may serve as triggers for the suicide. These include getting into trouble at home, in school, or with legal authorities; personal losses in relationships, opportunities, or even losses of less tangible things like self-esteem or hopes for the future. Life changes for which the student feels overwhelmed or unprepared such as moving or the transition after high school graduation can also serve as triggers. The most worrisome time is between the occurrence of the triggering situation and its resolution—in that period of uncertainly before the outcome is known (SPC-NY, 2019).

*This version of FACTS is taken from Suicide Safety for Teachers and School Staff, Lifelines Prevention, and Act on FACTS: Making Educators Partners in Youth Suicide Prevention.

How Is The Prevention Of Suicide Framed?

School districts play a central public health role in combating infectious diseases, malnutrition, community violence, accidental injuries, substance use and/or problem gambling addictions, and sexually transmitted infections by implementing such measures as health screenings, school nutrition programs, and health and safety education. These efforts seek to protect school communities through health education, prevention screenings, and intervention across an entire school’s population. In each of these cases, schools have utilized a multi-tiered approach.

As the risk factors for suicide are numerous and their relationship with suicide risk is complex, the prevention of suicide requires that multiple strategies be employed. The World Health Organization calls for the use of a multi-tiered approach when addressing suicide prevention. The MTSS model is familiar to most school professionals, given that it is utilized for many school-based prevention initiatives, including academic concerns, bullying prevention, school climate, or mental health education literacy.

Tier I interventions include universal-level interventions. At this level, we are looking proactively at the awareness and training needs of all members of our school community including parents, assessing our school environment and school climate for how protective factors can be enhanced, and considering upstream prevention programs. Tier I interventions alone are adequate for roughly 80% of the population.

Tier II interventions include selective strategies targeting 1) groups who may be at higher risk, 2) students exhibiting warning signs, and 3) students experiencing stressful life events that may put them at elevated risk. Interventions at this level will include social supports and key target points in time when screening for suicide risk may be prudent. Tier I interventions combined with Tier II supports are adequate for 15% of the population.

Tier III interventions are focused on individual students that are acutely affected by a suicide loss, are engaging in suicidal behavior, or are demonstrating acute suicide risk. Tier III interventions combined with Tier I and Tier II supports and combined, are appropriate for the remaining 5% of the population (Schaffer, 2017).

The Suicide Prevention Center of New York (SPC- NY) offers a free School Readiness Workbook to assist in the suicide prevention planning process. Additionally, the Comprehensive Developmental School Counseling/Guidance Plan can support evidence-informed suicide prevention practices. Suicide prevention programming can be considered in the development of this district-wide planning process which is designed to operationalize comprehensive multi-tiered programming to support the emotional and behavioral well-being of young people.

Tier I

School districts should develop policies and programs which include Tier I universal suicide prevention. One way to envision suicide prevention in school is through the lens of a “Competent and Caring School Community” (Underwood, 2010). This setting is one in which all members of the school community play a role in prevention, from the school board to parents, staff, and to students. Everyone is responsible for the safety and well-being of each other and have the competency to recognize when to ask for help and know how and where to access assistance if there is a concern about suicide.

Faculty and Staff Awareness Training

It is critical that the district develop written procedures for the staff to follow when warning signs of suicide are observed or suspected. Staff awareness training should include how to identify warning signs and the procedures to follow when referring a student thought to be at risk for suicide. Faculty education must also include:

• Guidelines about what educators can do to promote protection from suicide including the promotion of positive mental health
• How to handle suicide related topics in the classroom
• How to identify developmentally appropriate materials for classroom use and school/community resources

High quality resources for staff awareness training are readily available. The Society for the Prevention of Teen Suicide provides a free online two-hour course, Making Educators Partners in Youth Suicide Prevention: Act on FACTS. A three-minute trailer is available and the training modules can be accessed by registering at SPTS University. Suicide Safety for School Staff is a brief training (60 to 90 minutes) designed by the Suicide Prevention Center of New York (SPC-NY) to meet the basic awareness needs of faculty and school staff. A network of over 200 trainers are available and connected to 10 regional training centers across New York. To find a trainer or to learn more about this initiative, contact SPC-NY. New York City educators also have the option of accessing free online modules of Kognito’s At Risk.

Focus on Social Emotional Competency Development (SEL)

Extensive research indicates that effective mastery of social emotional competencies is associated with greater well-being and better school performance. On the other hand, the lack of competency in these areas can lead to a variety of personal, social, and academic difficulties. In fact, a study of young students found a significant relationship between students’ social emotional competencies in first grade and their outcomes 13 years later (Bradshaw, 2013). Those students with early pro-social skills were more likely to graduate from high school on time, complete a college degree, and achieve and maintain full-time employment. Further, during high school, they were less likely to be involved with the police, use alcohol or misuse opioids, or require medication for emotional or behavioral issues. In addition to the many other benefits of SEL, lifetime suicide risk is diminished when students learn social problem-solving skills and learn to cope with emotional challenges and life stressors. Effective SEL programs have demonstrated an increase in social connectedness, which is an additional protective factor against suicide risk.

In 2018 and 2019, the New York State Education Department (NYSED) published new resources to assist schools and districts in implementing SEL strategies through explicit instruction, integration with academic curricula, general teaching practices, integration of SEL in school and district policy and practice, and professional development and SEL support for adults in the school community. These resources can be found on NYSED’s SEL website, and include:

1. SEL benchmarks for voluntary implementation,
2. A framework document explaining SEL concepts and the need for and benefit of SEL
3. A guidance document to provide implementation strategies and resources for districts and schools
4. District-developed crosswalks aligning SEL competencies, academic standards, classroom activities, and general teaching practices. Social-Emotional Learning: Essential for Learning, Essential for Life provides a framework explaining SEL concepts, and the need for and benefit of SEL to assist schools with the implementation of the NYSED recommended SEL benchmarks. The Collaborative for Academic, Social, and Emotional Learning (CASEL) provides an extensive collection of resources, including a Guide to Schoolwide Social and Emotional Learning, to assist schools and districts in the implementation of Social Emotional Learning strategies.

School Connectedness and School Climate

School connectedness is best defined as a belief held by students that adults and peers at school care about them and about their learning. School connectedness leads to both positive educational and health outcomes which includes a sense of student belonging and contribution, believed to be important protective factors against suicide risk. CDC developed School Connectedness: Strategies for Increasing Protective Factors Among Youth, a resource document for schools.

School climate is defined as the way school culture affects a child’s sense of safety and acceptance, and consequently is a critical determinant of their ability to focus on the task of learning. Measuring school climate is a crucial step in creating a safe and caring environment. Collecting data through surveys of students, parents, and staff is an important component of a school climate assessment. The NYSED promotes efforts to build and maintain positive and healthy school climates, and has engaged in a School Climate Pilot Project using United States Department of Education School Climate Surveys.

Upstream Prevention Programs

Research suggests that universal prevention programs for children may effectively reduce adolescent emotional and behavioral problems that are risk factors for future suicidal behavior. While many upstream prevention programs, such as Positive Behavioral Interventions and Supports (PBIS) framework, Second Step program and mindfulness training, may enhance protection against suicide for students, few programs have actually been studied for this outcome. Two programs, the Good Behavior Game, and Youth Awarenessof Mental Health are universal interventions that have shown to reduce suicide ideation over time. Sources of Strength is a program that utilizes trained student peer leaders and adults and has been shown to improve school- wide help-seeking and engagement of adult help for suicidal peers, with the greatest benefits for suicidal youth (Wyman, 2010).

Mental Health Literacy Education

Mental health literacy is defined  as  “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention.” A growing body of research in mental health literacy suggests that an increased understanding of mental health will improve help-seeking behaviors, reduce stigma, and promote better health outcomes (Kutcher, 2016). This is true for both young people and their supporters such as families, teachers, and peers.

Health education that respects the importance of mental health, as well as the challenges of mental illness, will help young people and their families and communities feel more comfortable seeking help, improve academic performance and, most importantly, save lives. According to the CDC, “focusing on establishing healthy behaviors during childhood is more effective than trying to change unhealthy behaviors during adulthood.” An equally important part of this conversation is to help students identify risk and protective factors, as learning and resiliency can result in positive decision-making and life-long success, which are the primary goals of health and education.

In June 2018, NYSED published a comprehensive guide Mental Health Education Literacy in School: Linking to a Continuum of Well-being to provide guidance for developing effective mental health education instruction in the classroom. The guidelines comply with the recent amendments to Education Law 804, while also looking at embedding mental health well-being within the broader context of the school environment to promote a positive culture and climate.

The School Mental Health Resource and Training Center was established by the Mental Health Association in New York State, Inc. (MHANYS) to help schools comply with the new law. The Center provides free online mental health training (CTLE- Eligible) and instructional resources for educators, as well as mental health resources for parents and guardians, students, and community-based mental health providers. Statewide, Resource Center staff can provide professional development for school staff, including MHANYS Mental Health and Wellness 101, mental health instruction for students, and technical assistance for developing mental health curriculum and school-wide mental health promotion strategies.

Finally, the Resource Center can provide support in establishing school-community partnerships. MHANYS addresses suicide prevention in their white paper Mental Health Education in New York Schools: A Review of Legislative History, Intent, and Vision for Implementation. This document offers core elements that should be included in school mental health curricula and acknowledges that unrecognized, untreated and late treated mental illness elevates the risk of mental health disabilities, suicide, and self-injury (Richter, 2017).

In addition, teenmentalhealth.org is an evidence-based, comprehensive mental health curriculum for grades 8-10 that is implemented through a train-the-trainer model. The training has been shown to significantly increase educators’ knowledge about mental health and significantly decrease stigma. National Alliance on Mental Illness NYS (NAMI NYS) offers Ending the Silence presentations for students, educators, and families, a stigma-reducing program. The American Foundation for Suicide Prevention (AFSP), which has chapters across NYS, offers More than Sad for students, educators, and families, a video-based educational presentation on teen depression.

Student Suicide Prevention Education

Suicide prevention education can begin in middle school or high school. It should include common warning signs and how and when to seek help. However, it should be noted that not all suicide prevention education efforts are helpful. Presentations can inadvertently stigmatize a student who may need help. In some cases, sensational presentations by persons with a compelling story have raised concerns about suicide contagion and about students learning how to kill themselves from such presentations. Yet, suicide prevention education can improve student knowledge of how, when, and where to seek help.

When implementing suicide prevention education, it is important that the educator be well trained in evidence-based suicide prevention that is developmentally appropriate, that the presentation be integrated with other similar content rather than standing alone, and that it be done in a classroom or small group, rather than in an auditorium presentation. Classroom teachers are wise to collaborate with student support service providers in the development of the presentation. When student support service providers co-teach or support classroom teachers, they can assure that students know how to access help. Since the best outcome of any such education would be that students would recognize signs of distress in themselves and their classmates and reach out for help, it is best that parents and adults in school have also had suicide prevention awareness education.

The SPC-NY offers a tip sheet for classroom presentations. Several programs and curriculum exist for student suicide prevention awareness. As an example, Lifelines Prevention is a manualized curriculum from Hazelden Publishing that has lessons plans for middle and high school students. Another program, Sources of Strength (SOS) engages peer leaders to enhance protective factors across a high school population. SOS has been shown to improve social norms associated with suicide prevention with the greatest changes being among students with suicidal ideation. Major findings include improved perceptions of support from adults and an increased likelihood that they would tell an adult if they were concerned about suicide (Wyman, 2010).

Parent Education

Parents need information about the prevalence of youth suicide, its warning signs, how to respond if their child or another child is at risk, and where to turn in their community for help. Some parents do not relate well to written materials or videos, especially on difficult topics like suicide, and may respond better to verbal or personal communication.

The Society for the Prevention of Teen Suicide offers several resources that can be helpful for designing parent awareness or education activities. Among their resources is a free 17-minute video titled Not My Kid designed to answer the questions most frequently asked by parents about suicide. The Mayo Clinic offers a 5 minute video that focuses on the warning signs and how to respond. The Suicide Prevention Center of New York offers a parent brochure that can be downloaded or linked.  The Jed Foundation offers a conversation guide for concerned parents of teens.

Tier II

Tier II interventions include selective strategies targeting (1) groups who may be at higher risk, and (2) those experiencing stressful life events that may put them at elevated risk. Below, are some, but not all groups that research has demonstrated have a higher risk of suicide (King, 2013). In discussing groups that may be at higher risk, it is important to question what it is about being in that group, that might lead to increased risk. It is these circumstances for which school health and mental health professionals including school psychologists, social workers, school counselors, nurses, or on-site community mental health providers can then consider appropriate interventions.

While the characteristics that define a student as a member of a higher risk group might be a fixed fact and may or may not be alterable, a focus on stressful life events provides a slightly different lens. If we recognize that the anticipation and aftermath of a stressful life event, particularly those that represent a meaningful loss to the individual, can be a critical time for suicide risk, we can preemptively intervene with supports and consider opportunities for screening and recognizing warning signs of suicide.

Groups at higher risk

• LGBTQ+ (Robinson, 2012)
• Latina youth (Zayas, 2009)
• Students with depression (AFSP, 2019)
• Students using drugs or alcohol (AFSP, 2019)
• Students with a previous attempt
• Students with emotional dysregulation
• Students with a history of self-injury (Klonski, 2014)
• American Indian or Alaska Native
• Students with intellectual disabilities (Ludi, 2013)
• Students with health problems and physical disabilities (Jones, 2008)

Stressful life events that may increase risk (AFSP, 2019)

• Family separation
• Death of a friend or family member
• Death of a parent
• Exposure to violence
• Disciplinary action
• Failure
• Loss of home
• Exposure to the suicide of another
• Engaged in bullying

Groups at Higher Risk

Lesbian, Gay, Bisexual, Transgender, Queer/ Questioning (LGBTQ) Youth

Students identifying as lesbian, gay, or bisexual may be 4 to 5 times more vulnerable to suicide risk than their heterosexual peers. Lesbian, gay or bisexual youth are also more likely to experience discrimination, bullying, violence, and victimization. However, victimization alone does not explain the elevated risk (Robinson, 2012). The risk for attempts in this group is significantly lessened if the student is in a supportive social environment (Hatzenbuehler, 2011). A student who feels they can talk about their problems to just one school staff member is 30% less likely to report making multiple suicide attempts than youth who do not have a safe adult to talk to, highlighting the importance of training school staff to support LGBTQ youth with sensitivity and cultural competence (AFSP, 2019).

Transgender adolescents and gender non-conforming adolescents as a demographic group experience high rates of suicide attempts (Becerra-Culqui, 2018). It is recommended that school personnel be educated about the risk and that social supports are critically important. Because harassment, discrimination, and victimization are implicated in elevated suicide risk for this group, it is critical that schools have policies in place that create safe and supportive school environments. In July of 2015, NYSED published Guidance to School Districts for Creating a Safe and Supportive School Environment for Transgender, and Gender Nonconforming Students.

The Trevor Project is a national resource that offers online learning modules as a teacher resource for middle schools and high school classrooms. They also offer 24-hour crisis support via text, chat, and phone for LGBTQ youth experiencing emotional distress.

Latina Youth

Latina adolescents report feeling sad and hopeless at higher rates than their black or white classmates. They also have higher rates of serious suicide attempts requiring medical attention (CDC, 2018).

Comunilife’s Life is Precious (LIP) program provides culturally and linguistically appropriate services for Latina teens, who are living with depression and/or have seriously considered or attempted suicide and their families. LIP provides educational support (tutoring and school system navigation), creative art therapies, wellness activities, case management, and concrete family services. Preliminary evaluation demonstrated LIP is effective in reducing suicidal ideation and depression (Humensky, 2016).

Students with Emotional Dysregulation and Self-Injurious Behavior

The relationship between non-suicidal self-injury (NSSI) and suicide is complex. Research demonstrates that non-suicidal self-injury is an important risk factor for a suicide attempt (Klonsky, 2014). Additionally, a previous suicide attempt is an important risk factor for death by suicide. Both risk factors can be viewed as indications of emotional pain and increased capability to engage in self-harm that may lead to death.

Emotional dysregulation related to a chronic or situational stressor, or a child’s vulnerability to distress can lead to maladaptive behavior patterns in certain vulnerable children. Essential life skills for such students include: 1) Awareness, understanding, and acceptance of emotions, 2) Ability to engage in goal-directed behaviors and inhibit impulsive behaviors when experiencing negative emotions, 3) Use of situationally appropriate strategies to modulate the intensity or duration of emotional responses rather than eliminating emotions entirely and 4) Willingness to experience negative emotions as part of pursuing meaningful activities.

DBT in Schools is a promising program. It is an adaptation of an effective therapeutic clinical intervention Dialectical Behavior Therapy (DBT) that has been proven to decrease suicidal behavior and suicidal ideation. It includes lesson plans for classroom social/emotional skills development (Dadd, 2016).

Youth with Mental Health and/or Substance Use Disorders (SUD)

Mental health conditions: depression, attention-deficit hyperactivity disorder, eating disorders, intermittent explosive disorder, and conduct disorder are important risk factors for suicidal behavior among young people. An estimated one in five children have a diagnosable mental disorder that can result in significant impairment; therefore, school staff may play a pivotal role in recognizing and referring the student to treatment that may reduce risk and improve longer-term outcomes.

Suicide is the leading cause of death among those with substance use disorders and 20% of suicide deaths involve alcohol. Acute alcohol intoxication is present in 30 to 40% of all suicide attempts. The disinhibition that is associated with alcohol consumption is one factor. When a student with suicide risk is also using alcohol, there should be an increased concern for the possibility of a suicide attempt (SAMHSA, 2016).

Screening, Brief Intervention, Referral to Treatment (SBIRT) is a framework that takes a comprehensive approach to address substance use. Many local prevention providers across New York can partner with schools to offer this evidence-based practice.

The NYS Office of Alcohol and Substance Abuse Services (OASAS) offers a Directory of local Substance Use Prevention Programs. Teen Intervene is a brief early intervention program for purchase for students ages 12- to 19-years who display mild to moderate problems associated with alcohol or drug use.

Tier III

Helping a student at risk for suicide is a collaborative process, one in which parents, community providers, school professionals, and the student all have a role to play and must work together to keep a student safe. Intervention should be undertaken with developmental competency and an attempt to understand cultural concerns. The process outlined below includes assessment and triage, brief safety planning intervention, collaborative decision-making, and referral to community providers, and includes a plan for a student’s safe return to school.

Tier III intervention is for students identified as exhibiting warning signs and for whom there is some identified concern for suicide. Standardized written procedures for intervening when a student is identified to be at risk for suicide is a considerable asset for those charged with assisting students who are struggling.

However, given that suicidal behavior is hard to predict, and the safety concerns are so significant, it is critical that all school health, mental health, and designated administrative staff, have adequate and ongoing professional development and support to implement standardized procedures with fidelity.

As noted above in Tier I, teachers and other school staff play a critical role in recognizing warning signs in students and connecting at-risk students to the identified school-based health and mental health professionals who can assess the level of risk and intervene appropriately. Every school district should have a protocol in place for referring students who may be at risk.

Determining Level of Suicide Risk

Any student exhibiting any of the aforementioned FACTS warning signs should receive an immediate screening for suicide risk by school-based health or mental health professionals who have received appropriate training.

The six-question Columbia Suicide Severity Rating Scale (CSSRS) is a recommended screening instrument. Numerous studies support the psychometric properties of the CSSRS, including: its sensitivity to change, internal consistency, inter-rater reliability, and cross-cultural and multilingual application. Research demonstrates its effectiveness as a tool for preventing suicides.

In developing suicide prevention policies, school leaders should identify who conducts such screening, what instrument to use, how it should be documented, how the information from the screening should be communicated, and who has access to it. Additionally, all staff needs to be provided with training on the procedures to follow if a student is identified as exhibiting warning signs.

Assessment and Triage

As a first step, standardized procedures should be in place regarding the assessment and triage of students who may be at risk for suicide. Once a student is identified at risk for suicide, the student should remain under supervision until an appropriate level of risk is assigned and intervention is in place. Assessment for suicide risk is best understood as happening in the midst of a semi-structured interview. Students often react better to a discussion of what is bothering them than to a rote clinical interview. Prepare to meet the student with calm reassurance and collect additional objective data ahead of time if possible, including grades, attendance, disciplinary referrals, and medications. Have as much information as possible about the reason for the referral. It can be helpful to directly address any resistance by the student. With younger children, they may need reassurance that they are not in trouble.

The goal of suicide risk assessment by school-based health and mental health professionals should be for the purpose of triage and safety planning. As part of the semi-structured interview, use of a brief, standardized tool with some evidence of reliability and validity is recommended. The CSSRS is one such tool. It is offered in both brief (six-question) and long form versions and the language can be modified to be culturally or developmentally relevant. The tool is available in 114 languages and can incorporate information gleaned from other sources than just the interview. The tool and training on the use of the tool are offered free of charge and accessible online at the Columbia Lighthouse Project. Another advantage to this tool is that it can be administered by various professionals and it has been proven to be more accurate than a clinical interview.

The six-question CSSRS also helps with triage decisions. Typically, schools stratify risk into low, moderate, or high risk and designate a checklist of minimal interventions at each level.

Advantages to a Second Person

It is recommended, whenever possible, that intervention is achieved with two professionals. One is looking out for the physical and emotional needs of the student and providing constant supervision, while the other is more focused on the logistical and communications aspects of the intervention.

Helping Students at Risk for Suicide

Helping Students at Risk for Suicide (HSAR) is a model for school-based suicide intervention that utilizes a collaborative approach. HSAR was developed through a partnership between the New York Association of School Psychologists (NYASP), SPC-NY, and the Alberti Center for Bullying Abuse Prevention at the University of Buffalo. HSAR incorporates evidence-based tools including the CSSRS and the Stanley/ Brown Suicide Safety Plan.

Brief Safety Planning Intervention

While a student benefits when school and community mental health professionals can collaborate in planning to assist a student, it is recognized that brief interventions at school can also be helpful. Safety Planning Intervention is an evidence-based intervention in which a mental health professional works collaboratively with a student to think through coping strategies and resources that they can access to help keep themselves safe from suicide. Students benefit from having supports that are customized to their individual needs in the school environment (Stanley, 2012).

Additionally, students benefit when school professionals can competently discuss access to medications, weapons, and other means of self-harm with students and their parents. CALM training prepares professionals for this conversation. A means reduction discussion is an important part of a school safety planning meeting.

The next step in any intervention is to ensure that students and their parents have access to 24-hour crisis services. While every community in New York should have some access to emergency mental health services, it is important for school leaders to reach out and understand what the resources can and cannot do before referring families in crisis. Additionally, the 988 Suicide & Crisis Lifeline (call or text 988)  and the Crisis Textline (Text “Got5” to 741-741) provide access to emotional support 24 hours a day. For residents of New York City, NYC WELL is an additional resource.

Working with Parents

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, social worker, school counselor, or a staff member with a special relationship with the student or family. Staff needs to be sensitive toward the family’s culture, including attitudes towards suicide, mental health, privacy, and help-seeking. It can be helpful to recognize that while the school knows a more public side of a student’s life, parents know more about the student’s personal life. It is through the combination of these two perspectives that the best understanding of the situation and consequently how to help can be reached. Garnering information from the family by going slow, demonstrating empathy and an interest in understanding a parent’s perspective, and asking open-ended questions can set the stage for collaboration.

Questions should impart the school professional’s desire to partner with the family on the collective goal of helping and keeping the child safe.

When meeting with parents or guardians:

1. Describe the situation and ask that they come to school
2. When the parent/guardian arrives, explain why their child is thought to be at risk for
3. Explain the importance of securing all firearms, medications, alcohol, and other dangerous
4. Explain options for follow-up with mental health services or further emergency evaluation based on level of risk. Provide information about services and if possible assist with making
5. Ask parents/guardians to sign a form acknowledging that they were notified about concerns, recommendations, and plan for follow-up
6. Identify the staff member who will be following up with parents/guardians and discuss when the follow-up will occur.
7. Explain that a return to school meeting will be scheduled for safety planning and support.
8. Request permission to share information with a health care or mental health care

Family support is critical in ensuring a student is safe from suicide risk. And yet, families are often unprepared and without professional supports, they may need to deal with the complex emotions, shock, or distress they may encounter when notified that their child is at risk for suicide. Parents often need support and assistance to come to terms with their child’s risk and their reaction to it. *Adapted from “Preventing Suicide: A Toolkit for High Schools’ pg72 (SAMHSA,2012).

Families Together in New York State (FTNYS) is a state-wide, parent-governed, non-profit organization that represents families of children with social, emotional, behavioral health, and cross-systems challenges. FTNYS has chapters in all regions of New York State and offers peer support, advocacy, and education for families navigating the mental health system.

Working with Community Mental Health

Students are safest when the mental health professionals at school partner with mental health professionals in their communities. While some schools benefit from strong relationships with community mental health providers, other schools struggle to find accessible mental health care for students. Much work is being done on the state and national levels to ensure that mental health services are more accessible to students. New York State Office of Mental Health offers guidance and resources for schools and mental health services to improve access to care, Improving School and Community Outcomes for Children and Adolescents with Emotional and Behavioral Challenges.

Systems of Care (SOC) initiatives are a growing resource in communities across New York State. These interagency committees, consisting of mental health and social service resource providers, meet to discuss the needs of children, youth, and families with a goal of improving access to care. They can be a great resource to schools as brainstorming partners to develop solutions to meet immediate or emerging needs. The Conference of Local Mental Hygiene Directors’ website provides contact information for Single Point Of Access (SPOA) Coordinators and Local Mental Hygiene Directors, who in many cases are coordinating SOC initiatives. Contact them to inquire about the existence of a local SOC committee and how they may be a resource to your school community. More information on the SOC framework may be found on Multiple Systems Navigator.

Plan for Safe Return to School

When a student returns to school from a mental health referral in the community, after medical treatment for a suicide attempt, or after psychiatric hospitalization it is a crucial time for ensuring that appropriate supports are in place.

Ideally, a return to school meeting is scheduled in which current suicide risk can be assessed, safety plan, current medications, and mental status can be reviewed. Students may need academic supports or accommodations if there has been a significant absence or if there are residual changes in cognitive reserve for learning related to new mental health diagnoses or injuries. Students may require assistance navigating the social milieu at school. Are there environments, classes where they might more likely become emotionally distressed, and do they have strategies in place for managing this? They also need to have a schedule for check-ins with school-based mental health professionals and ways to access supports in a hurry when needed.

Students may need assistance sorting out what to say about their suicidality and to whom. They may need help managing rumors or explaining their absence or explaining visible injuries, which can also be a source of considerable distress. The Honest, Open, Proud workbook provides a tool for school professionals to assist students to understand their story from a strength-based perspective and make strategic decisions about sharing highly sensitive and personal information like their mental health or suicide history.

In-School Suicide Attempts

In the case of an in-school suicide attempt, the physical and mental health and safety of the student are paramount. In these situations:

• First aid will be rendered until professional medical services and/or transportation can be received, following district emergency medical procedures.
• School staff will supervise the student to ensure their
• Staff will move all other students out of the immediate area as soon as possible.
• Staff will request a mental health assessment for the youth as soon as feasibly possible. Since self-harm behaviors are on a continuum of level and urgency, and not all instances of suicidal ideation or behavior warrant hospitalization, a mental health assessment including suicide risk assessment can help determine the best treatment plan and disposition.
• The school-employed mental health professional or principal will contact the student’s parent or guardian, as described in the Working with Parents section.
• Staff will immediately notify the principal or school suicide prevention coordinator regarding the incident of in-school suicide
• The school will engage their building/district level crisis team, as necessary, to assess whether additional steps should be taken to ensure the safety and well-being of the student, and those who may have had emotional or physical proximity to the victim

Out-of-School Suicide Attempts

If a staff member becomes aware of a suicide attempt by a student that is in progress in an out-of-school location, the staff member will:

• Call 911 (police and/or emergency medical services).
• Inform the student’s parent or guardian.
• Inform and supervisor and principal.
• Maintain contact with student if possible until help

*Adapted from Model School District Policy on Suicide Prevention, AFSP, 2014

Postvention

The death of a student or staff member present challenges to the school community. When the death is by suicide there can be even greater challenges. The complex nature of suicide grief, the sudden, unexpected, and often violent aspects of this kind of loss, and the difficulty we have understanding and talking about suicide create the circumstances that can leave school leaders in shock and struggling to meet the needs of staff and students.

Written protocols, policy, preplanning, well-defined roles, and professional development specific to suicide loss are essential supports that enable school leaders and crisis team members to respond in a coordinated and effective manner. After a Suicide: A Toolkit for Schools, published in 2018 by the American Foundation for Suicide Prevention (AFSP) and the Suicide Prevention Resource Center (SPRC), can be used in the immediate aftermath of a suicide death.

Chapter 3 in Preventing Suicide: A Toolkit for High Schools has information and templates that can be helpful for policy development and preplanning. Additionally, AFSP, The Trevor Project, and the National Association of School Psychologists (NASP) document Model School District Policy for Suicide Prevention has a section devoted to suicide postvention guidance.

The Suicide Prevention Center of New York has resource staff who are connected to local resources across NYS that can support schools with short-term and long-term recovery needs through direct consultation and telephone support, or professional development workshops. They support crisis team development through consultation and training based on the Lifelines Postvention: Responding to Suicide and Other Traumatic Death model (Underwood, 2017).

The goals of postvention should be to resolve the crisis and restore the learning environment, provide appropriate information about the crisis, identify students and staff who may be affected and assure grief and trauma supports are in place and identify those who may be at risk. A word about suicide contagion. Research has demonstrated that exposure to suicide within one’s family, in one’s peer group, school community, or even through media sources, can result in increased suicidal behavior and death in others. Direct or indirect exposure to suicidal behavior or suicide death has been shown to increase suicide risk in others, especially adolescents and young adults. This risk can be minimized by efforts to provide factual and concise information, offering access to grief and crisis supports, and by checking in with students and staff members who may be vulnerable. (HHS, 2019)

Additional Resources

For School Leaders

School Readiness Workbook: This workbook offers a framework, checklists, and resources that school leaders and/or school implementation teams, can use to:

1. Assess current suicide prevention, intervention, and postvention readiness
2. Obtain professional development and training for staff
3. Develop suicide intervention and postvention procedures
4. Produces a plan to implement suicide prevention, intervention, and postvention initiatives
5. Find high-quality resources
6. Track effectiveness of efforts

Model School District Policy for Suicide Prevention – This model policy was created through a collaboration between the Trevor Project, the American Foundation for Suicide Prevention, the American School Counselors Association, and the National Association of School

Preventing Suicide: A Toolkit for High Schools – Published by SAMHSA, this toolkit provides best practice guidance and many templates and It can be downloaded or hard copies can be ordered at no cost.

After a Suicide: A Toolkit for Schools – can be printed and offers a grab and go guide for responding.

Mental health Education Literacy in Schools: Linking to a Continuum of Well-Being –  A comprehensive guide for New York Schools published by NYSED.

School Mental Health Resource and Training Center –  at MHANYS was established to support schools to implement Chapter 390 of the Law of 2016, requiring mental health instruction as part of the K-12 health

School and Mental Health Partnerships: Improving School and Community Outcomes for Children and Adolescents with Emotional and Behavioral – This guide explores the benefits of Community mental health provide and school partnerships, discusses the benefits and provides helpful tips for developing partnerships between school and community provider leaders.

Promoting Parent Engagement: Improving Student Health and Academic Achievement – Parent engagement in schools contributes to students’ health and learning.  This guide is one of a series of guides from the CDC that offer practical tips for school leaders.

Online Resources For Parents

Society for the Prevention of Teen Suicide Parent Pages – Society for the Prevention of Teen Suicide offers answers to common parent questions about suicide.  They offer web-based, video, and printable resources for parents on a variety of related topics.

Mayo Clinic parent awareness video, brief, warning signs – The Mayo Clinic offers a brief awareness video for parents.

The American Academy of Child and Adolescent Psychiatry Suicide Resource Center  -Is a website dedicated to providing resources to parents, medical students, and primary care physicians on the prevention on child and youth suicide.

Printable Resources For Parents

SPC-NY Parent brochure – The Suicide Prevention Center of New York has a brochure for parents on talking to their teens about suicide.

CDC Adolescent and School Health Division – offers School Connectedness for Parents and Families, a printable

What to do if you’re concerned about your teen’s mental health: A conversation guide – The JED Foundation offers a guide for parents who are concerned about their teen’s mental health.

Ways to Engage in Your Child’s School to Support Student Health and Learning – The Center for Disease Control and Prevention has a tip sheet for parents on how to work with their child’s school when there are health or learning challenges.

Online Resources For Educators

Act on FACTS: Making Educators Partners in TeenSuicide Prevention – two-hour online training for educators.

Warm Handoff Guideline – A brief video to provide common warning signs of suicide and how to make a warm handoff to school mental health resources.

Self-care and compassion resilience are two important concepts in protecting the mental health of educators

Printable Resources For Educators

SPC-NY Teachers brochure – What every teacher should know about suicide provides information about the warning signs of suicide and some practical tips to prepare school staff to respond.

The role of high school teachers in preventing suicide – This tip sheet from the Suicide Prevention Resource Center provides resources as well as clear guidance on the role of educators in suicide prevention.

Wise Wisconsin – offers 7 promises of a trusted adult and a Safe Persons Decal for those who challenge themselves to uphold the 7 promises.

Online Resources for Working with Students

27 Resiliency Activities and Worksheets for Students and Adults – This website from Positive Psychology.com offers free, and practical worksheets and activities that educators can use to help students learn resiliency skills.

Sources of Strength –  This website not only offers information about how schools can enroll in the Sources of Strength program, but it also offers plenty of resources and tips about how students can run a positive, strength-based messaging campaign.

Intervention Central – offers information on how to implement the Good Behavior Game, an elementary classroom intervention and evidence-based practice for improving pro-social behavior.

DBT STEPS – A universal intervention teaching the skills to manage emotional distress and targeting emotional dysregulation which has been implicated in suicidal ideation and self-injury.

Strategic Disclosure workbook and facilitators guide – helps students with mental health challenges gain a sense of personal empowerment and confidence in achieving goals through reducing self-stigma.

Preventing Youth Suicide Through Lessons of Hope – This program offers 10 free lesson plans for use in classrooms to teach the skills to find and maintain hope.

National Center for Safe and Supportive Learning Environments –  offers free School Climate Surveys. c School Climate survey and resources

Social Emotional Learning: A guide to Systemic Whole SchoolImplementation – A NYSED Guidance documents on Social Emotional Learning.

The TrevorProject – offers telephone, text and chat support and crisis services for LGBTQ+ youth. They also offer ally training to adults who support youth.

Reach Out – Preventing Teen Suicide – This video created by the Mayo Clinic encourages teens to reach out to trusted adults for help.

Printable Resources for Working with Students

SPC-NY Awareness Brochure – What every student should know about suicide is a teaching aid for high school students that includes the warning signs of suicide and some practical tips to prepare students to respond.

CDC Adolescent and School Health Division – Fostering school connectedness is a series of resources providing practical tips for educators about how to improve student health and academic achievement through making them feel more connected and cared about at school.

SPC-NY Talking Points for Classroom Discussions on Suicide – This tip sheet provides guidance on safely talking about suicide in the classroom.

Online Resources for School-based Health and Mental Health Professionals

The Columbia Lighthouse Project – offers training and free access to protocols and suicide assessment and screening tools

Center for Practice Innovations at New York State Psychiatric Institute – offers free online training in the AIM-SP model for Suicide Safer Care for Children and Adolescents

Safety Planning Intervention template with telephone app.

Safety Plan Template for use on electronic devices – Safety planning is an evidence-based intervention for suicidal individuals.

NYS Office of Mental Health School and Mental Health Partnerships – What School Leaders Should Know When Creating School and Mental Health Partnerships.

A Practitioner’s Resource Guide: Helping Families Support Their LGBT Children – Family acceptance and rejection play a critical role in the mental health, development, safety, and well-being of LGBTQ Children and adolescents.   This guide challenges mental health and child welfare providers to take a critical look at how to understand and working with families of LGBTQ youth.

The Role of High School Mental Health Providers in Suicide Prevention – This tip sheet from the Suicide Prevention Resource Center provides resources as well as clear guidance on the role of school-employed mental health providers in suicide prevention.

Printable for School-based Health and Mental Health Professionals

SPC-NY Awareness Brochure – What every student should know about suicide is a teaching aid for high school students that includes the warning signs of suicide and some practical tips to prepare students to respond.

Fostering School Connectedness Information for Teachers and Other School Staff – Fostering school connectedness is a series of resources providing practical tips for educators about how to improve student health and academic achievement through making them feel more connected and cared about at school.

SPC-NY Talking Points for Classroom Discussions on Suicide – This tip sheet provides guidance on safely talking about suicide in the classroom.

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Acknowledgements

This guide was developed by the Schools and Youth Workgroup of the Suicide Prevention Council at New York State Office of Mental Health to provide best practice guidance and resources to schools toward the prevention of youth suicide. Written by Pat Breux and Mitchell Samet, the guide would not have been possible without the generous contributions of thought, expertise, and time of many people for which we are very grateful.

Schools and Youth Workgroup

Pat Breux, Director of School & Youth Initiatives – Suicide Prevention Center of New York

Sam Brinton, Head of Advocacy and Government Affairs – The Trevor Project

Rosa Gil, President and CEO – Comunilife, Inc.

Madelyn Gould, Professor of Epidemiology in Psychiatry – Columbia University Irving Medical Center

Brianna Gower, Director – YOUTH POWER! Families Together in NYS, Inc.

Glenn Liebman, Chief Executive Officer – Mental Health Association in New York State, Inc.

Renee Rider, Executive Director – New York State Council on Children and Families

Mitchell Samet, Workgroup Chair – New York Association of School Psychologists

Victor Schwartz, Chief Medical Officer – The Jed Foundation

Peter Wyman, Professor of Psychology – University of Rochester School of Medicine 

Additional Contributors and Reviewers

Scott Bloom, NYC Office of School Health

Rosa Cifre, Comunilife

Nancy Craig, Families Together in NYS

Peter Faustino, NYASP

Laura Ficarra, NYS OASAS

Sara Gorman, Jed Foundation

Brett Harris, NYS OMH

John Kelly, NYASP

Kathleen Liedka, Families Together in NYS

Sarah Miles, NYC Office of School Health

Keygan Miller, The Trevor Project

Amy Molloy, MHANYS, Inc.

Casey Pick, The Trevor Project

Kathryn Provencher, NYS OMH

New York State Education Department Suicide Prevention Workgroup

Maribeth Barney, NYSED

Donna Bradbury, NYS OMH

City of Albany School District Pupil Services Team

Kathleen DeCataldo, NYSED

Carrie Manchester, NYSED

Martha Morrissey, NYSED