Tier III: Individualized Interventions – Guide for NY Schools

Individualized Interventions - 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 need 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 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 who 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 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 National Suicide Prevention Lifeline at 1-800-273- 8255 and the Crisis Text line (Text “Got5” to 741-741) provide access to emotional support 24 hours a day. For residents of New York City, NYCWELL 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 need 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
  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 the 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 http://clmhd.org/contact_ local_mental_hygiene_departments/ 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 www.msnavigator.org.

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