The Key Role of Schools in Youth Suicide Prevention

The coronavirus disease 2019 (COVID-19) pandemic has presented unprecedented challenges for youth and families dealing with remote school and work, lack of childcare, and social isolation over the course of 2 years. In response, the US Surgeon General recently published an advisory warning of a mental health crisis among youth,1Protecting Youth Mental Health: The US Surgeon General’s Advisory.https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdfDate: 2021Date accessed: September 7, 2022Google Scholar noting that youth with intellectual and developmental disabilities, racial/ethnic and sexual/gender minority youth, and youth in low-income, rural, and immigrant households were at higher risk of mental health challenges in the pandemic. The advisory arrived on the heels of an emergency declaration about child and adolescent mental health put forth by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association in October 2021. Both emphasize that the COVID-19 pandemic exacerbated already growing youth mental health concerns and highlight the key role schools must play in preventing youth suicide. In this commentary, we make the case for why we need schools to be in the business of youth suicide prevention. Although more research is needed to develop and test promising school-based suicide prevention programs,2Singer J.B. Erbacher T.A. Rosen P. School-based suicide prevention: A framework for evidence-based practice.School Mental Health. 2019; 11: 54-71https://doi.org/10.1007/s12310-018-9245-8Crossref Scopus (65) Google Scholar policymakers recognize that schools play a key role in suicide prevention. Most state governments had already increased their budgets for school-based mental health and suicide prevention training before the pandemic.3American Foundation for Suicide Prevention. State Laws: Suicide Prevention in Schools (K-12).https://www.datocms-assets.com/12810/1650599253-afsp-k-12-schools-issue-brief.pdfDate: 2020Date accessed: September 7, 2022Google Scholar More recently, the federal government added $122 billion in school funding in part to address the suicide prevention needs of students during the pandemic. In contrast, however, some community members and parents are escalating concerns about whether it is appropriate to implement suicide prevention in schools in the first place (vs in clinical settings or homes). Such concerns may be driven partly by cultural and societal polarization and partly by misconceptions about suicide prevention. For example, some families may fear that talking about suicide in school can “put ideas into kids’ heads” that they weren’t having before. Schools also may have these concerns and worry about adding suicide prevention to a growing list of issues they often take on, such as food insecurity, housing instability, and teacher burnout. As disagreements around schools as a suicide prevention setting escalate, mental health researchers and practitioners will be asked to respond. The purpose of this commentary is to outline key, evidence-based points that the Journal readers can use to communicate about the value and importance of school-based suicide prevention efforts. Asking adults and adolescents about suicidal thoughts and behaviors using validated screening tools is not harmful.4Polihronis C. Cloutier P. Kaur J. Skinner R. Cappelli M. What’s the harm in asking? A systematic review and meta-analysis on the risks of asking about suicide-related behaviors and self-harm with quality appraisal.Arch Suicide Res. 2022; 26: 325-347https://doi.org/10.1080/13811118.2020.1793857Crossref PubMed Scopus (18) Google Scholar Research also shows that youth are generally supportive of efforts to ask them about their suicidal thoughts and behaviors5Ballard E.D. Stanley I.H. Horowitz L.M. Pao M. Cannon E.A. Bridge J.A. Asking youth questions about suicide risk in the pediatric emergency department: Results from a qualitative analysis of patient opinions.Clin Pediatr Emerg Med. 2013; 14: 20-27https://doi.org/10.1016/j.cpem.2013.01.001Crossref PubMed Scopus (27) Google Scholar and that youth suicide risk identification and prevention in schools is likely to help high-risk youth obtain needed treatment that they otherwise would not have received. One study on a high school suicide screening program found that 72% of youth identified as at risk for suicide were not yet receiving any kind of mental health treatment.6Gould M.S. Marrocco F.A. Hoagwood K. Kleinman M. Amakawa L. Altschuler E. Service use by at-risk youths after school-based suicide screening.J Am Acad Child Adolesc Psychiatry. 2009; 48: 1193-1201https://doi.org/10.1097/CHI.0b013e3181bef6d5Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Of youth referred for treatment, 70% obtained care that they may not have received without the screening program. School-based suicide screening can be universal or more targeted (eg, screening only students with a mental health diagnosis), depending on available resources and capacities. However, data show that there are major advantages to screening for suicide specifically (vs general mental health screening only): screening for related problems such as depression, but not for suicide risk specifically, fails to detect about one-third of youth experiencing suicidal thoughts and behaviors.7Horowitz L.M. Mournet A.M. Lanzillo E. et al.Screening pediatric medical patients for suicide risk: Is depression screening enough?.J Adolesc Health. 2021; 68: 1183-1188https://doi.org/10.1016/j.jadohealth.2021.01.028Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Taken together, the evidence indicates that talking to youth about suicidal thoughts and behaviors is not harmful and could result in life-saving benefits. Having schools involved in preventing and detecting suicide risk can be particularly impactful because parents/caregivers may not realize that their child is at risk for, or know how to talk to their child about, suicide. One recent study of 11,814 children 9 and 10 years old found very low agreement between parent and child reports of child suicidal thoughts and behaviors.8DeVille D.C. Whalen D. Breslin F.J. et al.Prevalence and family-related factors associated with suicidal ideation, suicide attempts, and self-injury in children aged 9 to 10 years.JAMA Netw Open. 2020; 3e1920956https://doi.org/10.1001/jamanetworkopen.2019.20956Crossref PubMed Scopus (96) Google Scholar Among children reporting suicidal ideation, 77% of their parents did not report that their child experienced suicidal thoughts or behavior. Moreover, 88% of the parents whose children reported suicide attempts did not report that their child had attempted suicide. This elevates the importance of suicide risk identification and prevention efforts in schools, where students at risk can be identified using safe, valid, and reliable approaches within a familiar and trusted setting. Upstream, universal school-based suicide prevention delivered in elementary schools can prevent the development of suicidal thoughts and behaviors in adolescence.9Wilcox H.C. Kellam S.G. Brown C.H. et al.The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts.Drug Alcohol Depend. 2008; 95: S60-S73https://doi.org/10.1016/j.drugalcdep.2008.01.005Crossref PubMed Scopus (161) Google Scholar Thus, while parents should feel empowered to talk with their children about suicidal thoughts and behaviors, K-12 schools play an important role in preventing youth suicide and connecting at-risk students with needed services. An overall shortage of mental health care providers, further stretched by the COVID-19 pandemic, along with financial costs and mental health stigma mean that many youth—especially marginalized youth who are at increasing risk for suicide—face numerous barriers to accessing mental health care. As nearly all US youth have access to school settings, delivering suicide prevention in schools expands access, regardless of sex/gender, race/ethnicity, and other characteristics that are associated with unequal access to mental health care. Universal school-based suicide prevention strategies that use measurement-based approaches are less likely to worsen inequities that can result from more bias-prone, subjective approaches to determining who receives help (eg, individual school staff judgment). To the extent possible, providers should also consider expanding their own community practice/consultation boundaries to include school-based services or offer guidance to schools on culturally competent best practices associated with youth suicide prevention programming. However, mental health care providers often lack specific training in suicide prevention,10Mitchell S.M. Taylor N.J. Jahn D.R. et al.Suicide-related training, self-efficacy, and mental health care providers’ reactions toward suicidal individuals.Crisis. 2020; 41: 359-366https://doi.org/10.1027/0227-5910/a000647Crossref PubMed Scopus (18) Google Scholar so while it is important to bolster the suicide prevention skills of mental health and primary care, reliance on this already stretched workforce is insufficient. School staff see students many hours a day or week, which uniquely positions them to have conversations with students about their mental health, including when they observe suicide warning signs. That said, it is crucial to note that teachers need not be tasked with all suicide prevention activities: a growing body of evidence shows that trained and supervised laypersons can successfully deliver evidence-based mental health strategies. Providers can work with schools to train a range of school staff or community health workers to deliver evidence-based mental health and suicide prevention programming. Leveraging technology (eg, through validated electronic screening tools and telehealth) also can help to expand schools’ capacities. With youth suicide of increasing concern, it is critical for mental health providers, suicide experts, and researchers to find ways to support school-based youth suicide prevention programming. Schools are stretched thin, and lack of consensus on effective approaches to addressing mental health and student safety is making implementation more difficult and adding stress. Mental health and suicide researchers and providers should communicate the value of suicide prevention efforts in schools and the importance of using valid, culturally competent, measurement-based approaches so that progress can be documented.