Suicide Prevention in Schools

Suicidal Feelings and Behaviors - Facts and Figures

The National Youth Risk Behavior Surveillance Survey, a self-report survey conducted in high schools by the Centers for Disease Control and Prevention (CDC) every 2 years, has found steady increases in youth experiencing sadness and hopelessness (28% to 42%), seriously considering suicide (16% to 22%), making a suicide plan (13% to 18%) and attempting suicide (8% to 10%) from 2011 to 2021.

In 2021, 13% of females and 7% of males surveyed reported a suicide attempt in the previous year. Rates were highest among students who identified as American Indian/Alaska Native (16%), Black (14%), Multiracial (12%), Hispanic (11%) and Native Hawaiian/Pacific Islander (10%). Students who identified as LGBQ+ were almost 4 times as likely to have attempted suicide (22%) as students who identified as heterosexual (6%).

A review of the mortality files from the National Vital Statistics System found that suicide rates in 2021 nearly equaled the previous all-time high of 2018. Among youth from ages 10 to 24, rates of death by suicide increased in every ethnic/racial group except white youth; death rates in American Indian/Alaska Native youth were 36.3/100,00 youth, more than twice as high as Native Hawaiian/Pacific Islander youth (16.2/100,00) and three times the rate for white youth (12.1/100,00). Although death rates were lower for African American youth (11.2), this figure represents a 36.3% increase over 2018.

Suicide Language

Most young people spend a significant part of their day at school under the supervision of school staff or other trusted adults, such as coaches and mentors. Recently, those at the forefront of suicide prevention have transitioned to applying trauma-informed, non-stigmatizing language. Providing education and promoting the utilization of trauma-informed language is extremely important when discussing suicidal risk and events with young people. This helps create a safe, compassionate space and encourage those experiencing thoughts of suicide to seek help. 

One of the most significant changes is referring to suicide as a cause of death. In the past, phrases such as he/she/they “committed suicide” or “completed suicide” were frequently used. However, “commit/committed” is felt by many to have an implication of criminality - as in “she committed a murder.” As a society, we often refer to crimes as having been “committed,” which can lead to the criminalization of people who have died by suicide. Furthermore, the use of “completed” may suggest that an act has been accomplished or been “successful,” often sending the message that suicide is an achievement or a task to be fulfilled. The current goal is to prioritize safety through our vernacular and tone. Another goal is to maintain neutrality rather than judgement in the words we choose to use when discussing suicide. We want to steer away from labeling actions or thoughts as “good” or “bad” by just focusing on the facts.  

How to Talk About Suicide

Source: Language Matters When Talking About Suicide 

The Blueprint for Youth Suicide Prevention, developed by the AAP, includes more detailed information on talking about suicide risk with families, in addition to this handout.

Helpful Resources on Suicide Language Include:

• SpeakingofSuicide.com - includes posts about “10 Things to Say to a Suicidal Person” and  “10 Things Not to Say to a Suicidal Person” by Stacey Freedenthal, PhD, LCSW
• irmi.com - Language Matters: Why We Don't Say "Committed Suicide"
• psychology.org - Suicide and language: Why we shouldn't use the ‘C’ word
• American Foundation for Suicide Prevention - Speaking Out About Suicide

Determination of Suicide Level, Plan and Intent

When there are school-based nurses, mental health personnel or a school-based health center provider on site, staff members who have suspicion or a disclosure of suicidality from a student must notify the provider as soon as possible to assess for suicide.

The student needs to remain in the clinic or office, within eyesight supervision until assessed by a provider. 

Once the screening  is complete, the provider can then determine the appropriate next step, which may include completing an Outpatient Safety Plan with the student.  

The parent or guardian needs to be notified immediately if their student has been identified for being at risk for suicide.  The provider can share a copy of the safety plan to the student and parent/guardian. A copy of the safety plan may be provided to trusted on-campus adult(s) if given permission by the student. A scanned copy of safety plan in should be included in the electronic health record (EHR).

• For students with some ideation but NO clear plan or intent, a “Safety Plan” is an appropriate next step.
• For students with ideation and some intent, require further investigation and consultation with behavioral health providers.  More information on next steps for providing support to students who need further care can be found in the Blueprint for Youth Suicide Prevention.
• For students with clear ideation, a plan and clear intent initiating crisis procedures is necessary.  If the assessor is unsure of the risk status of the student and no behavioral health provider or medical provider is available to consult, calling emergency crisis services is the appropriate next step, including law enforcement who may be able to conduct a more thorough assessment.
  • If a student meets the criteria for involuntary psychiatric hold, identify a safe space (eg, exam room, kitchen, office space) with staff to supervise the student until EMS arrives. If ambulance transport is called, notify EMS/law enforcement where to park and have security unlock gates for privacy. Have police/ambulance directed to go to a location with least witnesses to enhance privacy. Notify school administration that an ambulance has been called for a patient.
  • If the parent/guardian is not with the student, call the parent/guardian.
  • Do not leave the students unattended for any reason. Utilize support staff for monitoring so as not to disrupt flow. Minimize disruptions during assessment and emergency intervention.
• 988 is the suicide and crisis lifeline. The lifeline provides 24/7, free and confidential support for anyone in distress, prevention and crisis resources. The lifeline can be shared with students, families and school staff for additional support.

Ensuring Clinic Confidentiality in Schools

If the school-based clinic or provider is NOT a school employee, they are subject to Health Insurance Portability and Accountability ACT (HIPAA) rules and State confidentiality laws. For clinicians who are school employees, they can be subject to Family Educational Rights and Privacy Act (FERPA) rules, and also to HIPAA in some cases.

Additional Resources on Confidentiality Include:

• Information-Sharing and Confidentiality in School-based Health Centers: A Resource Guide to HIPAA and FERPA, by Rebecca Gudeman, JD, MPA and Abigail English (2023)
• AAP HIPAA and FERPA: Basics

Reentry after Psychiatric Hold

Before a student returns to school after being placed on a psychiatric hold, the following considerations should be made:

• Contact the parent/family to ask when the student will be returning to school.
  • Discuss with parent/family/student and recommend that they sign HIPAA release of information (ROI) - to allow sharing with health personnel and appropriate staff at the school.
  • Discuss benefits of close follow-up at school and any reservations that caregivers and the student may have about sharing this information.
  • Gather information on therapy and support the student is receiving outside of school.
  • Request the “Care Plan” from the admitting hospital.
  • Let the student know you are glad they are there and that you care about them.
• Notify appropriate school staff/teacher(s) prior to the student returning to school, including how to welcome back the student. Involved parties may include school administrator(s), therapist, school counselor, restorative justice facilitator, family resource liaison, after school program staff, behavioral consultant, resource specialist, school psychologist, case-manager, teacher and/or mentor.
  • Discussion should include the following:
    • What would help ease the transition back to school, and any needed accommodations;
    • School health professionals periodically checking in with the student to help with the readjustment;
    • Designating a time period for any extra needs of the student, and then fading support or reevaluating;
    • Administration disclosing non-specific information to the student’s teachers and other relevant staff
• Assign a trusted teacher/staff/clinician to facilitate the student’s return.
  • The re entry plan should involve the school, clinicians, family and the student
  • It’s important to work with school staff and teachers to minimize gossip
  • If the student wants to discuss experiences in class, the teacher and appropriate provider (such as a counselor, social worker or psychologist) should meet first with the young person to determine what they want to disclose and potential risks
• Possible concerns of the student that should be addressed prior to return:
  • How will peers react?
  • How will they make up missed work?
  • Any side effects of psychiatric medication that may interfere with concentration.

Additional Resources on School Reentry

• Preventing Suicide: A Toolkit for High Schools (SAMHSA) was developed to help high schools, school districts, and their partners design and implement strategies to prevent suicide and promote behavioral health among their students.
• National Association of School Psychologists & American School Counselor Association - School Reentry Considerations: Supporting Student Social and Emotional Learning and Mental and Behavioral Health
• School Reintegration Following Psychiatric Hospitalization: A Review of Available Transition Programs This study aimed to 1) identify transition programs for school reintegration after youth psychiatric hospitalization, and 2) assess these programs using criteria established by Blueprints for Healthy Youth Development.

Preventing Suicide Clusters Through Postvention

Postvention refers to working with schools and community settings after a student dies by suicide. Young people are at most risk of contagion and suicide clusters after an initial death by suicide. What is done in the school setting following a student death by suicide can either increase or decrease the risk of additional deaths by suicide among the student community so it is important for school district’s to have a postvention plan in place.

In the event of a death by suicide of a student, school districts should consider the following:

• Training school administrators, teachers and clinicians on how to refer students for follow up counseling and care, have in-classroom discussions to help students understand and manage emotions or conducting postvention gatherings.
• Avoid spreading details of the site and method used to prevent contagion.
• Allowing students to grieve and remember the student who died – fear of contagion should not be a barrier to allowing students a space to grieve and process their feelings.
• Arranging for follow-up counseling in the weeks and months following the suicide. 

Additional Resources on Postvention Include:

• Daily Postvention Protocols- Heard Alliance
  A detailed description of actions to be taken when a school experiences a loss to suicide. A schematic flow chart of these actions and a communication template are provided.
• American Foundation on Suicide Prevention- After Suicide: A Toolkit for Schools
  The toolkit offers best practices and practical tools to help schools in the aftermath of suicide.
• Cluster and Contagion Information/Resources
  This CDC website provides definitions of suicide clusters, contagion, and prevention resources.
• Kognito Training Module: Coping with Loss at School
  The module is interactive role-play simulation to prepare schools for responding to a death in the school community. Teachers and administrators learn key elements of a crisis response plan, including postvention, and best practices for communicating with students and colleagues impacted by a loss in the school.
• Resources for After a Suicide Death (Dougy Center)
  A collection of informational handouts and personal stories (available in both English and Spanish) to provide support to caregivers and children/adolescents.