Suicide Risk in Schools: What Social Workers Need To Know

by Jonathan B. Singer, Ph.D., LCSW

(Editor's note: This article was published in our online Suicide Prevention Month 2018 series, in collaboration with the American Association of Suicidology. See the complete series at: https://bit.ly/2Q8AWX5)

NOTE: This article has been translated to Spanish. Read it at: Riesgo de suicidio en las escuelas: lo que los trabajadores sociales deben saber

     Most people assume that homicide is the number 1 killer in the USA. Wrong. In the USA, the suicide rate is almost 2.3 times as high as the homicide rate. In 2016, there were 323,127,513 people in the USA. Of those, 44,962 people died by suicide and 19,359 people died by homicide. Firearms accounted for more suicide deaths (22,963) than all homicide deaths combined. Youth 10–14 years old are more likely to die by suicide than to die in a car accident or be killed by someone else (“QuickStats,” 2016). In 2016, out of the 82,105,068 youth ages 10-19 years, 2,506 died by suicide. Most of those youth attempted to kill themselves with pills, but 86% of them died from firearms or by suffocation.

Why are youth suicide statistics important?

     I’m sharing youth suicide statistics because they give you an idea of the scope of the problem and some indication of where to focus your attention.

     Among K-12 youth, elementary school youth are significantly more likely to have thoughts of suicide than to make suicide attempts, and almost no youth under the age of 11 die by suicide. According to the Centers for Disease Control, in 2016, out of 28.7 million youth 11 and under, 53 died by suicide. What do we know about those youth? Research by Arielle Sheftall and colleagues found that elementary aged youth who died by suicide were more likely to be African American than White, more likely to die by suffocation (e.g. hanging) than by firearm, and more likely to have a diagnosis of ADHD than a mood disorder (Sheftall et al., 2016).

     As disturbing as these figures are, social workers are more likely to work with youth who are struggling with thoughts of suicide or who have made an attempt than to have a client die by suicide. How do we know about suicidal ideation, suicide plans, and suicide attempts? The main source is from the 39 states who administer the Youth Risk Behavior Survey to middle and high school students (Kann et al., 2018). Data from those surveys indicated that in 2017, 17.2% of high school students had at least one serious thought of suicide in the past year. Among females, suicidal ideation peaked in 10^th grade (23.4%) and declined through 12^th grade (19.5%), whereas among males, suicidal ideation increased every year between 9^th grade (10.3%) and 12^th grade (15.1%).  In 2017, 7.4% of high school students made a suicide attempt, with 9.3% of females and 5.1% of males reporting an attempt. Similar to suicidal ideation, the highest percentage of suicide attempts among females was in the 10^th grade (11.7%) and the lowest percentage was in 12^th grade (6.2%); the percentage of males attempting suicide increased between 9^th grade (5.0%) and 12^th grade (5.3%). One of the take home messages of these stats is that if you are addressing suicide risk in a high school, you might want to prepare 10^th grade staff for an increase among females, and 12^th grade staff for an increase among males. But suicide risk isn’t just divided by grade and sex. There are differences based on ethnicity, geography, access to lethal means, and a bunch of other variables. 

What do I do?

     As a social worker, you should be asking yourself, “What can I do to prevent suicide and help youth have lives worth living?” The good news is that there are several psychotherapies that have been shown to reduce suicidal thoughts and behaviors in youth, such as Attachment-Based Family Therapy, Dialectical Behavior Therapy for adolescents, Cognitive Behavioral Therapy for suicide prevention, and integrative cognitive behavioral therapy (see Singer, O’Brien, & LeCloux, 2017 for a review). The bad news is that very few mental health professionals have been trained in these models and none of them have been modified for use in schools (Erbacher, Singer, & Poland, 2015).

     I’ve developed five tips to help you be more effective in addressing youth suicidal thoughts and behaviors.

Tip #1: Know your role.

     School-based mental health professionals, including social workers, counselors, and psychologists, might be responsible for any or all aspects of suicide prevention, intervention, and postvention.

• If your school has a crisis team, you should be on it.
• If your school screens for suicide risk, you should have reviewed and evaluated the appropriateness of the screening tool and know what the protocols are for students who screen positive for suicide risk.
• If a student screens positive for suicide, are you responsible for doing the suicide assessment, or does your school have a memorandum of understanding with a community agency to do the assessments? If so, you are probably responsible for triage and referral. 
• If your role is crisis intervention, then what is the role of the teacher? Teachers are supposed to educate and manage classroom behavior. A well-trained teacher will know the difference between a behavior management issue and a psychiatric issue. School social workers run into problems when administrators do not have training in place to help school personnel distinguish between the two.

     Knowing your role means knowing what you should be responsible for. This includes knowing what your role is with suicidal youth, but it goes beyond suicide. A great resource for this broader discussion of roles, workload vs. caseload, and other related issues is SchoolSocialWork.net (https://schoolsocialwork.net/)

Tip #2: Know your students.

• Suicide risk changes with age. As noted above, elementary aged youth almost never die by suicide, but those who do are more likely to be African American and have diagnoses of ADHD. In contrast, the risk of death by suicide increases as youth get older, and middle and high school students are more likely to use firearms and be diagnosed with a mood disorder.
• The role of peers changes with age. Everyone knows that peers become more important in middle and high school. But this change has important implications for suicidal youth. Social network analysis by Anthony Fulginiti from the University of Denver’s School of Social Work, has shown that suicidal youth are much more likely to be friends with other suicidal youth than youth who are not suicidal (Fulginiti, Rice, Hsu, Rhoades, & Winetrobe, 2016). If you are working with a suicidal student, ask yourself, “Which one of their friends might also be suicidal?”
• Adolescent culture plays a role in suicide risk. Social workers should be aware of hashtags that are used to communicate feelings of distress, potentially lethal viral challenges (such as the Tide Pod Challenge or Cinnamon Challenge), and the normative increase in risk-taking behavior. Teens sometimes use hashtags like #sue (for suicide), and #cat and #deb (both for depression) as code to communicate feelings of distress. If you search Instagram for these hashtags, you will find thousands of photos of people who have engaged in self-harm or have posted messages of distress. Not all of these are problematic – sometimes adolescents feel a sense of community when they are able to share their pain with others who are going through the same thing.

Tip #3: Know your community.

     You can be the best trained school social worker in the world, but if your community lacks resources, you will have a harder time providing excellent care to your suicidal students.

• Community resources can include outpatient therapists who are trained in how to work with suicidal youth, including training in Attachment-Based Family Therapy, Dialectical Behavior Therapy, and Cognitive Behavioral Therapy for suicide prevention.
• Agencies can have memorandums of understanding with the school to provide crisis services or meet students and families to provide therapy in the schools.
• Faith communities should have religious leaders who have been trained in how to address suicide risk in their congregations (see https://cxmhpodcast.com/show-notes/2018/5/11/recast-suicide-prevention for a great discussion about what this can look like).
• Child welfare and juvenile justice systems have their own policies and protocols, but exert an enormous influence over the community.

Tip #4: Know your tools.

     The school social worker can gather essential information that mental health professionals in child welfare, juvenile justice, and community mental health do not have access to. One of the tools for gathering this information was developed by my co-author, Terri Erbacher, for our book Suicide in Schools. The Suicide Risk Monitoring Tool (Erbacher & Singer, 2018) enables school mental health professionals to quickly and easily monitor suicide risk in youth. If you have a student who you know is at risk (because of a suicide risk assessment, or because they were recently released from a psychiatric hospital), you have them fill out this brief form and track changes in suicidal thoughts and behaviors, reasons for living, hopelessness, and a sense of belonging. The tool enables you to track changes in suicide risk, and assuming proper release of information forms are signed, share invaluable information about risk with other providers.

     Suicide prevention apps such as MY3 and Virtual Hope Box can be invaluable tools in addressing the concern, “How will the student cope when not in my office?”

• MY3 (http://my3app.org/). MY3 is an app that enables users to add the contact information of the three people they would like to contact when suicidal. There are dedicated buttons for the National Suicide Prevention Lifeline and 911. You can customize and access resources. I recommend using MY3 with youth who have safety plans.
• Virtual Hope Box (http://t2health.dcoe.mil/apps/virtual-hope-box). Although the VHB app was developed by the military for veterans, it contains several features that are useful for youth. Students can use the VHB to store a variety of rich multimedia content that they find personally supportive in times of need. For example, a student can include family photos, videos, and recorded messages from loved ones; inspirational quotes; music they find especially soothing; reminders of previous successes, positive life experiences, and future aspirations; and affirmations of their worth in their VHB. Students can also collaborate with their providers to create coping cards to use in response to personal problem areas they experience. Finally, the VHB provides the student with positive activity planning, distraction tools, and interactive relaxation exercises including guided imagery, controlled breathing, and muscle relaxation. I recommend that the school mental health professional help the student set up the VHB and incorporate its use into services.

     One of the most popular approaches to suicide prevention in schools is to train peers to not be afraid to tell an adult if one of their friends is suicidal. There are programs like Hope Squads, Yellow Ribbon, or Sources of Strength. The standard line for encouraging a student to tell on a friend goes something like this: “Would you rather your friend be mad at you for a little while, or dead?” Anthony Fulginiti’s research points to one reason why peer monitoring might not be effective (Fulginiti et al., 2016). If student A is suicidal and Student A's best friend, Student B, is also suicidal, they would be less likely to be alarmed by suicidal thoughts or behaviors. Student B might not be willing to tell an adult, because doing so could "out" Student B as suicidal. Research by Maddy Gould and colleagues in New York found that when students think that their peers are more suicidal than they actually are, suicide risk goes up (Gould et al., 2018). This means that if a student has three friends who are suicidal, then they are more likely to think “all kids are suicidal.” Not only is this not true, but this belief appears to place students at greater risk for suicide.

Tip #5: Know your resources.

     The following are excellent resources for suicide prevention:

• Suicide Prevention Resource Center: SPRC is a clearinghouse of suicide prevention programs and practices.
• American Foundation for Suicide Prevention: AFSP provides outstanding education resources.
• American Association of Suicidology: This is a member organization that all social workers who have suicidal clients should join.
• Crisis lines: 800-273-TALK, or text “Home” to 741-741.

     I hope these five tips will make your work with suicidal students more effective. 

References

Erbacher, T. A., & Singer, J. B. (2018). Suicide risk monitoring: The missing piece in suicide risk assessment. Contemporary School Psychology, 22(2), 186–194. https://doi.org/10.1007/s40688-017-0164-8

Erbacher, T. A., Singer, J. B., & Poland, S. (2015). Suicide in schools: A practitioner’s guide to multi-level prevention, assessment, intervention, and postvention. New York, NY: Routledge.

Fulginiti, A., Rice, E., Hsu, H.-T., Rhoades, H., & Winetrobe, H. (2016). Risky integration: A social network analysis of network position, exposure, and suicidal ideation among homeless youth. Journal of Crisis Intervention and Suicide Prevention, 37 (3), 184–193.

Gould, M. S., Lake, A. M., Kleinman, M., Galfalvy, H., Chowdhury, S., & Madnick, A. (2018). Exposure to suicide in high schools: Impact on serious suicidal ideation/behavior, depression, maladaptive coping strategies, and attitudes toward help-seeking. International Journal of Environmental Research and Public Health, 15 (3), 455. https://doi.org/10.3390/ijerph15030455

Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., … Ethier, K. A. (2018). Youth risk behavior surveillance—United States, 2017. MMWR. Surveillance Summaries, 67 (8), 1–114. https://doi.org/10.15585/mmwr.ss6708a1

QuickStats: Death rates for motor vehicle traffic injury, suicide, and homicide among children and adolescents aged 10–14 Years—United States, 1999–2014. (2016). MMWR. Morbidity and Mortality Weekly Report, 65 (43), 1203. https://doi.org/10.15585/mmwr.mm6543a8

Sheftall, A. H., Asti, L., Horowitz, L. M., Felts, A., Fontanella, C. A., Campo, J. V., & Bridge, J. A. (2016). Suicide in elementary school-aged children and early adolescents. Pediatrics, 138 (4), e20160436. https://doi.org/10.1542/peds.2016-0436

Singer, J. B., O’Brien, K. H. M., & LeCloux, M. (2017). Three psychotherapies for suicidal adolescents: Overview of conceptual frameworks and intervention techniques. Child and Adolescent Social Work Journal, 34 (2), 95–106. https://doi.org/10.1007/s10560-016-0453-5

Jonathan B. Singer, Ph.D., LCSW, is associate professor of social work at Loyola University Chicago, founder and host of the Social Work Podcast, Secretary of the American Association of Suicidology, and co-author of the 2015 Routledge text, Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention.

Read The New Social Worker's book review of Suicide in Schools.