Lessons Learned from Ten Years of Using School-Based Screenings for Suicide Postvention.

Author:Mirick, Rebecca G.

Suicide is a significant public health issue for adolescents. In the United States, suicide is the second leading cause of death for youth ages fifteen to twenty-four and the third leading cause of death for youth ages ten to fourteen (Centers for Disease Control and Prevention [CDC], 2015). Adolescent suicide is a growing public health issue. Currently, rates of adolescent suicide are at a thirty-year high (CDC, 2017). The suicide rate for adolescent girls doubled from 2007 to 2015, with the largest increase for the youngest girls (ages 10 to 14; CDC, 2017). The suicide rate for adolescent boys increased by 30 percent during the same time period. These rising rates mean that more schools experience the death of a student by suicide and that suicide is a growing concern for school social workers.

Losing a peer, classmate, or friend to suicide increases an adolescent's own risk of dying by suicide (Abrutyn & Mueller, 2014; Nanayakkara, Misch, Chang, & Henry, 2013; Swanson & Colman, 2013). Approximately 2 to 5 percent of youth suicide deaths are connected to a peer's suicide (Gould, Wallenstein, Kleinman, O'Carroll, & Mercy, 1990). An adolescent's risk of a suicide attempt is greater when he or she was exposed to a friend's suicide attempt or death in the past twelve months (Randall, Nickel, & Colman, 2015). In addition to increasing the risk of suicide, the suicide death of a peer increases an adolescent's risk of depression and anxiety for up to three years after the death (Brent, Moritz, Bridge, Perper, & Canobbio, 1996; Randall et al., 2015; Swanson & Colman, 2013). Exposure to suicide seems to have the largest impact on younger adolescents (12 to 13 years of age) as their risk of suicide after exposure to a peer's suicide death is greater than that of older youth (Swanson & Colman, 2013).

Adolescents often do not disclose their suicidal thoughts and behaviors to an adult, making identification of these youth a challenge (Mojtabai & Olfson, 2008). School-based universal screenings are an effective way to identify students with depression, suicidal thoughts, and behaviors (Gould et al., 2005; Robinson et al., 2011, 2013), and universal screenings are recommended by many suicide prevention experts (Mazza, 1997; Miller, Eckert, DuPaul, & White, 1999; Shaffer & Craft, 1999; Swanson & Colman, 2013). In contrast, schools and parents tend to be less supportive of universal screenings, and their concerns can become barriers to implementation of screenings. School social workers can play a unique role in a school system as advocates for universal screenings. Although many experts recommend screenings, little research has explored the use of universal screenings in a systematic way, including feasibility, effective approaches, cost effectiveness, validity and reliability of screening tools, and use of these tools across different types of schools and students (Mann, Apter, & Bertolote, 2005; Miller, Eckert, & Mazza, 2009). This article will describe one agency's screening procedures during ten years of screening, including characteristics of students identified, barriers encountered, and lessons learned.

Literature Review

Voluntary school-based screenings are an important suicide prevention approach for adolescents. Universal screenings, defined as screenings of all students in one grade or in the school, not just those identified as high risk, are often used by schools to identify students who are at risk for suicide. Universal screenings are conducted in a variety of ways (Cooper, Clements, & Holt, 2011). Some schools offer routine universal screenings. For example, they may conduct screenings at the start of each spring term (Husky, Sheridan, McGuire, & Olfson, 2011) or in the ninth grade each year (Husky et al., 2011; Torcasso & Hilt, 2017). Alternatively, schools may conduct screenings as one component of a postvention plan following student death by suicide. The research literature on screenings primarily discusses routine universal screenings versus those that are conducted following a suicide or cluster of suicides in the school or community (Robinson et al., 2013).

Universal Screenings

The primary benefit of universal screenings is that they facilitate the identification of high-risk youth, allowing school social workers to connect them with appropriate treatment services. Although some of the youth identified during screenings may already be in treatment, other youth disclose depression, suicidal thoughts, and behaviors for the first time. Husky and colleagues (2011), in a review of routine screenings (N = 2,488) in six suburban Wisconsin high schools, found that 20 percent screened positive, meaning that they were considered at risk for suicide. Of these students, 74 percent were not receiving treatment services but 76 percent did follow through on treatment referrals. These high follow-through rates are consistently demonstrated by research on screenings.

Gould and colleagues (2009) conducted a longitudinal study of students who screened positive (N = 317) during routine school-based screenings in six New York State high schools. When they screened positive, 72 percent of the at-risk students were not in treatment. Although students with a previous suicide attempt were in treatment at higher rates, more than half (58%) were not receiving treatment. Sixty-nine percent of students who screened positive followed through with treatment referrals. In a third study of routine universal screenings, Torcasso and Hilt (2017) looked at three years of screenings of ninth graders (N = 193) in one primarily white (84.6%) Midwestern high school. Of these students, 21 percent screened positive and 53 percent of those with positive screenings accessed new support services as a result. In addition, this school saw a significant decrease in the numbers of students reporting suicidal thoughts and behaviors over a three-year period.

Some researchers have explored the use of universal screenings in urban schools. Urban schools tend to have higher rates of positive screens than more affluent suburban schools. Hallfors and colleagues (2006) conducted a feasibility study of universal screenings (N = 1,323) in large urban high schools (N = 10) in the Southwest and Pacific Coast of the United States. These schools were in racially diverse urban communities with high rates of poverty. Twenty-nine percent of the students screened positive. In a second study, Brown and Grumet (2009) evaluated the outcomes of a grant-funded program to screen urban youth of color in schools (N = 13) in Washington, DC. Of the 229 youth screened, 45 percent screened positive.

Barriers to Screenings

Although screenings can identify at-risk students and link them with support services, stakeholders tend to perceive screenings as less acceptable than two other types of suicide prevention programs: curriculum-based education and in-service staff training. In a random survey of members of the National Association of Secondary School Principals (N = 185), principals described screenings as significantly less acceptable than these other two types of suicide prevention approaches (Miller et al., 1999). In a similar study, Eckert, Miller, DuPaul, and Riley-Tillman (2003) surveyed a random sample of members of the National Association of School Psychologists (N = 211), who rated the screening program as significantly less acceptable and significantly more intrusive than the other two types of suicide prevention programs. These opinions were echoed by school superintendents in a random survey of members of the American Association of School Administrators (N = 210; Scherff, Eckert, & Miller, 2005).

Preliminary research suggests that adolescents may have similar feelings about screenings. Eckert, Miller, Riley-Tillman, and DuPaul (2006) surveyed first year college students (N = 662), asking them to compare the three types of suicide prevention programs. Study participants perceived screening programs as less acceptable than the alternatives. Whitney, Renner, Pate, and Jacobs (2011) used qualitative interviews with principals (N= 7) to explore these feelings in more depth. Although these principals all agreed that suicide prevention in schools is critical, they believed that universal screening was not a good option, in part because of a lack of parental support. Some were concerned that students would be at higher risk of suicide due to the screening. Others identified a lack of mental health resources for students who screened positive. Clearly, if schools are to adopt a universal screening approach, outreach to school administrators, staff, and parents is...

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