AAS 2024
School-based suicide risk assessment as a process
Presented by: Marina Niznik and Scott Poland
A plethora of recent data highlight that adolescent mental health issues are on the rise (CDC, 2023; World Health Organization, 2021), including clinically significant depression, suicidal ideation, and self-harm (CDC, 2020; Holmes et al., 2020). Gen Z (digital native “zoomers” born between 1997–2012) indicate they are “the most likely of all generations to report poor mental health” (APA, 2018), rating themselves as having more stress compared to adults about the rise in suicide rates (62% vs. 44%) (APA, 2020).
Responding to mental health issues at school has become increasingly complex. “Assessment and management of suicide risk are among the most daunting tasks faced by mental health clinicians who work with children and adolescents” (Pettit et al., 2018, p. 460). It is well established that assessing suicidal thoughts and behaviors is an integral part of preventing suicide (American Psychiatric Association, 2003, as cited in Law et al., 2015). School-based mental health professionals are well positioned to generate effective prevention strategies (Law et al., 2015).
Recent data reveal that 22% of high school students seriously considered suicide during the past year, and 10% carried out a suicide attempt (CDC, 2023). Alarmingly, this suggests that school mental health professionals could justifiably be conducting risk assessments for one-quarter of the student population in a given school year. Increased rates were noted for females, adolescents identifying as LGBTQ+, and adolescents who are Black or Hispanic. Given that 42% of high school students report feeling persistently sad or hopeless, school mental health professionals are increasingly tasked with addressing this serious issue.
Assessing suicidal thoughts and behaviors is an integral part of preventing suicide (American Psychiatric Association, 2003), as assessment informs intervention. Yet “there is no perfect, one-size-fits-all approach to suicide risk assessment and management” (Pettit et al., 2018, p. 16). To do so effectively, risk assessments should be managed as an ongoing process rather than a one-time event.
School mental health professionals serving on multidisciplinary crisis response teams are expected to possess competency in suicide and threat procedures and are often at the forefront regardless of previous training or level of confidence (Stein-Erichsen, 2010). Not only do many mental health professionals report feeling inadequately trained to handle suicide risk assessment (Dexter-Mazza & Freeman, 2003), but assessment of suicidal behaviors has been identified as one of the most stressful and impactful aspects of working with adolescents (Pettit et al., 2018).
The heterogeneity of suicidality in adolescents requires an exploration of contextual and individual factors to understand drivers—defined as the thoughts, feelings, and behaviors that lead to the individual becoming suicidal (Tucker et al., 2015)—to better yield opportunities for intervention (O’Connor et al., 2014). Contextual factors that may impinge on suicide risk can include: environmental (e.g., adverse life events, school victimization); internal (e.g., previous harmful behavior, presence of a mood disorder, history of destructive behavior); familial (e.g., history of suicide and/or violence, immigrant status, socioeconomic disadvantage); behavioral (e.g., substance use, eating disorders); and access to lethal means (e.g., firearms, carrying a weapon) (Runkle et al., 2023). Increasingly, the intersectionality of these factors—and other salient factors that disproportionately impact groups (e.g., social demographics such as race, gender, class, and sexual orientation)—are considered important components of culturally competent risk assessment (The Jed Foundation, 2023; CDC, 2023).
Within school settings, the challenge lies in determining the degree of severity of adolescent risk in order to guide appropriate interventions. Mental health professionals have long relied on well-honed clinical interviews for assessment, yet the addition of structured assessment tools can improve clarity, as research suggests they are better at identifying risk than clinical interviews alone (Posner, 2011).
This session will focus on suicide assessment as a process that school mental health professionals share as part of a multidisciplinary team. Evidence-based and easily accessible tools for assessing suicide risk in adolescents will be presented (e.g., Columbia-Suicide Severity Rating Scale, Suicide Status Form, CAMS-4Teens, Ask Suicide-Screening Questions). Focus will be on adding established tools to aid in risk assessment as well as utilizing contextual frameworks to further identify drivers of suicidal behavior in adolescents.
“Definitional issues aside, suicidal crises can escalate rapidly in youths and attempts can occur with minimal planning. The field’s ability to assess and predict the likelihood of such rapid escalation is poor, a fact that highlights the importance of taking appropriate planning and prevention steps with youths at all levels of risk” (Pettit et al., 2018, p. 3).
References list
American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behavior. Washington, DC: Author.
American Psychological Association. (2020). Stress in America, 2020: A national mental health crisis.https://www.apa.org/news/press/releases/stress/2020/report-october
American Psychological Association. (2018). Stress in America: Generation Z.https://www.apa.org/news/press/releases/stress/2018/stress-gen-z.pdf
Centers for Disease Control. (2023). Youth Risk Behavior Survey: Data summary and trends report 2011–2021.https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf
Dexter-Mazza, E. T., & Freeman, K. A. (2003). Graduate training and the treatment of suicidal clients: The students’ perspective. Suicide and Life-Threatening Behavior, 33(2), 211–219. https://doi.org/10.1521/suli.33.2.211.22769
Felix, E. D., Janson, M., Fly, J., & Powers, J. (2022). Social-cognitive mediators of the relationship of media exposure to acute mass violence and distress among adolescents. American Journal of Orthopsychiatry, 92(1), 1–10. https://doi.org/10.1037/rmh0000208
Holmes, E., O’Connor, R., Perry, H., Simon, T., Arsneault, W., Ballard, C., Christensen, H., Silver, R., Everall, I., Ford, T., John, A., Kabir, T., King, K., Madan, I., Michie, S., Przybylski, A., Shafran, R., Sweeney, A., Worthman, C., Yardley, L., Cowan, K., Cope, C., Hotopf, M., & Bullmore, E. (2020). Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science. Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(20)30168-1
Law, M. K., Furr, R. M., Arnold, E. M., Mneimne, M., Jaquett, C., & Fleeson, W. (2015). Does assessing suicidality frequently and repeatedly cause harm? A randomized control study. Psychological Assessment, 27(4), 1171–1181. https://doi.org/10.1037/pas0000118
O’Connor, S. S., Brausch, A., Ridge, A. A., & Jobes, D. A. (2014). Applying the collaborative assessment and management of suicidality (CAMS) to suicidal adolescents. International Journal of Behavioral Consultation and Therapy, 54(3), 53–58.
Pettit, J. W., Buitron, V., & Green, K. L. (2018). Assessment and management of suicide risk in children and adolescents. Cognitive Behavioral Practice, 25(4), 460–472. https://doi.org/10.1016/j.cbpra.2018.04.001
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershov, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266–1277.
Runkle, J. R., Harden, S., Hart, L., Moreno, C., Michael, K., & Sugg, M. M. (2023). Socioenvironmental drivers of adolescent suicide in the United States: A scoping review. Journal of Rural Mental Health, 47(2), 65–80.
Stein-Erichsen, J. L. (2010). School psychologists’ confidence level with suicide intervention and prevention in the schools. PCOM Psychology Dissertations, Paper 132.
The Jed Foundation. (2023). Youth suicide: Current trends and the path to prevention.
Tucker, R., Crowley, K., Davidson, C., & Gutierrez, P. (2015). Risk factors, warning signs, and drivers of suicide: What are they, how do they differ, and why does it matter? Suicide and Life-Threatening Behavior, 45.https://doi.org/10.1111/sltb.12161
World Health Organization. (2021). Mental health of adolescents. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health