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Suicidal Risk and Prevention in Children and Adolescents: What to do about it? (Part 3 of 3)

This the conclusion of our 3 part series on risk and protective factors associated with suicidality in children and adolescents.
This week our guest post comes from nationally certified school psychologist Jason Basinger. Jason is currently part of the Trauma Team for the Utah Education Association, is a board member for the Utah Association of School Psychologists, and serves on the Utah Youth Suicide Prevention Coalition. This is the conclusion of our special 3 part series on risk and protective factors associated with suicidality.

Suicidal Risk and Prevention in Children and Adolescents: What to do about it? (Part 3 of 3)  by Jason Basinger

Protective factors: What helps mitigate suicidality risk?
Now that we have discussed what leads to suicidality, let’s discuss protective factors that can help prevent or mitigate risk for suicide. 
Schools are in a unique situation to help address mental health concerns and decrease risk of childhood suicidality (Janiri, 2020). Schools can introduce prevention programs in early adolescence with positive outcomes (Flores, 2020). These programs can focus on individuals with depressed mood, as well as addressing other related risk factors (Schlagbaum, 2020). These programs can also be tailored to reach high-risk students with language, cultural, and social integration challenges (Flores, 2020). Lessons on resilience and coping skills can also be used to address stressful life events (Howarth, 2020).
Belongingness is a risk factor that schools can address through suicide prevention efforts. Hill and Katusic (2020) found that “the reduction of thwarted belongingness via the development of social relations with family and peers… may proactively contribute to suicide prevention” (p. 8). They also found that contributing to others, participating in volunteer activities, or engaging in helpful activities can decrease feelings of burdensomeness (Hill & Katusic, 2020).
Schools can also implement bullying prevention programs to decreased suicidality (Holden, 2020). Bullying prevention programs can promote social inclusion, provide ongoing teacher training, and create better student understanding surrounding bullying and suicide (Holden, 2020).
Additionally, schools can address suicide prevention by educating parents on risk factors and related behaviors. Janiri (2020) found that parents with a higher level of education were more likely to report concerns of suicide (Janiri, 2020). Overall, increased parental supervision and positive school involvement are both factors that decrease suicidal risk in early adolescents (Janiri, 2020). Through parent and family education, schools can encourage and create appropriate attitudes about mental health and decrease risks for suicidality. 
Identification, Referral, and Treatment
School-wide screenings are an important way that schools can address suicide prevention. Screenings can be provided by teachers, and don’t necessarily require a mental health professional. Screenings can and should be systematic, although not complex. Simply asking teachers to rank their top 3 students with emotional/behavioral concerns can help identify which students need referrals. Doing this on a scheduled twice a year basis (fall and spring) can help provide structure to these referrals.
There is also a more direct way to identify suicidal risk: by asking the student “Have you thought about hurting yourself recently?” or “Have thought about killing yourself?” Slesnick (2020) was able to appropriately identify youth needing further help by directly asking if they had current or recent thoughts of wanting to harm themselves. Sometimes we want to shy away from bringing up the topic of suicide, thinking that we will make the situation worse. In fact, research continually finds that asking about suicidality does not increase risk of suicide. 
Hill and Katusic (2020) suggest that using concrete questions and timeframes would also help identify suicidality in individuals with Autism Spectrum Disorder (ASD) who may interpret questions in an overly narrow or literal manner. For example, a good question may be “In the last two weeks, have you thought about suicide?” (Hill & Katusic, 2020, p. 11). Appropriately identifying suicide risk is important for individuals with ASD considering that mental health professionals often inaccurately conclude that individuals with ASD have no suicide risk—even though research indicates that individuals with ASD experience suicidality more frequently than the general population (Jager-Hyman, 2020).
However, identifying youth at-risk for suicide is difficult when they do not have depressed mood or externalizing behaviors (Schlagbaum, 2020). LGBT females have fewer externalizing behaviors and English Language Learners often have fewer social connections, making it difficult to identify suicide risk in these youth (Flores, 2020). It is important that schools make conscious efforts to identify suicidality in underrepresented groups. One school district monitored students’ suicidal threats on social media in order to identify and make referrals to mental health support (Byars, 2020). Another study found that adolescents felt comfortable reporting suicidality through a website, demonstrating that telehealth may be able to facilitate identification of suicidality (Iorfino, 2017). Technology may be helpful for students with no externalizing behaviors. 
After initial identification, referrals can be made to a qualified mental health professional for a suicide risk assessment and mental health services (Howarth, 2020). A risk assessment should include standardize screening tools. Studies have shown that “clinicians who use standardized screening measures are more likely to accurately detect clients’ suicidal thoughts or behaviors than those who do not” (Jager-Hyman, 2020, p. 6). Mental health professionals can include school counselors, social workers, or school psychologists. School psychologists are typically available to help with suicide prevention practices in schools, helping to both identify and intervene with students at-risk for suicide (Erps, 2020).
A few years ago, a high school administrator approached me with a concern that a student was suicidal. I quickly started a suicide risk assessment—which included a review of records (grades, school attendance, disciplinary issues), interviews with teachers, information from parents (family life, social history, mental health history), and an interview with the student. In the end, we concluded that this student was at low risk for suicide despite concerns with mood. I was grateful for the teachers’ and administrator’s care in referring this student. While there was a low risk for suicide in this instance, we were able to provide appropriate school-based mental health services.
Treatment practices have been effective in reducing self-harm and suicidal ideation. Sinyor (2020) found that cognitive behavioral therapy resulted in fewer instances of repeat self-harm in youth, with only 11% having repeat self-harm incidents following treatment compared to 30% in youth with no treatment. Similarly, Slesnick (2020) found that cognitive therapy led to faster declines in suicidal ideation. Telehealth practices may also help decrease risk for suicide, with studies suggesting that telehealth and in-person assessments are similarly effective (May, 2020). Suicide prevention telephone hotlines have been effective in decreasing suicides over a 10-year period (Hailey, 2008). Suicide prevention smartphone apps are also helpful following discharge for teenage suicidality, providing a confidential communication method that decreases the risk for suicide between clinician visits (O’Brien, 2017). While there is some concern that technology removes personalized aspects of therapy, adolescents prefer smartphones as an access point to mental health services—suggesting that smartphones can potentially increase treatment compliance and decrease risk of suicidality (O’Brien, 2017).
As I conclude this blog post on suicidality and as we conclude National Suicide Prevention Week, it is important to consider how schools and parents can come together to support children and adolescent, not just to decrease suicide fatalities, but to promote mental wellness for our youth. The current global pandemic is negatively impacting mental health especially in adolescents. Because suicidality is a major concern, understanding risk factors and following the proper steps of identification, referral, and treatment are crucial. Schools are in a unique position to help prevent adolescent suicide because of their access to mental health professionals and the channels available to them to educate both students and parents. 
I hope that we can create home and school environments that encourage emotional and mental health management daily. I hope that access to mental health professionals is more common and used preventatively, not only for crisis response.

About the Author

Jason Basinger is a Nationally Certified School Psychologist in Salt Lake City School District. He is currently part of the Trauma Team for the Utah Education Association, is a board member for the Utah Association of School Psychologists and serves on the Utah Youth Suicide Prevention Coalition. He enjoys playing and watching sports with his family, plays guitar, and loves running. He may be contacted at jason.basinger@gmail.com or on Twitter @jason_basinger.
**National Suicide Prevention Week is September 6-12, 2020 and World Suicide Prevention Day is September 10, 2020**
The following are good resources and organizations that promote youth suicide prevention:
If you or someone you know is suicidal, get help immediately via 911, the National Suicide Prevention Lifeline at 1-800-273-TALK or the Crisis Text Line (text “HOME” to 741741).
References
  • Byars, J., Graybill, E., Wellons, Q., & Harper, L. (2020). Monitoring social media and technology use to prevent youth suicide and school violence. Contemporary School Psychology.
  • Erps, K. H., Ochs, S., & Myers, C. L. (2020). School psychologists and suicide risk assessment: Role perception and competency. Psychology in the Schools. 
  • Flores, J. P., Swartz, K. L., Stuart, E. A., & Wilcox, H. C. (2020). Co-occurring risk factors among US high school students at risk for suicidal thoughts and behaviors. Journal of Affective Disorders, 266, 743–752. 
  • Hailey, D., Roine, R., & Ohinmaa, A. (2008). The effectiveness of telemental health applications: A review. The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie, 53(11), 769–778.
  • Hill, R. M., & Katusic, M. (2020). Examining suicide risk in individuals with autism spectrum disorder via the interpersonal theory of suicide: Clinical insights and recommendations. Children’s Health Care. 
  • Holden, R., Mueller, J., McGowan, J., Sanyal, J., Kikoler, M., Simonoff, E., Velupillai, S., & Downs, J. (2020). Investigating bullying as a predictor of suicidality in a clinical sample of adolescents with autism spectrum disorder. Autism Research. 
  • Howarth, E. J., O’Connor, D. B., Panagioti, M., Hodkinson, A., Wilding, S., & Johnson, J. (2020). Are stressful life events prospectively associated with increased suicidal ideation and behaviour? A systematic review and meta-analysis. Journal of Affective Disorders, 266, 731–742. 
  • Iorfino, F., Davenport, T. A., Ospina-Pinillos, L., Hermens, D. F., Cross, S., Burns, J., & Hickie, I. B. (2017). Using new and emerging technologies to identify and respond to suicidality among help-seeking young people: A cross-sectional study. Journal of Medical Internet Research, 19(7), 62–75.
  • Jager-Hyman, S., Maddox, B. B., Crabbe, S. R., & Mandell, D. S. (2020). Mental health clinicians’ screening and intervention practices to reduce suicide risk in autistic adolescents and adults. Journal of Autism and Developmental Disorders. 
  • Janiri, D., Doucet, G. E., Pompili, M., Sani, G., Luna, B., Brent, D. A., & Frangou, S. (2020). Risk and protective factors for childhood suicidality: A US population-based study. The Lancet Psychiatry, 7(4), 317–326.
  • May, A. M., Pachkowski, M. C., & Klonsky, E. D. (2020). Motivations for suicide: Converging evidence from clinical and community samples. Journal of Psychiatric Research, 123, 171–177.
  • O’Brien, K. H. M., LeCloux, M., Ross, A., Gironda, C., & Wharff, E. A. (2017). A pilot study of the acceptability and usability of a smartphone application intervention for suicidal adolescents and their parents. Archives of Suicide Research, 21(2), 254–264. 
  • Schlagbaum, P., Ruch, D. A., Tissue, J. L., Sheftall, A. H., & Bridge, J. A. (2020). Depressed mood prior to death: Implications for precipitating factors of youth suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 
  • Sinyor, M., Williams, M., Mitchell, R., Zaheer, R., Bryan, C. J., Schaffer, A., Westreich, N., Ellis, J., Goldstein, B. I., Cheung, A. H., Selchen, S., Kiss, A., & Tien, H. (2020). Cognitive behavioral therapy for suicide prevention in youth admitted to hospital following an episode of self-harm: A pilot randomized controlled trial. Journal of Affective Disorders, 266, 686–694.
  • Slesnick, N., Zhang, J., Feng, X., Wu, Q., Walsh, L., & Granello, D. H. (2020). Cognitive therapy for suicide prevention: A randomized pilot with suicidal youth experiencing homelessness. Cognitive Therapy and Research, 44(2), 402–411.

Watch Jason Basinger’s Webinar

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“Mindfulness in Schools: Strategies for Promoting Mental Wellness in a COVID Environment”
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