suicide prevention programs in the schools: a review and ......2008/08/05 · literature review of...

Suicide Prevention Programs in the Schools:A Review and Public Health Perspective

David N. MillerUniversity at Albany, State University of New York

Tanya L. EckertSyracuse University

James J. MazzaUniversity of Washington

Abstract. The purpose of this article is to provide a comprehensive review ofschool-based suicide prevention programs from a public health perspective. Aliterature review of empirical studies examining school-based suicide preventionprograms was conducted. Studies were required to contain information pertainingto the implementation and outcomes of a school-based program designed toaddress suicidal behaviors among children and youth. A total of 13 studies wasidentified. Most of the studies (77%) were classified as universal suicide preven-tion programs (n � 10), with the remaining studies classified as selected suicideprevention programs (n � 3). Studies were coded based on key methodologicalfeatures of the Task Force on Evidence-Based Interventions in School PsychologyProcedural and Coding Manual (Kratochwill & Stoiber, 2002). The highestmethodology ratings were obtained by two universal suicide prevention programs(Klingman & Hochdorf, 1993; LaFromboise & Howard-Pitney, 1995) and oneselected prevention program (Randell, Eggert, & Pike, 2001), although theselected suicide prevention programs demonstrated proportionally more keymethodological features than the universal suicide prevention programs. How-ever, only 2 of the 13 studies reviewed demonstrated strong evidence for statis-tically significant effects on primary outcome measures. Very few studies pro-vided promising evidence of educational/clinical significance (7.6%), identifiablecomponents linked to statistically significant primary outcomes (23.1%), andprogram implementation integrity (23.1%). Furthermore, no studies providedevidence supporting the replication of program effects. The implications of theseresults for practice are discussed as well as needs for future research.

Youth suicide continues to be a majorpublic health problem in the United States. Toput this problem in context, suicide is the fifth

leading cause of death among children ages5–14 and the third leading cause of deathamong adolescents and young adults ages 15–

Correspondence regarding this article should be addressed to David N. Miller, University at Albany,SUNY, 1400 Washington Avenue, ED 215, Albany, NY 12222; E-mail: [email protected]

Copyright 2009 by the National Association of School Psychologists, ISSN 0279-6015

School Psychology Review,2009, Volume 38, No. 2, pp. 168–188

168

24. In recent years, more young people diedfrom suicide than from cancer, heart disease,HIV/AIDS, congenital birth defects, diabetes,and other medical conditions combined (Cen-ters for Disease Control and Prevention,2007). Suicidal behavior is not conceptualizedas being restricted to suicide alone; it alsoincludes suicidal ideation and suicide at-tempts, and each of these behaviors affectsthousands of children, adolescents, and fami-lies in the United States each year (Mazza,2006). As such, youth suicidal behavior is asignificant public health issue for individualsas well as entire communities. First, the loss oflife that results from suicide is both tragic andpreventable. Second, those who attempt sui-cide and survive may have serious injuriessuch as broken bones, brain damage, or organfailure. Moreover, individuals who survive asuicide attempt often experience depressionand/or other mental health problems. Familyand friends of youth who exhibit suicidal be-havior may also experience a variety of mentalhealth problems, and the financial, medical,social, psychological, and emotional costs ofsuicide on members of the community is sub-stantial (Centers for Disease Control and Pre-vention, 2006).

Because of the seriousness and perva-siveness of this problem, and given that chil-dren and youth spend much of their time inschools, school personnel have been asked totake an increasingly prominent role in suicideprevention efforts (Gould & Kramer, 2001;Kalafat, 2003; Mazza, 1997; Miller & DuPaul,1996). This development has been intensifiedby calls for school psychologists to becomemore proactive in the prevention of youth sui-cide (Lieberman, Poland, & Cassel, 2008) andother mental health problems (Power, 2003),and to shift from an individualized servicedelivery model to a population-based (Doll &Cummings, 2008), public health approach(Hoagwood & Johnson, 2003; Nastasi, 2004;Power, 2000; Power, DuPaul, Shapiro, & Ka-zak, 2003; Strein, Hoagwood, & Cohn, 2003).Recent initiatives by the federal government,including the surgeon general’s Call to Actionto Prevent Suicide (U.S. Department of Healthand Human Services, 1999) and the National

Strategy for Suicide Prevention: Goals andObjectives for Action (U.S. Public Health Ser-vice, 2001), have also recognized the impor-tance of youth suicide prevention by classify-ing it as an urgent public health priority. Forexample, in 2004 the nation’s first youth sui-cide prevention bill, the Garrett Lee SmithMemorial Act, was signed into law. In passingthis legislation, the U.S. Congress noted that“youth suicide is a public health tragedylinked to underlying mental health problemsand that youth suicide early intervention andprevention activities are national priorities”(p. 1).

Purpose of the Article

The purpose of this article is to providea comprehensive review of school-based sui-cide prevention programs from a public healthperspective. First, the article describes howtaking a public health approach to the school-based prevention of youth suicidal behavior isa useful and appropriate response to this na-tional problem. Next, the article provides ahighly systematic review of the literature onschool-based suicide prevention within a pub-lic health framework, using the Task Force onEvidence-Based Interventions in School Psy-chology Procedural and Coding Manual(Kratochwill & Stoiber, 2002). The articleconcludes by describing the implications ofthese results for practice and by outliningneeds for future research.

A Public Health Perspective on School-Based Suicide Prevention

The central characteristic of a publichealth model is its emphasis on prevention(Strein et al., 2003; Woodside & McClam,1998). Specific aspects of the public healthmodel that have particular relevance forschools include (a) applying scientifically de-rived evidence to the delivery of psychologicalservices; (b) strengthening positive behaviorrather than focusing exclusively on decreasingproblem behavior; (c) emphasizing commu-nity collaboration and linked services; and (d)using appropriate research strategies to im-prove the knowledge base and effectively

Review of Suicide Prevention Programs

169

evaluate school psychological services (Streinet al., 2003). The importance of taking a pub-lic health approach to prevention and interven-tion in schools is reflected in recent landmarkevents and publications in school psychology,including the 2002 Multisite Conference onthe Future of School Psychology (Harrison etal., 2004) and the National Association ofSchool Psychologists Blueprint for Trainingand Practice III (Ysseldyke et al., 2006).

A school-based public health approachcan perhaps best be illustrated by Walker etal.’s (1996) three-tiered model. This publichealth model includes three overlapping tiersthat collectively represent a continuum of in-terventions that increase in intensity to meetindividual student needs (Sugai, 2007). Thefirst tier is referred to as the universal orprimary level, because all individuals in agiven population (e.g., school; classroom) arerecipients of interventions designed to preventparticular emotional, behavioral, or academicproblems. The second tier, referred to as theselected or secondary level, is comprised ofmore intensive interventions for those studentswho do not adequately respond to universalinterventions. The third tier, referred to as theindicated or tertiary level, is characterized byhighly individualized and specialized inter-ventions for those students who do not ade-quately respond to universal and selected lev-els of prevention and intervention (Sugai,2007; Walker et al., 1996). School psychologyis increasingly embracing this perspective,which can be seen most clearly in the growingresponse to intervention movement (Burns &Gibbons, 2008) and in school-wide positivebehavior support (Horner, Sugai, Todd, &Lewis-Palmer, 2005) This same public healthapproach can also be potentially useful in theschool-based prevention of youth suicide(Hendin et al., 2005; Kalafat, 2003).

Universal suicide prevention programsappear to be the most widely used approach inthe schools and typically focus on increasingawareness of suicide, providing informationregarding risk factors and warning signs, dis-pelling myths about suicide, teaching appro-priate responses to peers who may come intocontact with someone who may be suicidal,

and potentially identifying youth who may besuicidal or at risk for suicidal behavior (Mazza& Reynolds, 2008). These programs are pre-sented to all students in a given populationregardless of their level of risk, and the keyassumptions underlying them are that the con-ditions that contribute to suicide risk in youth“often go unrecognized, undiagnosed, and un-treated, and that educating students and gate-keepers about the appropriate responses willresult in better identification of at-risk youth,and an increase in help seeking and referralsfor treatment” (Hendin et al., 2005, p. 446).

Historically, many universal preventionprograms have been of short duration, fre-quently promoting a “stress” model of suicideprevention (i.e., suggesting to students thatsuicidal behavior can occur primarily or ex-clusively as a result of extreme stress), andfailing to assess program effects on more se-vere forms of suicidal behavior, despite re-search suggesting that these programs shouldbe of longer duration, have a comprehensivemental health focus, and assess a broaderspectrum of suicidal behaviors (e.g., suicideattempts) rather than simply focusing onknowledge and attitude change (Berman,Jobes, & Silverman, 2006; Kalafat, 2003;Mazza, 1997; Miller & DuPaul, 1996; Miller& Sawka-Miller, in press). Further, there areindications that students most likely to be sui-cidal may benefit from these programs lessthan their nonsuicidal peers, and that studentsat risk for a number of mental health prob-lems, including suicide, are less likely to at-tend preventative education programs (Ber-man et al., 2006). Some universal preventionprograms have attempted to reduce the stigmaof suicide by deemphasizing the relationshipbetween suicidal behavior and psychopathol-ogy (Hoberman & Garfinkel, 1988). By under-emphasizing this relationship and essentially“normalizing” suicidal behavior, Shaffer, Gar-land, Gould, Fisher, and Trautman (1988) sug-gested that these programs may heighten therisk of imitation.

Selected suicide prevention programsfocus on the subpopulation of students whomay be at higher risk for engaging in suicidalbehavior. For example, this may include ado-

School Psychology Review, 2009, Volume 38, No. 2

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lescents who have mental health problems,Native American males, youth who have ac-cess to firearms in their home, students at riskfor dropping out of school, or students who areknown to have family members with an affec-tive disorder or to have engaged in previoussuicidal behavior (Hendin et al., 2005). Possi-ble components of a selected program mayinclude developing and teaching decision-making skills and strategies, identifying re-sources in the school and community for help,emphasizing peer involvement and the role ofpeers in responding to someone who may besuicidal, and developing strategies for identi-fying high-risk youth (Mazza & Reynolds,2008). Student screening programs such as theColumbia TeenScreen program (Shaffer et al.,2004) and the Signs of Suicide program (Asel-tine & DeMartino, 2004) provide another ex-ample of selected suicide prevention pro-grams. Although screening programs are typ-ically administered to all students in aparticular environmental context (e.g., school,classroom), because their purpose is to iden-tify and intervene with high-risk individualsthey are generally considered to be selectedprevention programs rather than universalones.

Indicated suicide prevention programstarget youth who have already engaged insuicidal behavior, such as students who haveexpressed the desire to kill themselves or whohave made one or more previous suicide at-tempts. As such, the focus of indicated pro-grams is to reduce the current crisis or conflictas well as the risk for further engagement insuicidal behavior. In addition, because theseprograms are designed to treat specific prob-lems students are experiencing, indicated pre-vention programs are generally based heavilyon individualized, evidence-based interven-tions. Possible components of indicated pro-grams in schools may include developing andteaching adaptive decision-making strategiesthat focus on times of stress or emotionaldysregulation, accessing emergency help, pro-viding ongoing support to students during acrisis, and identifying at least one caring adultin the school or community from whom toseek help (Mazza & Reynolds, 2008).

School psychologists and other school-based mental health professionals are oftenhighly involved at this level, through conduct-ing suicide risk assessments (Davis & Sando-val, 1991; Miller & McConaughy, 2005), in-tervening directly with suicidal youth (Lieber-man et al., 2008; Sandoval & Zadeh, 2008), oroffering suicide postvention (Brock, 2002; Po-land, 1989). Although postvention involvesstrategies to implement after a suicide occurs,it serves a preventive function because it isdesigned to reduce the likelihood of additionalsuicides or further suicidal behavior (Brock,2002). Research has suggested that if schoolsand/or communities implement appropriatepostvention procedures in a timely manner,the likelihood of other suicides may decrease(Etzersdorfer & Sonneck, 1998; Gould, 2001).Given that some youth may be vulnerable topossible suicide contagion effects (Berman etal., 2006; Gould & Davidson, 1988), havingclear postvention policies in place is clearlyessential. Brock (2002), Davis and Sandoval(1991), Poland (1989), and Poland and Mc-Cormick (1999) provide useful guidelines forsuicide postvention procedures in schools.

Selection of School-Based SuicidePrevention Programs for Review

To be included in the literature review,studies needed to meet predetermined selec-tion criteria. At the most general level, studieswere required to contain information pertain-ing to the implementation of a school-basedprogram designed to address suicidal behav-iors among children and youth. More specificselection criteria for inclusion was as follows:(a) the study was published in English; (b) thestudy examined the effectiveness of suicideprevention programs and contained outcomedata; (c) the study included child and/or youthpopulations; (d) the suicide prevention pro-gram was implemented in a school setting; (e)the research design was either an empiricalinvestigation or a descriptive study; and (f) themethods and results were specified in the text.

A number of strategies were incorpo-rated to locate potential studies for inclusion inthe literature review. First, potential studies


171

were identified through computerized biblio-graphic searches from the PsycINFO andERIC databases in February 2008. For bothdatabases, computerized searches were con-ducted based on the available electronicrecords at that time (September 1967 to Feb-ruary 2008). We conducted multiple searchesin these databases, pairing the followingterms: suicide, prevention, intervention, andpostvention. In addition to the computerizedsearches, an ancestral search was conductedwherein the reference lists of all studies iden-tified were reviewed to assist in locating ad-ditional studies. We also manually reviewedthe journals of the following leading journalsrelated to suicidal behaviors: American Jour-nal of Public Health, Journal of the AmericanAcademy of Child and Adolescent Psychiatry,Journal of Counseling Psychology, and Sui-cide and Life-Threatening Behavior. Further-more, because computerized databases updatetheir contents quarterly, we manually re-viewed journals in which the identified studieswere published between the years 2007 and2008.

The first and second authors reviewedthe title and abstract of each potential study(n � 52) to determine whether it met theinclusionary criteria. The two most commonreasons for excluding studies were as follows:(a) not using a school-based prevention pro-gram and (b) not using experimental or quasi-experimental methodologies. Each studymeeting the inclusionary criteria was then in-dependently reviewed by a research assistant.The research assistant evaluated the intercoderagreement relative to the inclusionary criteriaof those identified studies. Intercoder reliabil-ity based on percentage of agreement for theinclusionary criteria was 100%.

Based on population-based interventionclassifications proposed by Mazza and Reyn-olds (2008), studies were categorized based onthree types of prevention program: (a) univer-sal prevention programs (i.e., programs thattarget an entire population, such as all studentsin a school or all staff in a particular school);(b) selected prevention programs (i.e., pro-grams that focus on an at-risk group of stu-dents); and (c) indicated prevention programs

(i.e., programs that focus on students whohave already engaged in suicidal behavior). Toestablish reliability of the categorization pro-cedures used in this literature review, the sec-ond author and a research assistant categorizedall of the studies. Intercoder reliability basedon percentage of agreement for the preventionprogram categories was 100%.

In addition, all studies were assessed oneight methodological indicators based on theTask Force on Evidence-Based Interventionsin School Psychology Procedural and CodingManual (Kratochwill & Stoiber, 2002). Theseeight key features (i.e., measurement, compar-ison group, statistically significant outcomes,educational/clinical significance, identifiablecomponents, implementation fidelity, replica-tion, site of implementation) were coded on a4-point rating of evidence (i.e., 0 � no evi-dence; 1 � marginal or weak evidence; 2 �promising evidence; 3 � strong evidence).The scores for the eight key features wereaveraged to provide a mean methodology rat-ing for each study. Prior to coding the studies,the second author provided the research assis-tant with training on the coding criteria. Once100% intercoder agreement was obtained onfive mock studies, the second author and theresearch assistant independently coded eachstudy. If a disagreement was discovered in theassignment of a specific rating, the codersreached consensus and adjusted the rating ac-cordingly. The final intercoder agreementbased on percentage of agreement for keycoding criteria (i.e., study category, key fea-tures, rating level of evidence) was 89%(range: 83% to 100%).

Results

A total of 13 studies published between1987 and 2007 were identified as meeting theinclusionary criteria (see Table 1). The major-ity of studies (69%) were published in leadingjournals related to suicidal behaviors. The re-maining studies were published in journalsrelated to social work (15%; Social Work;National Association of Social Workers) oryouth development (15%; Journal of Adoles-cence; Adolescence). None of the studies was


172

Tab

le1

Ch

arac

teri

stic

sof

Sch

ool-

Bas

edSu

icid

eP

reve

nti

onP

rogr

ams

for

Ch

ildre

nan

dY

outh

( n�

13)

Ref

eren

ceT

ype

ofPr

ogra

man

dC

ompo

nent

s

Sam

ple

Size

and

Part

icip

ant

Cha

ract

eris

tics

Tar

get

Beh

avio

rsSe

tting

and

Len

gth

Find

ings

Ase

ltine

&D

eMar

tino

(200

4)[S

1]

Sele

cted

;su

icid

eaw

aren

ess

curr

icul

um(S

OS)

,bri

efm

enta

lhe

alth

scre

enin

g

Tre

atm

ent:

1,02

7st

uden

tsC

ontro

l:1,

073

stud

ents

Gra

de:

9–12

Sex:

50%

fem

ale

Eth

nici

ty:

23%

NH

W,

29%

NH

B,3

4H

L,

11%

M,5

%O

Self

-rep

ort

ofsu

icid

eat

tem

pts

and

suic

idal

idea

tion,

know

ledg

ean

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titud

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ors

Publ

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lfof

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ion

leng

thno

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port

ed

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repo

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sign

ifica

ntly

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ced

rate

sof

suic

ide

atte

mpt

san

dim

prov

edkn

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and

attit

udes

abou

tde

pres

sion

and

suic

ide.

No

sign

ifica

ntef

fect

sw

ere

obse

rved

for

suic

idal

idea

tion

orhe

lp-s

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havi

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Cif

fone

(199

3)[S

2]U

nive

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;te

achi

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arni

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and

peer

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Tre

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ent

203

stud

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Con

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1st

uden

tsG

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:10

Sex:

47%

fem

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Eth

nici

ty:

not

repo

rted

Self

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Publ

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Part

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sign

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ifica

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tal

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tobe

anop

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for

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vidu

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with

men

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this

sues

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iffo

ne(2

007)

[S3]

Uni

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diss

emin

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gst

aff

inte

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polic

ies,

enco

urag

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self

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inbo

thsc

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dist

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sfo

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lar

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targ

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(Tab

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cont

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s)


173

Tab

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Con

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(199

5)[S

4]

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A:

36st

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stud

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ol:

202

stud

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Sex:

42%

fem

ale

Eth

nici

ty:

2.9%

AIA

N,5

.7%

API

,2.

9%H

L,7

.6%

M,

1.9%

NH

B,7

2.5%

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W,7

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Self

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gfe

mal

es.N

oim

prov

emen

tin

lone

lines

sw

asre

porte

d.Pr

ogra

mac

cept

abili

tyw

ashi

gh.

(Tab

le1

cont

inue

s)


174

Tab

le1

Con

tin

ued

Ref

eren

ceT

ype

ofPr

ogra

man

dC

ompo

nent

s

Sam

ple

Size

and

Part

icip

ant

Cha

ract

eris

tics

Tar

get

Beh

avio

rsSe

tting

and

Len

gth

Find

ings

LaF

rom

bois

e&

How

ard-

Pitn

ey(1

995)

[S7]

Uni

vers

al;

ZL

SDcu

rric

ulum

that

prov

ides

suic

ide

awar

enes

san

din

terv

entio

nas

wel

las

addr

essi

ngri

sk-

taki

ngbe

havi

ors

Tre

atm

ent:

69st

uden

tsC

ontr

ol:

59st

uden

tsG

rade

:9

and

11Se

x:63

%fe

mal

esE

thni

city

:10

0%A

IAN

Self

-rep

ort

ofsu

icid

evu

lner

abili

ty,

hope

less

ness

,de

pres

sion

,and

self

-ef

ficac

y;ob

serv

atio

nsof

prob

lem

-sol

ving

skill

s;pe

erra

tings

ofpr

oble

m-s

olvi

ngsk

ills.

Publ

icsc

hool

;30

wee

ks,3

sess

ions

/wee

k;se

ssio

nle

ngth

not

repo

rted

Part

icip

ants

repo

rted

redu

ctio

nsin

suic

ide

vuln

erab

ility

and

hope

less

ness

.Obs

erva

tions

and

peer

ratin

gsin

dica

ted

impr

oved

prob

lem

-sol

ving

skill

s.N

oim

prov

emen

tsin

depr

essi

onor

self

-effi

cacy

wer

ere

port

edN

elso

n(1

987)

[S8]

Uni

vers

al;

prev

entio

nse

min

ars

prov

ided

toyo

uth,

pare

nts,

and

scho

olst

aff,

nosp

ecifi

catio

nre

gard

ing

com

pone

nts

370

stud

ents

,132

scho

olst

aff,

and

40pa

rent

sG

rade

:10

–12

Sex:

50%

fem

ales

Eth

nici

ty:

10%

API

,17

%H

L,1

6%N

HB

,49%

NH

W,

8%O

Self

-rep

ort

ofat

titud

esre

gard

ing

dist

ress

,kn

owle

dge

rega

rdin

gsu

icid

e,an

dre

late

dfa

ctor

s;ab

ility

toid

entif

ysu

icid

albe

havi

ors

inot

hers

;pr

ogra

mac

cept

abili

ty

Publ

icsc

hool

;4

hrst

uden

ttr

aini

ng;

90m

inst

aff

and

pare

nttr

aini

ng

Stud

ent

part

icip

ants

repo

rted

impr

oved

attit

udes

and

grea

ter

know

ledg

ere

gard

ing

suic

ide

follo

win

gpr

ogra

mco

mpl

etio

n.St

uden

ts,s

taff

and

pare

nts

repo

rted

high

prog

ram

acce

ptab

ility

.

Orb

ach

&B

ar-J

osep

h(1

993)

[S9]

Uni

vers

al;

prev

entio

npr

ogra

mth

atin

clud

esst

uden

tw

orks

hops

onco

ping

stra

tegi

esto

addr

ess

self

-des

truc

tive

beha

vior

san

dst

aff

trai

ning

Tre

atm

ent:

215

stud

ents

Con

trol

:17

8st

uden

tsG

rade

:11

Sex:

55%

fem

ales

Eth

nici

ty:

not

repo

rted

Self

-rep

ort

ofsu

icid

alte

nden

cies

,ho

pele

ssne

ss,e

goid

entit

y,an

dco

ping

skill

s;pr

ogra

mac

cept

abili

ty

Publ

icsc

hool

;7

wee

ks,s

essi

onle

ngth

2hr

Part

icip

ants

inat

leas

tha

lfof

the

scho

ols

repo

rted

redu

ced

suic

idal

tend

enci

esan

dfe

elin

gsof

hope

less

ness

.Im

prov

edco

ping

skill

san

deg

oid

entit

yw

ere

repo

rted

bypa

rtic

ipan

tsin

atle

ast

half

ofth

esc

hool

s.Pr

ogra

mac

cept

abili

tyw

ashi

ghan

dno

stud

ents

repo

rted

nega

tive

effe

cts.

(Tab

le1

cont

inue

s)


175

Tab

le1

Con

tin

ued

Ref

eren

ceT

ype

ofPr

ogra

man

dC

ompo

nent

s

Sam

ple

Size

and

Part

icip

ant

Cha

ract

eris

tics

Tar

get

Beh

avio

rsSe

tting

and

Len

gth

Find

ings

Ran

dell,

Egg

ert,

&Pi

ke(2

001)

[S10

]

Sele

cted

;C

-CA

RE

incl

udes

copi

ngan

dpr

oble

m-

solv

ing

skill

s,co

gniti

vest

rate

gies

tore

info

rce

stre

ngth

san

din

terr

upt

risk

beha

vior

s,ac

cess

tosu

ppor

tse

rvic

es;

CA

STin

clud

esC

-CA

RE

com

pone

nts

and

prov

ides

spec

ific

trai

ning

inse

lf-

este

emen

hanc

emen

t,m

ood

man

agem

ent,

subs

tanc

eab

use

cont

rol,

and

acce

ssin

gsu

ppor

tse

rvic

es

C-C

AR

E:

117

part

icip

ants

CA

ST:

103

part

icip

ants

Ass

essm

ent:

112

part

icip

ants

Gra

de:

9–12

Gen

der:

48%

fem

ales

Eth

nici

ty:

2%A

IAN

,13

%A

PI,7

%H

L,

13%

M,1

2%N

HB

,40%

NH

W,

9%O

Self

-rep

ort

ofsu

icid

albe

havi

ors,

depr

essi

on,

ange

r,fa

mily

and

pers

onal

prot

ectiv

efa

ctor

s

Publ

icsc

hool

;C

-C

AR

E,3

–4hr

;C

AST

,3–4

hrpl

us6

wee

ksof

two

1-hr

sess

ions

/w

eek

Part

icip

ants

inal

lth

ree

grou

psre

port

edle

sssu

icid

eri

skbe

havi

ors,

depr

essi

on,a

nger

cont

rol

prob

lem

s,an

dfa

mily

dist

ress

.Im

prov

emen

tsin

self

-es

teem

,per

sona

lco

ntro

l,an

dpe

rcei

ved

fam

ilysu

ppor

tw

ere

repo

rted

for

all

part

icip

ants

.N

oim

prov

emen

tsw

ere

repo

rted

for

prob

lem

-sol

ving

copi

ng.I

nco

mpa

riso

nto

typi

cal

yout

hs,b

oth

prog

ram

sre

sulte

din

larg

eef

fect

sfo

rsu

icid

eri

sk,p

erso

nal

prot

ectiv

efa

ctor

s,an

dfa

mily

fact

ors.

Shaf

fer,

Gar

land

,V

iela

nd,

Und

erw

ood,

&B

usne

r(2

001)

[S11

]

Uni

vers

al;

suic

ide

curr

icul

umpr

ogra

ms;

Prog

ram

1em

phas

ized

awar

enes

san

dcl

inic

alfe

atur

esof

suic

ide;

Prog

ram

2em

phas

ized

supp

ort

netw

orks

;Pr

ogra

m3

emph

asiz

edpr

oble

m-s

olvi

ngte

chni

ques

Tre

atm

ent:

758

stud

ents

Con

trol

:68

0st

uden

tsG

rade

:9

and

10Se

x:52

%fe

mal

eE

thni

city

:22

%H

L,

25%

NH

B,4

8%N

HW

,4%

O

Self

-rep

ort

ofat

titud

esan

dkn

owle

dge

ofsu

icid

e;he

lp-s

eeki

ngbe

havi

ors;

prog

ram

acce

ptab

ility

Publ

icsc

hool

;1

sess

ion,

sess

ion

leng

th1.

5to

3hr

Part

icip

ants

repo

rted

grea

ter

know

ledg

eof

help

-see

king

beha

vior

s.N

odi

ffer

ence

sw

ere

repo

rted

for

attit

udes

and

know

ledg

eof

suic

ide.

Stud

ents

repo

rted

mod

erat

eto

high

prog

ram

acce

ptab

ility

,w

itha

smal

lnu

mbe

rof

stud

ents

repo

rtin

gne

gativ

esi

deef

fect

s.

(Tab

le1

cont

inue

s)


176

Tab

le1

Con

tin

ued

Ref

eren

ceT

ype

ofPr

ogra

man

dC

ompo

nent

s

Sam

ple

Size

and

Part

icip

ant

Cha

ract

eris

tics

Tar

get

Beh

avio

rsSe

tting

and

Len

gth

Find

ings

Spir

ito,

Ove

rhol

ser,

Ash

wor

th,

Mor

gan,

&B

ened

ict-

Dre

w(1

988)

[S12

]

Uni

vers

al;s

uici

deaw

aren

ess

curr

icul

umth

atdi

scus

sed

attit

udes

rega

rdin

gsu

icid

ean

dre

late

dbe

havi

ors,

suic

ide

fact

san

dris

kfa

ctor

s,an

dpe

erid

entifi

-ca

tion

and

refe

rral

tech

niqu

es

Tre

atm

ent:

291

stud

ents

Con

trol

:18

2st

uden

tsG

rade

:9

Sex:

not

repo

rted

Eth

nici

ty:

not

repo

rted

Self

-rep

ort

ofat

titud

esan

dkn

owle

dge

ofsu

icid

e;he

lp-s

eeki

ngbe

havi

ors,

hope

less

ness

,and

copi

ngsk

ills

Publ

icsc

hool

;6

wee

ks,s

essi

onle

ngth

not

repo

rted

Part

icip

ants

repo

rted

grea

ter

incr

ease

sin

cert

ain

copi

ngsk

ills

and

area

sof

know

ledg

e.Pr

etes

tse

nsiti

zatio

nre

sulte

din

cont

rol

stud

ents

repo

rtin

gin

crea

sed

know

ledg

e,an

dat

titud

esof

suic

ide

asw

ell

asde

crea

sed

hope

less

ness

.Z

ener

e&

Laz

arus

(199

7)[S

13]

Uni

vers

al;d

istri

ct-w

ide

suic

ide

prev

entio

nan

dcr

isis

man

agem

entp

rogr

amth

atin

clud

edst

aff

in-s

ervi

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inin

g,pa

rent

educ

atio

n,dr

uged

ucat

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curr

icul

um(T

RU

ST),

life

skill

sm

anag

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tcur

ricul

umin

10th

grad

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dres

sing

suic

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and

rela

ted

risk

beha

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s,fo

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scho

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tosu

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even

tion

and

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,you

thcr

isis

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ne,p

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Tre

atm

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330,

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Gra

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177

published in school psychology journals. Themajority of studies included in the literaturereview were classified as universal preventionprograms (77%, n � 10). A smaller percent-age of studies were classified as selected pre-vention programs (23%, n � 3), and no studieswere classified as indicated prevention pro-grams. The specific findings for each type ofprevention program are discussed in the sec-tions that follow.

Universal Suicide Prevention Programs

The majority of universal preventionprogram studies typically focused on curriculumprograms presented to students. Although spacelimitations prohibit an extensive discussion ofthese studies, the majority of programs wereembedded within the context of health educationclasses (Ciffone, 1993, 2007; Kalafat & Elias,1994; Shaffer et al., 1991) and constituted anextended (Klingman & Hochdorf, 1993; La-Fromboise & Howard-Pitney, 1995; Spirito,Overholser, Ashworth, Morgan, & Benedict-Drew, 1988) or abbreviated (Nelson, 1987; Or-bach & Bar-Joseph, 1993) psychoeducationalcurriculum for students. However, the work ofZenere and Lazarus (1997) deviates significantlyfrom the other universal prevention programs inthat a system-wide school-based prevention andintervention program was developed and imple-mented over a 5-year period. The main charac-teristics of each study can be seen in Table 1.

Universal Suicide Prevention Programs:Methodological Quality

The methodological features of the uni-versal suicide prevention programs variedconsiderably (see Table 2). Although the siteof implementation (i.e., school setting) wasconsistent across all 10 studies, examinationof the average methodology rating per studysuggested that a majority of studies demon-strated weak to promising evidence (i.e., 54%of studies with ratings greater than 1.00). Theprograms evaluated by Klingman and Hoch-dorf (1993, Study 6) and LaFromboise andHoward-Pitney (1995, Study 7) demonstratedthe highest methodological rigor of the univer-sal prevention programs reviewed, including

establishing strong evidence for statisticallysignificant effects on the primary outcomemeasures and providing promising to strongevidence of program implementation integrity.In addition, LaFromboise and Howard-Pit-ney’s investigation was one of the few studiesproviding strong evidence for their outcomemeasures, which included using a multim-ethod (i.e., self-reports, behavioral observa-tion), multisource (i.e., participant and peerreports) method to examine program effects.Moreover, this was the only study to adopt aculturally tailored approach to developing aschool-based suicide prevention program foruse among Native American youth.

Consistent methodological weaknesseswere noted with the majority of universal sui-cide prevention programs reviewed. A relativelysmall percentage of studies included reliable andvalid measures (30%), demonstrated education-al/clinical significance (10%), documented pro-gram implementation fidelity (20%), and repli-cated the effects (0%). The use of analyticaltechniques to account for nested models withindata sets (i.e., classrooms nested within school)was not employed in any of the reviewed stud-ies. In addition, follow-up analyses were rarelyconducted regarding the moderating effects ofrelevant demographic factors (e.g., gender, drugand alcohol abuse, mental health risks), with thenotable exception of Orbach and Bar-Joseph(1993; Study 9), who compared post-assessmentoutcomes based on those participants receivinglow and high suicidal tendency scores at base-line. Furthermore, important factors related toschool-based implementation (e.g., characteris-tics of the program implementer, cost analysisdata, training and support resources, feasibility)were reported in only a limited number of stud-ies. Finally, it is important to highlight that themajority of the studies provided either weak(50%) or promising evidence (30%) for statisti-cally significant outcomes.

Selected Suicide Prevention Programs

To date, only three empirical studieshave used selected approaches to suicide pre-vention (Aseltine & DeMartino, 2004; Eggert,Thompson, Herting, & Nichols, 1995; Ran-


178

dell, Eggert, & Pike, 2001); the main charac-teristics of each study are presented in Table 1.The selected approach used by Aseltine andDeMartino, the Signs of Suicide program,combines curricula to raise awareness of sui-cide and related issues with a brief screeningfor depression and other risk factors associatedwith suicidal behavior. In the didactic compo-nent of the program, students are taught thatsuicide is directly related to mental illness,typically depression, and that suicide is not anormal reaction to stress or emotional upset.Youth are taught to recognize the signs ofsuicide and depression in themselves and oth-ers, as well as specific action steps for re-sponding to those signs. Action steps are de-scribed using the acronym ACT, which stands

for Acknowledge, Care, and Tell: “First, ac-knowledge the signs of suicide that others dis-play and take those signs seriously. Next, letthat person know that you care and that youwant to help. Then, tell a responsible adult”(Aseltine & DeMartino, 2004, p. 446).

The selected approaches to school-basedsuicide prevention used by Eggert, Thompson,et al. (1995) and Randell et al. (2001) focusedon at-risk youth (i.e., at risk for school dropoutand suicidal behavior) and included an assess-ment interview. In the Eggert, Thompson, etal. (1995) study, the selected program knownas Personal Growth Class I provided one se-mester of small-group activities related to so-cial support, weekly monitoring of mood man-agement activities, interpersonal communica-

Table 2Summary of Evidence for Key Methodological Features of School-Based

Suicide Prevention Program Studies (n � 13)

Feature

Study NumberMeanRatingS1a S2b S3b S4a S5b S6b S7b S8b S9b S10a S11b S12b S13b

Measurement 1 0 0 2 1 1 3 0 2 2 1 1 3 1.31Control or

comparisongroup 3 1 1 2 2 2 2 0 2 3 2 2 0 1.69

Statisticallysignificant keyoutcomes 2 1 1 1 2 3 3 1 2 2 1 1 2 1.69

Educational/clinicalsignificance 1 1 1 1 1 1 1 0 1 1 0 0 2 0.85

Identifiablecomponents 0 0 0 1 1 2 2 0 1 2 0 0 1 0.77

Implementationfidelity 0 0 0 1 1 2 3 0 0 3 0 1 0 0.85

Replication 0 0 1 0 1 0 0 0 1 0 0 0 1 0.31Site of

implementation 3 3 3 3 3 3 3 3 3 3 3 3 3 3.00Total methodology

rating 10 6 7 11 12 14 17 4 12 16 7 8 12 10.46Mean methodology

rating 1.25 0.75 0.88 1.38 1.50 1.75 2.13 0.50 1.50 2.00 0.88 1.00 1.50

Note. S � Study. Ratings range from 0 to 3; 0 � no evidence/not reported, 1 � weak evidence; 2 � promising evidence;3 � strong evidence.aSelected suicide prevention program.bUniversal suicide prevention program.


179

tion, training in self-esteem enhancement,decision making, and personal control train-ing. The second selected approach evaluatedin this study, Personal Growth Class II, in-cluded one semester of the Personal GrowthClass I coupled with one semester of skillapplications in home and school environmentsas well as developing adaptive recreation andsocial activities. In the Randell et al. (2001)study, two selected approaches were evaluatedand included the following: (a) CounselorsCARE (C-CARE) (i.e., brief counseling pro-tocol and the facilitation of social supportfrom school personnel and a parent); and (b)C-CARE plus Coping and Support Training(CAST) (i.e., small-group skills training andsocial support model adapted from Reconnect-ing Youth, a peer-group approach to buildinglife skills, Eggert, Nicholas, & Owens, 1995).

Selected Suicide Prevention Programs:Methodological Quality

The methodological features of the se-lected suicide prevention programs varied (seeTable 2, Studies 1, 4, and 10), with the site ofimplementation (i.e., school setting) consistentacross studies. Randell et al. (2001, Study 10)demonstrated the greatest methodological rigorof the three studies, including strong evidence ofintervention adherence and use of an active com-parison group. This study was also unique in thatit was one of the few studies to include a high-risk group of participants (i.e., potential highschool dropouts) and compare the selected sui-cide prevention programs to a “typical interven-tion” comparison group. Finally, this study aswell as the work of Eggert, Thompson, et al.(1995, Study 4) compared outcomes as a func-tion of those participants who completed theprogram versus those participants who werenoncompleters. This analytical consideration is arelevant and important feature within the contextof suicide prevention programs. Another analyt-ical advancement was reported in Aseltine andDeMartino (2004, Study 1), which incorporatedhierarchical linear modeling to more fully exam-ine the effect of nested models in school-basedsuicide prevention program research.

Consistent methodological weaknesseswere noted across all three studies. Only Ran-dell et al. (2001) documented intervention ad-herence and used analytical techniques toidentify which identifiable components oftheir prevention programs were related to sta-tistically significant primary outcomes (Ran-dell et al., 2001, Study 10). None of the threestudies reviewed demonstrated promising orstrong evidence for educational/clinical signif-icance or the replication of effects. In addition,many of the methodological criticisms notedpreviously for the universal suicide preventionprograms (i.e., role of participant demographicfactors moderating outcomes, factors relatedto school-based implementation) were charac-teristic of the selected suicide prevention pro-grams reviewed. Finally, it is important tohighlight that none of these studies providedstrong evidence for statistically significantoutcomes because the outcome measures re-lied on a single informant source (i.e., studentself-report measures of knowledge, attitudes,and behaviors) and reliability evidence for amajority of these measures was not reported.Although the reliance on self-report methodsis pervasive in school-based suicide preven-tion program research, establishing reliableand valid measures is crucial, as well as con-sidering multimethod approaches to programevaluation. In addition, statistical significancewas not observed for the majority (i.e., greaterthan 75%) of the primary outcome constructs,and none of these studies demonstrated thatthe suicide preventions programs was superiorto a no-intervention or active-comparisongroup condition.

Indicated Suicide Prevention Programs

For the purposes of this literature re-view, no studies were classified as indicatedprevention programs. As a result, there is lim-ited information about effective programs atthis level. Promising approaches to treatmentof suicidal youth have been developed how-ever, including dialectical behavior therapy,which has shown consistent results in reducingsuicidal behavior among adults (Mazza, 2006)and is now being increasingly used with sui-


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cidal youth (Miller, Rathus, & Linehan, 2007),and the Youth Nominated Support Team(King et al., 2006), which has been used suc-cessfully with adolescents who have been hos-pitalized for suicidal behavior. Designed foryouth for whom suicide recidivism is a signif-icant concern, this program consists of a psy-choeducational-social network intervention toincrease social support and treatment compli-ance and decrease negative parental percep-tions of youth who have made previous sui-cide attempts and are at high risk for furthersuicidal behavior. Both dialectical behaviortherapy and the Youth Nominated SupportTeam could be potentially employed with sui-cidal youth in school settings, although to dateneither has been empirically evaluated in thatcontext.

Discussion

Given the results of this review, it isclear that the current scientific foundation re-garding school-based suicide prevention pro-grams is very limited. Grounded on the criteriaof the Task Force on Evidence-Based Inter-ventions in School Psychology Procedural andCoding Manual (Kratochwill & Stoiber,2002), consistent and considerable method-ological weaknesses were noted for nearly allof the universal and selected suicide preven-tion programs reviewed. For example, ofthe 13 studies reviewed, only 5 studies showedpromising evidence for statistically significantoutcomes, and only 2 (Klingman & Hochdorf,1993; LaFromboise & Howard-Pitney, 1995)demonstrated strong evidence in this area. Theresults for educational/clinical significancewere even less encouraging, with only 1 study(Zenere & Lazarus, 1997) demonstratingpromising evidence and no studies showingstrong evidence. Further, 76.9% of the studiesdemonstrated either weak or no evidence ofimplementation fidelity or the ability to iden-tify which components of their programs wererelated to statistically significant outcomes,and all of the studies either had weak evidence(n � 4) or no evidence (n � 9) to support thereplication of program effects.

Two universal prevention programs(Klingman & Hochdorf, 1993; LaFromboise& Howard-Pitney, 1995) and one selected pre-vention program (Randall et al., 2001) wererated as relatively stronger than the other stud-ies in their methodology ratings, althougheach of these studies had significant method-ological limitations as well. Both the Kling-man and Hochdorf (1993) study and the La-Fromboise and Howard-Pitney (1995) studyestablished strong evidence for statisticallysignificant effects on their primary outcomemeasures and either promising (Klingman &Hochdorf) or strong (LaFromboise & Howard-Pitney) evidence of program implementationintegrity. The LaFromboise and Howard Pit-ney study is particularly interesting because ofits multimethod approach to evaluating pro-gram effects and its use with a high-risk (i.e.,Native American) group of students in thecontext of a universal prevention program.The Randell et al. (2001) study demonstratedthe greatest methodological rigor of any se-lected prevention program and was also nota-ble for including a high-risk group of partici-pants (i.e., potential high-risk dropouts).

Implications for Practice

Given the methodological limitations ofthese studies, discussing their implications forpractice presents a challenging task. Unfortu-nately, results of this review provide littleguidance for school personnel interested inimplementing empirically supported school-based suicide prevention programs. Neverthe-less, some tentative implications for practicemay be provided. In general, there is someevidence that prevention programs that in-clude providing information to students re-garding suicide awareness and intervention,teaching them coping and problem-solvingskills, and teaching and reinforcing strengthsand protective factors while addressing risk-taking behaviors may lead to improvements instudents’ problem-solving skills and self-effi-cacy as well as reductions in self-reportedsuicide vulnerability. As such, incorporatinginformational and skill-building elements inprevention programs appears to be a poten-


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tially useful strategy, although the extent towhich these programs have actually reducedmore severe forms of suicidal behavior (e.g.,suicide attempts) remains open to question.Moreover, programs should ensure that theyare providing accurate information to students,including emphasizing the link between sui-cide and mental health problems. The inclu-sion of skill-building elements (e.g., copingskills; problem solving) appears to be an im-portant component of more promising preven-tion programs, especially given that increasedknowledge alone appears insufficient tochange behavior (Berman et al., 2006).

In regard to selected or indicated pre-vention programs, it is difficult to draw anyfirm conclusions based on this review, giventhe limited number of studies. In particular,although school-based screening programshave been widely recommended by research-ers (e.g., Gutierrez, Watkins, & Collura, 2004;Mazza, 1997; Miller & DuPaul, 1996; Reyn-olds, 1991; Shaffer & Craft, 1999), there arelimited data currently available regarding theireffectiveness for reducing suicidal behavior.For example, although Aseltine and DeMar-tino (2004) found significantly reduced ratesof suicide attempts and improved knowledgeand attitudes about depression and suicide fol-lowing implementation of the curriculum andscreening program known as Signs of Suicide,the methodological limitations of this studycombined with a dearth of other studies of thiskind indicate that more research in this area isneeded before more definitive practice guide-lines can be provided.

Additional Considerations

Based on the results of this review,school psychologists and other school person-nel looking for guidance on how to best de-velop suicide prevention programs may beoptimally served by examining the literatureon the prevention of other social/emotional/behavioral problems. For example, because ofthe high prevalence of problems often relatedto youth suicide, such as depression, substanceabuse, and conduct problems, there is a sig-nificant need for school psychologists to iden-

tify and disseminate effective prevention pro-grams generally. In particular, school psychol-ogists need to understand the principles ofeffective school-based prevention programs(Nation et al., 2003) and how to successfullyimplement, coordinate, sustain, and evaluatethem (Elias, Zins, Graczyk, & Weissberg,2003; Greenberg et al., 2003; Miller & Sawka-Miller, in press; Power et al., 2003). An im-portant element in this process is capacitybuilding (Schaughency & Ervin, 2006). Tobuild and sustain capacity in schools for thepurpose of effectively meeting students’ di-verse needs, a public health approach involv-ing multiple elements (e.g., multilayered pre-vention focus) is imperative (Merrell &Buchanan, 2006).

Research examining other types of pre-vention programs, including those closely as-sociated with suicidal behavior (e.g., sub-stance abuse), indicates they are most effec-tive when they involve multiple levels ofinfluence and when they address multiple riskfactors (Kazdin, 1993; Nation et al., 2003).Suicide prevention may therefore be most ef-fective when it is related to overall mentalhealth problems and is embedded in this largercontext (Kalafat & Elias, 1995; Miller & Du-Paul, 1996). For example, prevention pro-grams that reduce the use of drugs and al-cohol, focus on identifying and alleviatingdepression, and/or build social skills and self-concept can potentially supplement and en-hance suicide prevention efforts (Forman &Kalafat, 1998). Indeed, one important aspectof effective suicide prevention programs isthat they may reduce the severity and/or fre-quency of specific risk factors for suicidalbehavior as well as other mental health prob-lems (Mazza & Reynolds, 2008).

School psychologists will likely be con-fronted with a variety of barriers and chal-lenges in their attempts to implement and sus-tain school-based suicide prevention pro-grams. These may include the perpetuation ofmisinformation and myths about youth suicideand what causes it, parent/caregiver refusal tohave youth participate in suicide screeningprograms, resistance to suicide preventionprograms from school administrators and/or


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school personnel, possible funding problems,and potential ethical and legal issues (Mazza,2006; Miller & DuPaul, 1996). These andother obstacles will have to be overcome forschool-based suicide prevention programs tobe successful. Finally, school psychologistswill need to continuously update their knowl-edge and skills regarding effective suicide pre-vention programs and strategies. Professionalorganizations such as the American Associa-tion of Suicidology (www.suicidology.org),the American Foundation for Suicide Pre-vention (www.afsp.org), and the NationalAssociation of School Psychologists (www.nasponline.org) provide valuable informationand training opportunities in school-based sui-cide prevention.

Future Research Needs

The results of this review clearly revealthat there is much still unknown about effec-tive school-based suicide prevention. Most ofthe studies in this review exhibited significantmethodological shortcomings that should beaddressed in future research. For example, fu-ture studies should attempt to address the keymethodological features outlined in the TaskForce on Evidence-Based Interventions inSchool Psychology Procedural and CodingManual (Kratochwill & Stoiber, 2002). Thestandards of evidence for school-based pre-vention programs can also be examined inother ways. For example, Flay et al. (2005)have articulated a comprehensive set of stan-dards for prevention programs that providesseparate criteria for efficacy, effectiveness,and dissemination.

In addition, most of the prevention pro-grams reviewed targeted outcomes whose re-lationship to youth suicide has not been pre-cisely determined. For example, many of theseprograms reported increased knowledge re-garding suicide, although the effect of thisknowledge on actual suicide behavior (e.g.,suicide attempts) is not generally known.More attention also needs to be given to ad-dressing the “gender paradox” of youth sui-cide, particularly how to prevent suicidal be-havior in males, who are at much higher risk

for suicide than females. Research is neededas well to identify long-term behavioral out-comes among students who are the recipientsof school-based suicide prevention programs,particularly among those students with identi-fiable risk factors (Hendin et al., 2005). Giventhe relatively low base rate of youth suicidalbehavior, however, particularly suicide andsuicide attempts, this presents significant chal-lenges for researchers.

There are also many currently unan-swered questions about selected and indicatedsuicide prevention programs, particularly stu-dent screening programs. These programs ap-pear to be more direct and proactive than othersuicide prevention programs (e.g., staff inser-vice training), and reliable and valid screeningmeasures are available (Gutierrez & Osman,2008; Reynolds, 1991; Shaffer et al., 2004).Further, although fears have been raised re-garding the possibility that directly asking stu-dents about suicide-related behaviors mightincrease the probability of their occurrence,research has not found this to be the case(Gould et al., 2005). Indeed, directly askingyouth about suicide communicates to themthat the school is concerned about their healthand safety, a condition that may lead studentsto feel more comfortable disclosing possiblesuicidal behavior (Mazza, 2006). Unfortu-nately, although increasing the number of re-ferrals to treatment is a primary goal of screen-ing programs, there is currently no clear evi-dence of a linkage between increased referralsand decreased youth suicidal behavior (Hen-din et al., 2005). Moreover, screening pro-grams have generally not identified effectiveprocedures for encouraging larger numbers ofyouth identified as being at risk for suicideengage in treatment. There is little data cur-rently available about the cost-effectiveness ofscreening programs, as well as when and howoften they are best used (Stoner, 2006). Forexample, given that youth suicidal ideation isoften transitory, a screening conducted earlyin the school year may identify a differentgroup of students than a screening done in themiddle or at the end of the school year (Guti-errez & Osman, 2008).


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Moreover, research has found that stu-dent screening programs are rated as signifi-cantly less acceptable than other forms ofschool-based suicide prevention (e.g., inser-vice training) among high school principals(Miller, Eckert, DuPaul, & White, 1999),school psychologists (Eckert, Miller, DuPaul,& Riley-Tillman, 2003), school superinten-dents (Scherff, Eckert, & Miller, 2005), andstudents (Eckert, Miller, Riley-Tillman, & Du-Paul, 2006). Finally, as with predicting whichstudents will engage in school violence (Mul-vey & Cauffman, 2001), accurately predictingprecisely which students will engage in sui-cidal behavior has inherent limitations. De-spite their potential utility (Gould et al., 2005;Gutierrez et al., 2004; Reynolds, 1991; Shaffer& Craft, 1999), universal (e.g., classwide orschool-wide) student screening approaches tosuicide prevention present multiple logisticaldifficulties that will likely make their imple-mentation a significant challenge to schoolpersonnel.

There also is a need for researchers todevelop and evaluate school-based suicideprevention programs that emphasize greaterinterdisciplinary partnerships with familiesand communities (Power, 2003; Power et al.,2003), and to better understand the context ofsuicidal behavior among youth of differentcultural backgrounds. In particular, researchexamining culture-specific triggers or pro-cesses leading to suicidal behavior, as well asculture-specific risk and protective factors, issorely needed (Goldston et al., 2008). Culturalconsiderations have not been widely consid-ered in the development, implementation, orevaluation of school-based suicide preventionprograms, and this area is in great need offurther research. In particular, more research isneeded to address students from culturalgroups who are at higher risk for suicidalbehavior, such as Native American youth. Forexample, Hendin et al. (2005) observed thatmost programs for Native American youthhave focused on changing individuals ratherthan the “external forces in the social andcultural environment” (p. 464) that contributeto the difficulties these young people face.

In addition, there is a need to evaluateprevention programs that promote individualstudent strengths, competencies, and healthyliving skills. Future research on suicide pre-vention may therefore benefit from incorporat-ing findings from the professional literature onhealth promotion (Nastasi, 2004; Power et al.,2003) and the emerging field of positive psy-chology (Peterson, 2006; Snyder & Lopez,2007). For example, given that depression andhopelessness are highly associated with sui-cidal behavior, promoting hope and optimism(Gillham, Hamilton, Freres, Patton, & Gallop,2006; Gillham & Reivich, 2004) and otherpositive emotions (Fredrickson & Joiner,2002) and cognitions (Wingate et al., 2006) inchildren and youth could be a potentially use-ful approach to school-based suicide preven-tion. Similarly, developing programs designedto enhance students’ perceived social support(Demaray & Malecki, 2002) and school con-nectedness (Appleton, Christenson, & Fur-long, 2008) may promote their sense of be-longingness, a potentially important protectivefactor that may decrease suicide risk (Joiner,2005). The emphasis within positive psychol-ogy on wellness promotion (Miller, Gilman, &Martens, 2008; Phelps & Power, 2008) andincreasing competencies rather than merelydecreasing problems is strongly aligned with apublic health approach to prevention and in-tervention (Miller, Nickerson, & Jimerson,2009).

Finally, on a broader level, there re-mains the question of how to best use limitedresources in developing and evaluating futureschool-based suicide prevention programs(Berman et al., 2006). Should primary effortsat suicide prevention, for example, be directedto all students in a given population, or thosemost at risk? Should greater prevention effortsbe directed not at education but rather towardchanging particular environmental conditionsor legislation, such as gun control or drugabuse? As noted by Berman et al. (2006): “Weneed a theory of change and an effective pub-lic health model with which to define whattargets should be approached best by whomand when—and all this at an affordable cost”(p. 316).


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Conclusion

Youth suicide is a significant publichealth problem; as a result, schools and schoolpersonnel have been asked to take a greaterrole in its prevention. On the basis of thisreview, most of the studies examining the ef-fects of school-based suicide prevention pro-grams have exhibited a number of method-ological problems, making definitive conclu-sions about the efficacy of these programsdifficult. Nevertheless, school personnel willcontinue to be challenged by the presence ofsuicidal youth, and have an ethical and legalresponsibility to identify and intervene withthese students (Jacob & Hartshorne, 2007).Schools are logical and natural sites for sui-cide prevention, given this is where youthspend most of their time, where teaching andlearning are normative tasks, and where peerinteractions can be mobilized around a com-mon theme (Berman et al., 2006). Moreover,because schools have the primary responsibil-ity for the education and socialization of chil-dren and adolescents, they perhaps have thegreatest potential to moderate the occurrenceof risk behaviors and to identify and secureneeded assistance for suicidal youth (Kalafat,2003). Given the social service systems cur-rently in place in the United States, no insti-tutions other than schools directly oversee themental health needs of youth (Strein et al.,2003), a situation unlikely to change in theforeseeable future. As such, if universal, se-lected, and indicated suicide prevention pro-grams are to be provided, schools must take onthis responsibility. School psychologists andother school personnel are encouraged to pro-mote a public health approach to suicide pre-vention in the schools and to take leadershiproles in selecting, implementing, and evaluat-ing school-based suicide prevention programs.

Footnotes

*References marked with an asterisk indicatestudies included in the literature review

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Date Received: August 5, 2008Date Accepted: March 2, 2009Action Editor: Thomas Power �

David N. Miller, PhD, received his doctoral degree from Lehigh University in 1999 andis an associate professor and director of the school psychology program at the Universityat Albany, State University of New York. His research interests include issues inschool-based suicide prevention, childhood internalizing disorders, and positive youthdevelopment.

James J. Mazza, PhD, is a professor and director of the school psychology program at theUniversity of Washington in Seattle. His research focuses on adolescent mental healthissues and examines the risk and protective factors of youth at risk for depression orsuicidal behavior.

Tanya L. Eckert, PhD, received her PhD from Lehigh University in 1996 and is anassociate professor of psychology at Syracuse University. Her research interests includeexamining procedures for assessing academic and behavioral problems, developing class-room-based interventions, and measuring the acceptability of assessment and interventionprocedures. She is an associate editor of School Psychology Review.


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