INTRODUCTION
Suicide rates in individuals aged 10-24 years increased by 57.4% from
2008 to 2017.1 Among American adolescents aged 10-14
years, suicide is the second leading cause of death and among people
aged 15-24 years, suicide is the third leading cause of
death.2 Recent work using a nationally representative
sample of nearly 200,000 high school students found that one in five
endorsed suicidal ideation, and 14.7% had a suicide
plan.3 This issue is especially pertinent in Utah,
where the incidence of suicide is 16.6/100,000 in people aged 10-24
years, well above the national average of
10.3/100,000.1 There is a substantial amount of
research underway to understand the increasing incidence of suicidal
ideation and behaviors in the youth, adolescent and young adult
populations, and its connection to school-based behavioral health
interventions. However, the factors contributing to increased suicide
rates and their relationship with best practices in the school setting
are still being studied. 3, 4, 5, 6, 7, 8, 9
The school setting is an essential location for implementing suicide
prevention programs. Many risk factors for suicide are experienced in
the school setting including bullying, school connectedness, academics,
and in-school behavior.10 School-based suicide
prevention programs are widely used for addressing school-based
behavioral interventions.11
As awareness around youth and adolescent suicide increases, elected
representatives nationwide are passing legislation aimed at reducing
suicidal thoughts and behaviors in these age groups.12,
13, 14 One area of legislative emphasis is improving school district
suicide prevention policies. Several states across the nation now
require school districts to have suicide prevention policies in
place.15 In Utah, school districts have been required
to allocate funds for suicide prevention programs since 2018, however,
there is no specific requirement regarding the codification of these
programs into district policy.16 A key point of
distinction for the current study is the difference between school-level
suicide prevention programs and school-district suicide policies. The
former are measures carried about by the staff and faculty of a school
and the latter are guidelines determined by school districts by which
school-based suicide prevention programs are created for each individual
school. For example, a district-level policy may require all faculty and
staff to complete a training in
suicide prevention. Whereas a school-level program would be the specific
training that the school staff and faculty complete.
To our knowledge no research has been conducted on the connection
between school-district-level suicide-prevention policy and suicide
outcomes among school-aged adolescents, However, recent work has
concluded that the implementation of school-level suicide-prevention
programs may lead to a modest but significant reduction in suicidal
ideation and behaviors in youth and adolescents.17, 18,
19 These studies include meta-analyses that assessed the effects of
various suicide prevention programs such as Signs of Suicide,
HeadStrong, and Question Persuade Refer. Consequently, a critical
question is whether the implementation of more generalized principles
and practices as outlined in school-district-level suicide-prevention
policies might also be effective in reducing suicidal ideation and
behaviors among youth and adolescents. 20, 21, 22 For
example, would a district-level policy outlining a standardized protocol
for addressing students with suicide risk reduce suicidal ideation and
behaviors in the students at that school district?
Before district-level policy implementation and outcomes can be
assessed, the content of the policies themselves should be
scrutinized.23 To systematically conduct such an
assessment, a robust evaluation tool is needed. Ideally, it would be
easy to use, applicable throughout the country, and examine the various
facets of district-level policy pertaining to the prevention of and
response to student suicide. To our knowledge, this type of tool for
assessing school-district-level suicide prevention policies has not been
previously published.
There is, however, precedent for such a policy evaluation tool in school
health and wellness. Koriakin et al. 24 used the CDC’s
Whole School, Whole Community, Whole Child (WSCC) model to create an
assessment tool called the Wellness School Assessment Tool (WellSAT).
This tool aids school districts in evaluating alignment of the WSCC
model and their district policies regarding nutrition and physical
education. We took a similar approach and developed a tool for the
evaluation of school-based policies on suicide prevention based on
consensus recommendations found in the Model School District
Policy on Suicide Prevention (MSDP). This document was created in
collaboration by the American Foundation for Suicide Prevention (AFSP),
the American School Counselor Association (ASCA), the National
Association of School Psychologists (NASP), and The Trevor
Project.25 The MSDP “outlines model policies and best
practices for school districts to follow”25 regarding
suicide prevention, intervention, re-entry, and postvention. MSDP was
authored by six experts from the four organizations. The MSDP was
created by reviewing K-12 school district policies already in place in
various states across the country including, Connecticut, Pennsylvania,
Rhode Island, and Wisconsin. Additionally, broader reference documents
on suicide prevention in the school setting were utilized in the
development of the MSDP, including guidelines from the Center for
Disease Control (CDC), Substance Abuse and Mental Health Services
Administration (SAMHSA), and the American Association of Suicidology.
The scope of the MSDP covers suicide intervention at school and
school-related functions for students, parents, and school faculty. At
the core of the policy, its stated purpose is to “protect the health
and well-being of all students by having procedures in place to prevent,
assess the risk of, intervene in, and respond to
suicide”.25 Content validity was achieved by review
from 9 independent experts and 2 experts affiliated with AFSP and the
Trevor Project. Many states’ Boards of Education, including Utah’s,
provide the MSDP as a resource for districts to develop suicide
prevention policies. Given its comprehensive yet modular design, the
MSDP provides a strong basis for developing a tool to evaluate the
content of school district suicide prevention policies. Indeed, experts
in school psychology and policy regard the MSDP as a primary resource
for guidelines on making suicide prevention school district
policies.26