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