Addressing Youth Suicide Through School-Based Prevention and Postvention: Contemporary Scholarship Advancing Science, Practice, and Policy

Abstract

Youth suicide continues to be a significant public health issue, with especially elevated levels of suicide thoughts and behaviors experienced by marginalized students across race/ethnicity, gender, sexual orientation, and age demographics. This article highlights the importance of contemporary research informing and advancing professional efforts and also introduces a special topic section including eight articles that focus on key gaps in the literature related to mitigating suicide risk among youth in schools. Four survey studies and one systematic review aim to identify risk and protective factors for marginalized and understudied populations, with strong emphasis on cultural considerations around youth suicide; two studies center on the development and evaluation of school-based suicide prevention programs, with a focus on warning signs, professional development, and social validity; and the final paper focuses on learning from student perspectives to improve postvention. This special topic section represents the complexity of youth suicide prevention and postvention and offers school psychologists knowledge and strategies to prevent and intervene to reduce youth suicide. The introduction closes with several recommendations for further advancing science, practice, and policy related to mitigating suicide risk among youth in schools.

IMPACT STATEMENT

Prevention of youth suicide requires contemporary research and program development. School psychologists can play a critical role in preventing youth suicide through culturally relevant studies, evidence-based training and curriculum, and postvention strategies. Collectively, articles in this special series strengthen the literature for guiding school psychologists in mitigating suicide risk among youth in schools.

Keywords:

• youth suicide
• prevention
• intervention
• postvention
• school mental health

Youth suicide continues to be a public health crisis. Suicide among high school students ranging in age from 14 to 18 years is the second leading cause of death after unintentional injuries and there are distressing trends in suicidal thoughts and behaviors (STB) among youth across ages and demographics (Ivey-Stephenson et al., 2020). For example, during 2009–2019, the prevalence of suicide attempts increased overall, especially among female, non-Hispanic White, non-Hispanic Black, and 12th-grade students (Ivey-Stephenson et al., 2020). In the overall sample, 9% of youth reported attempting suicide, with prevalence estimates highest among females (11%), Black non-Hispanic students (12%), students who reported having sex with persons of the same sex or with both sexes (30%), and students who identified as lesbian, gay, or bisexual (23%). Equally distressing are data that reflect substantial differences by demographics regarding suicidal ideation and behaviors (Ivey-Stephenson et al., 2020). More specifically, during 2019, 19% of students reported seriously considering suicide, with prevalence estimates highest among females (24%), White non-Hispanic students (19%), those who reported same sex partners or those who reported having sex with both sexes (54%), and those identifying as sexual minorities (47%; Ivey-Stephenson et al., 2020). School systems and school-based professionals play a key role in mitigating STB among youth by intentionally engaging prevention and postvention efforts toward this end. School-based efforts can also benefit from efforts to target STB among youth that have been developed in clinical, medical, and other community settings. The purpose of this special series is to advance science, practice, and policy related to mitigating STB among youth by publishing original empirical work and systematic reviews on topics related to suicide prevention and postvention within schools and allied youth-serving settings.

RISK AND PROTECTIVE FACTORS IN SUICIDE PREVENTION

Decades of research has consistently identified numerous risk factors of STB. There is general agreement that STB is influenced by a complex interplay of genetic, biological, psychological, and social factors (Bridge et al., 2006; Vargas-Medrano et al., 2020). Risk factors include youth psychopathology such as depression, childhood adverse experiences, family history of psychopathology or suicidal behaviors, family conflict, impulsivity, access to lethal means, and bullying (e.g., Bilsen, 2018; Ortin-Peralta et al., 2021). In a recent review of risk and protective factors for youth bullying and suicide specifically, Cuesta and colleagues (2021) noted that significant additional risk factors were a previous suicide attempt, mental health problems, concurrent substance use, and history of physical or sexual abuse. Common protective factors for youth suicide were having good mental health, a safe school environment, positive family relationships, and having an involved teacher. While research in this area is progressing, there continues to be gaps in our understanding of risk and protective factors, especially related to health disparities experienced by youth from marginalized communities. For example, there is sparse research on the role of racism, discrimination, and historical trauma related to STB among youth.

More specifically, there is limited research focused on risk and protective factors for suicide among youth of color and those who identify as gender/sexual minorities. A couple articles in this special topic section addresses this important, underrepresented topic. In “School Risk and Protective Factors of Suicide: A Cultural Model of Suicide Risk and Protective Factors in Schools,” Marraccini, Griffin, and colleagues (2022) report on a systematic review of school related factors for American Indian and Alaskan Native, Hispanic/Latinx, Black/African American, and Asian American and Pacific Islander students. This review demonstrates the complexity and variability of risk and protective factors across race/ethnicity, sex/gender, and sexual orientation and their intersectionality. Nonetheless, factors that showed the most support across racial/ethnic groups were bullying as a risk factor and school connectedness and parent engagement with school as protective factors. Another contribution of this article is that it provides a framework integrating school-based risk and protective factors, cultural/racial/ethnic factors, stressors, and their links to identification, referral, and interventions provided for STB in the school setting. Further consideration is needed in the literature regarding how racism—both individual and institutional—impacts school risk and protective factors, as well as suicide risk assessment, triage, and prevention (Neblett, 2019).

The next article herein, “Understanding Protective Factors for Suicidality and Depression among U.S. Sexual and Gender Minority Adolescents: Implications for School Psychologists,” examines risk and protective factors for STB across sexual, gender, and racial identities using an intersectionality lens (Rivas-Koehl et al., 2022). This paper directly addresses the recent calls for applying an intersectional lens to the study of STB and the need for a greater focus on protective factors (Espelage et al., 2019; Johns et al., 2019). Examining data from 1,078 high school students in the U.S., largely identifying as White and Latinx, family support was found to be a robust protective factor of depression and STB among LGBTQ youth. Additionally, peer support, help-seeking beliefs, access to medical and counseling services, engaging in healthy activities, spirituality, and having trusted adults were identified as protective factors for other intersectional identity groups. Being female and LGBTQ was also related to heightened risk for depression and STB. Regarding race and ethnicity, being White was associated with a higher risk of depression compared to Latinx students, but only among gay and lesbian students, and race/ethnicity was not significantly associated with suicide-related behaviors for any group. Of note, the study sample had too few African-American youth across LGBTQ identities to have adequate statistical power to detect differences in STB among these groups. These findings on the importance of protective factors, coupled with the strong association between homophobic victimization and depression and STB for all groups, suggest that school psychologists should work to reduce the stigma associated with being a sexual or gender minority student at school. Programs and curricula should be put in place that address all too common homophobic epithets and sexism that pervade U.S. K–12 schools. Additionally, the authors situate their findings in the ongoing need for professional development around STB and depression across youth with intersecting identities.

While gender and sexual minority experiences of violence related to their identity are a particular risk factor for STB, other groups of minoritized youth are also at-risk for STB because of multiple forms of violence exposure (Castellví et al., 2017). Youth are exposed to various forms of violence in multiple settings, including schools (Jonson-Reid, 1998). In “Suicidality and Exposure to School-Based Violence Among a Nationally Representative Sample of Asian American and Pacific Islander Adolescents,” items from the nationally representative Youth Risk Behavior Survey are aggregated to represent a construct of exposure to school-based violence for high schoolers (Rajan et al., 2022). This study specifically focuses on Asian American and Pacific Islander youth, who are an understudied population in suicide research (Xiao & Lu, 2021). The findings reveal that exposure to school violence among Asian American and Pacific Islander adolescents is significantly and positively associated with suicidal ideation, suicidal plans, suicidal attempts, and suicidal attempts with an injury. Similar associations are found with those youth experiencing sexual violence. For youth with STBs, school-based violence and sexual violence were more likely endorsed compared to those without suicidality across racial/ethnic groups. The specificity of the types of school violence exposure and their associations with STBs is important to advance knowledge of risk factors for suicidality. Implications of these findings include intervening to promote school safety and address exposure to violence, to reduce suicide risk for all youth, and especially among Asian American and Pacific Islander youth.

Another key risk factor to consider in school-based suicide prevention is the constellation of warning signs that identify behaviors that warrant attention and further assessment for suicide risk. In “Patterns of Warning Signs Among Adolescents Who Contemplate Suicide: A Latent Profile Analysis,” person-centered methods are utilized among a sample of adolescents with recent suicide ideation to identify patterns of warning signs (Bertuccio et al., 2022). This article advances our understanding of how warning signs can aggregate to fit profiles of student behavioral risk presentation. Results indicated one group (representing 73% of the sample) exhibits elevated anxiety, hopelessness, and mood changes, while another group (representing 6% of the sample) displays more extreme behaviors encompassing elevated ideation, substance abuse, anger, recklessness, and mood changes. A final group (representing 21% of the sample) has average to below-average levels across all warning signs, with especially low levels of hopelessness. This group is important to emphasize because their warning signs are unlikely to be noticed. Findings from this study highlight how utilizing multiple ways to identify youth who may be at risk for suicide is critical, particularly as youth within marginalized groups are more likely to be missed. For example, in another study using data from the Youth Risk Behavior Survey, adolescents of color were more likely to skip answering the suicide attempt question compared to White youth (Anderson et al., 2015). Informing school personnel about the various behavioral profiles associated with suicidal ideation and attempts can enhance their ability to detect these youth.

Adults in the lives of youth, both at school and at home, play a critical role in identifying warning signs and mitigating other risk factors related to youth suicide. Specifically, adults may also play a critical role in reducing youths’ experiences of face-to-face and cybervictimization, which, in turn, lowers the risk of STBs. This is the topic of the article, “Do Parental Involvement and Adult Support Matter for Students’ Suicidal Thoughts and Behavior in High School?” In this study, Wang and colleagues (2022) surveyed 362,980 students across 412 high schools in Georgia using a comprehensive set of questionnaires covering school climate and safety, graduation rates, school dropout, alcohol and drug abuse, bullying and harassment, and student mental health. This article is unique to the literature as it includes an analysis of social support at the student-level as well as the school-level through multi-level modeling. Results found that victimization (face-to-face, cyber), perceived parental involvement, and adult support at the student-level and school-level were all associated with lower levels of STBs. Greater parental involvement and adult social support at the student-level mitigated the association between victimization and STBs. However, when social support was analyzed at the school-level, it was found to amplify the relation between peer victimization and STBs. Overall, the findings from this study echo the calls from the field for school psychology to continue to foster school-home collaborations, engage in training for parents and school personnel around victimization and STBs, and to address school-level climate issues that might be preventing youth from utilizing adult social support.

SCHOOL-BASED PREVENTION PROGRAMMING

Throughout the past three decades, school-based suicide prevention programming has proliferated, especially within middle and high school settings (Surgenor et al., 2016). Fortunately, there are now several high-quality, publicly available resources to support such programming, including those from the Suicide Prevention Resource Center (https://www.sprc.org/resources-programs), the American Association of Suicidology (https://suicidology.org/school-resources/), the American Foundation for Suicide Prevention (https://afsp.org/make-a-difference), and the Youth.Gov website (https://youth.gov/youth-topics/youth-suicide-prevention/). As use of school-based suicide prevention has grown in practice, dozens of original empirical studies have been conducted to evaluate the effectiveness of these efforts, and an increasing number of systematic reviews and meta-analyses have been conducted to synthesize this area of research. The upshot of original studies and reviews of the evidence has generally been mixed. Yet the quality and confidence of the empirical literature continues to improve over time.

The earliest systematic review of school-based suicide prevention programming, conducted by Mazza (1997), identified 11 studies published by the mid-1990s. Mazza concluded that most early research efforts had significant methodological flaws and focused primarily on outcomes related to knowledge acquisition and attitude change—showing little impact on youths’ STBs. A follow up systematic review by Miller and colleagues (2009), as part of an earlier special series in School Psychology Review on this topic (Volume 38, No. 2; Miller & Eckert, 2009), used more stringent criteria related outcome measurement compared to Mazza’s review. Miller and colleagues identified 13 studies published by the late-2000s. This review concluded that only two studies evaluating school-based suicide programs showed strong evidence for statistically significant effects—and that most studies had substantial methodological weaknesses. Since Mazza’s (1997) and Miller and colleagues (2009) reviews, several more recent reviews have concluded similarly. Although the empirical literature on school-based suicide prevention is expanding, most studies are still compromised by methodological weaknesses and there is still little evidence demonstrating positive impacts on actual STB (Andriessen et al., 2019; Breet et al., 2021; Cusimano & Sameem, 2011; Katz et al., 2013; Robinson et al., 2013).

However, a few reviews narrowing in on the most rigorous, controlled trials suggest a more promising evidence base is emerging (Calear et al., 2016; Zalsman et al., 2016). A recent review on the topic, by Gijzen and colleagues (2022), identified 11 studies of controlled trials consisting of 23,230 total student participants. The meta-analysis of the outcomes from these high-quality studies and found statistically significant post-test results characterized by small effect sizes for reducing both suicidal ideation (10 comparisons; g = 0.15) and suicidal behavior (six comparisons; g = 0.30) (Gijzen et al., 2022). Likewise, additional meta-analysis of studies evaluating short-term follow-up effects (ranging from 3–12 months) indicated statistically significant effects with small impacts on suicidal ideation (four comparisons; g = 0.22) and suicidal behavior (three comparisons; g = 0.30). Thus, the best available evidence indicates school-based prevention programming can indeed reduce suicide risk, albeit with small effect sizes.

A recent systematic review by Katz and colleagues (2013) classified contemporary school-based suicide prevention efforts according to five types: (a) education or awareness, (b) gatekeeper, (c) peer leadership, (d) skills training, and (e) screening or assessment. Erbacher and colleagues, (2015), Singer and colleagues (2019), and Miller (2021) provide helpful overviews of how these different types of suicide prevention programming can be organized across levels of support within a multitiered school-based prevention framework. While research and practice regarding STBs continues to evolve and improve, there remain several empirical unknowns. For instance, the research base is still limited regarding factors that moderate the effectiveness of programs as well as the logistics of implementing such programs (Surgenor et al., 2016). Additionally, although we know that different types of programs (e.g., gatekeeper and skill training) across different levels of service delivery (e.g., universal and targeted) are indeed effective, we know very little about the differential effectiveness of program types and levels when directly compared to each other (cf. Wasserman et al., 2015). Finally, although the value of assessing social validity has been increasingly emphasized in school psychology and other youth-serving professions over the last few decades (e.g., Strain et al., 2012), we still know very little about users’ perspectives regarding feasibility, acceptability, and overall satisfaction with the training and implementation of school-based suicide prevention programs. A couple articles from this special series make important contributions to the literature on this latter point.

Herein, “An Initial Evaluation of the Helping Students At-Risk for Suicide Professional Development Workshop,” Nickerson and colleagues (2022) describe the development and early evaluations of a professional development workshop designed specifically to train school-based mental health professionals in evidence-based practices for intervening with students who are presenting with possible suicide risk (Tier 2 or Tier 3). The Helping Students At-Risk for Suicide (HSAR) workshop is a one-day training developed by researchers in partnership with a university center, a state-level school psychology association, and a statewide mental health and suicide prevention center. HSAR focuses on training school-based mental health professionals in (a) assessing and identifying youth at-risk for suicide, (b) intervening with students exhibiting STBs, (c) assisting with referrals to out-of-school providers, and (d) arranging follow-up supports for at-risk students and their families. And it emphasizes the importance of following standardized procedures, engaging collaborative processes, and promoting shared decision-making throughout all school-based suicide prevention activities. Nickerson and colleagues report on a mixed-methods evaluations of the HSAR, carried out with a pilot sample (N = 71; three workshops) and initial sample (N = 251; nine workshops). Results of quantitative ratings indicated that, on average, participants from both the pilot and initial evaluation studies were highly satisfied with the objectives, content, and benefit received from the workshop. Findings emerging from qualitative responses obtained from participants across both implementations suggested that attendees (a) were motivated to improve their competencies in this area, (b) desired to use the knowledge and skills gained to support their local schools, yet (c) perceived several barriers to implementation in schools. The authors conclude that the HSAR workshop appears socially valid and may be used as a model for addressing the professional development needs of school-based mental health professionals related to evidence-based suicide prevention.

In “Evaluating the Signs of Suicide Program: Middle School Students at Risk and Staff Acceptability,” Clark and colleagues (2022) report on the evaluation of the Signs of Suicide (SOS) program with students at two U.S. middle schools (N = 2537). As described above, SOS is a commonly used, empirically-supported Tier 1 program that integrates education or awareness, gatekeeper, and screening elements into a unified, multiphase intervention protocol. Key implementation elements of the SOS program include use of (a) video dramatizations with accompanying guided discussions to aid in identifying warning signs of suicide, (b) the ACT acronym (i.e., Acknowledge, Care, Tell) for cueing students and teachers to support youth presenting with possible suicide risk, (c) student self-evaluation of suicide risk via the 7-item Brief Screen for Adolescent Depression, and, for those identified as at-risk, (d) individualized follow-up from a mental health professional. Given most school-based suicide prevention studies have been conducted at the high school level and only one previous study had been conducted evaluating the SOS with middle school students, Clark and colleagues’ study makes a valuable contribution to the literature by exploring the treatment acceptability of the SOS program among middle school staff. Results suggested that, on average, school staff had positive impressions of program acceptability. However, it is noteworthy that disaggregating the acceptability scale highlighted variability in acceptability. For example, there was a lower mean rating with more variability in response to the item “I like the procedure used in the SOS lessons/screener” compared to the item “I would be willing to use the SOS lessons/screener if I had to assess students’ suicidal ideation/experiences.” Findings from their program evaluation further indicated that about 20% of students were identified as at-risk for suicide—and that risk was significantly higher among females, younger students, students with disabilities, and those with lower socioeconomic status. Clark and colleagues identify and discuss factors that may improve acceptability of school-based suicide prevention programming and make several fruitful suggestions for future research and practice (e.g., balancing the scope of target outcomes to include protective factors and student well-being indicators).

SCHOOL-BASED POSTVENTION PROGRAMMING

Beyond prevention, interest in school-based postvention—or intentional responses to support those bereaved or otherwise affected by suicide—has also increased in recent decades. There are now freely available, high quality resources for supporting school-based postvention efforts, including the joint-expert document regarding best practices for reporting on suicide to community members and the media (see for instance https://reportingonsuicide.org), postvention guidance provided by the Readiness and Emergency Management for Schools: Technical Assistance Center (https://rems.ed.gov), After Suicide: A Toolkit for Schools developed by the Suicide Prevention Resource Center (https://www.sprc.org/webform/after-suicide-toolkit-schools), and the relevant postvention resources provided in NASP’s PREPaRE curriculum and associated workshops (https://www.nasponline.org/professional-development/prepare-training-curriculum). Yet compared to prevention, there has been much less research evaluating the effects of school-based postvention. A recent systematic review of the literature on the topic identified only eight empirical studies published since 2014 (Andriessen et al., 2019), only one of which was conducted within a school setting (i.e., Cha et al., 2018). Although more than half of the eight studies reported at least one positive outcome resulting from postvention efforts (e.g., improvement in grief scores, broader gains in mental health functioning, decreases in secondary suicidality), the authors concluded there is currently little evidence supporting the broader effects of postvention strategies. As another example, a larger systematic review of the postvention literature—covering 50 years of research—showed that only 24 of 443 articles (5%) published on the topic since 1965 included empirical evaluations of postvention effects (Maple et al., 2018). One potential explanation for this dearth of research related to evaluating school-based postvention programming is that conducting such studies amidst crisis, and especially in the aftermath of suicide, is complicated by logistical and ethical challenges.

Despite limited available evidence, there are an increasing number of best-practice guideline documents for supporting school-based postvention efforts. Andriessen and colleagues (2019) identified 12 relevant postvention guideline documents, seven of which were specifically geared toward school-based settings. A recent consensus building study, soliciting input and iterative feedback from 40 experts in the area of suicide postvention, resulted in a comprehensive set of school-based postvention guidelines comprised of the following 20 themes: (a) developing an emergency response plan; (b) forming an emergency response team; (c) activating the emergency response team; (d) managing a suspected suicide that occurs on school grounds; (e) liaising with the deceased student’s family; (f) informing staff of the suicide; (g) informing students of the suicide; (h) informing parents of the suicide; (i) informing the wider community of the suicide; (j) identifying and supporting high-risk students; (k) ongoing support of students; (l) ongoing support of staff; (m) dealing with the media; (n) internet and social media; (o) the deceased student’s belongings; (p) funeral and memorial; (q) continued monitoring of students and staff; (r) documentation; (s) critical incident review and annual review of the emergency response plan; and (t) future prevention (Cox et al., 2016). The NASP PREPaRE curriculum and workshops provide actionable, best-practice strategies for addressing most of these themes.

Compared to prevention, postvention also appears to be an area in which school psychologists feel particularly underprepared and inexperienced. For example, in a survey of 111 school psychologists in the state of North Carolina, more than half reported limited knowledge, preparedness, and confidence related to suicide postvention (O’Neill et al., 2020). Particularly striking was the fact that most school psychologists endorsed no experience providing suicide postvention (60%) and were unaware, or unsure, if their district had a suicide postvention protocol (54%). Given these findings, O’Neill and colleagues (2020) offered several recommendations for shoring up postvention training among school psychologists, including prioritizing training in this area at both the pre-service level (i.e., during graduate school) and in-service level (i.e., during routine professional development), offering opportunities for booster-session trainings that target critical issues in postvention (e.g., contagion effects and navigating reporting on suicide), and offering practice trials and procedural reviews at the local school level to support maintenance of relevant postvention competencies. Additional resources for supporting best-practice postvention policies and programming in schools can be found in practical overviews on the topic by Erbacher and colleagues (2015), Miller (2021), and Scott and colleagues (2021).

Although school-based postvention has historically been oriented toward responding comprehensively and effectively in the aftermath of student suicide (Cox et al., 2016), another aspect of postvention includes supporting communities and individuals following attempted or non-fatal suicide behaviors. While, as mentioned above, youth STB is broadly on the rise, non-fatal suicide behaviors among youth are also increasing. Martínez-Alés and Keyes (2019) review several sources of longitudinal data indicating this trend. One particularly striking point is that, among youth fewer than 18 years in the U.S., emergency hospitalization visits coded for non-fatal suicide behavior doubled between 2007–2015, without a corresponding increase in total visits (Burstein et al., 2019). That said, there remains little evidence regarding how to best support youth at school following non-fatal suicide behaviors—and particularly following hospitalization for suicide attempts. An article in this special series takes a novel approach to addressing this important topic. Herein, “Returning to School Following Hospitalization for Suicide-Related Behaviors: Recognizing Student Voices for Improving Practice,” Marraccini and Pittleman (2022) report qualitative findings from student perspectives. Students identified three areas (i.e., socio-emotional, academic, and parent engagement) in their return to school from psychiatric hospitalization following non-fatal suicide behaviors. Students also offered recommendations that can be utilized as postvention strategies. These recommendations fall under three themes: supports and services, adult relationships, and school-wide. These findings fit with the bioecological model proposed by Tougas and colleagues (2019), which emphasizes the different systems (i.e., individual, family, school, hospital) that are involved and need to coordinate when a youth is hospitalized for psychiatric purposes. Hearing students’ perspectives is beneficial for development of culturally and contextually appropriate postvention strategies.

CONCLUSIONS AND FUTURE DIRECTIONS

The purpose of this special topic section was to advance science, practice, and policy related to mitigating STB among youth by publishing original empirical work and conceptual or theoretical papers on topics related to suicide prevention and postvention within schools and allied youth-serving settings. Most of the studies herein realized this purpose by furthering an evidence-based understanding of key risk and protective factors related to youth STBs, especially among marginalized and minoritized students (Bertuccio et al., 2022; Marraccini, Ingram, et al., 2022; Rajan et al., 2022; Rivas-Koehl et al., 2022; Wang et al., 2022). A couple studies progressed evaluation research related to the social validity of school-based suicide prevention programming, focusing particularly on school personnel and naturalistic implementers (Clark et al., 2022; Nickerson et al., 2022). Additionally, one study explored and identified key themes for advancing postvention efforts to support students following hospitalization for non-fatal suicide behaviors (Marraccini & Pittleman, 2022). Collectively, these articles strengthen the literature for guiding educators, caregivers, school psychologists, and other mental health professionals in providing comprehensive, culturally informed, effective programming to mitigate STBs among youth in schools. While we celebrate the progress evidenced by these articles, we recognize that significant gaps in the literature persist—and, thus, much more research is needed to refine and improve upon current frameworks and practices.

In closing, we highlight a few future directions that seem especially warranted for advancing science, practice, and policy related to mitigating STB among youth in schools. First, we recommend continuing to identify protective factors for reducing suicide risk among marginalized students—and then using such findings to further develop and better tailor school-based suicide prevention programing with minoritized populations. This is particularly relevant as a recent national survey of high school students during the COVID-19 pandemic demonstrated that more than 50% of the Asian, Black, and Multiracial adolescents in the sample reported experiencing racism in school during their lifetime (Mpofu et al., 2022). Thus, it becomes critical to identify protective factors that address particular risk factors of STBs. Work toward this end will benefit from an ecological approach, as advanced by Marracinni and colleagues (2022), which integrates targeted suicide preventive efforts across multiple layers of students’ ecologies. Second, we recommend systematic evaluations of disparities accompanied by intentional efforts to promote equitable access to suicide prevention programming in schools. Such efforts would support the advocacy and policy strategies outlined in the Blueprint for Youth Suicide Prevention (https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention), which explicitly calls for building an evidence base to address observed disparities in youth suicide risk. Finally, we recommend investigating the viability of integrating suicide prevention programming with other common school-based prevention efforts, such as social-emotional learning, positive behavior interventions and supports, substance use prevention, and trauma-informed schools. Although there are some initial efforts toward this end (e.g., Posamentier et al., 2022), most school-based prevention programs run along parallel and non-overlapping tracks, making them inefficient, expensive, and challenging to sustain over time. Given the logic and theory outlined by Domitrovich and colleagues (2010) supporting integrated prevention models in schools, we suspect suicide prevention could yield greater positive impacts by leveraging effective components from other evidence-based programs—and vice versa. We encourage interested scholars to further these key areas of research to improve school-based suicide prevention and postvention efforts.

DISCLOSURE

The authors have no conflicts of interest to report.

Additional information

Notes on contributors

Dorothy L. Espelage

Dorothy L. Espelage, PhD, is a William C. Friday Distinguished Professor of Education in the Peabody School of Education at the University of North Carolina at Chapel Hill. She has conducted research on youth violence, bullying, and adolescent suicide for the past 25 years and her research focuses on translating empirical findings into school-based and tech-based interventions to prevent suicide and promote mental health outcomes. She has procured over sixteen million dollars in external funding and has an established record of leading clinical trials to address youth violence and suicide outcomes [NCT03014271; NCT01792167; NCT03339648].

Rhonda C. Boyd

Rhonda C. Boyd, PhD, is an Associate Professor in Psychiatry in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at the Children’s Hospital of Philadelphia (CHOP) and the University of Pennsylvania Perelman School of Medicine. Her research focuses on impact on maternal depression of children, youth depression and suicide risk and preventive interventions for at-risk youth in multiple settings. She has served as a Principal Investigator and Co-Investigator on multiple federal grants including those from the National Institutes of Health and the Maternal and Child Health Bureau. She is the Associate Director of the CHOP’s Child and Adolescent Mood Program and is also the Assistant Director of its Youth Suicide Prevention, Intervention and Research Center. Recently, she participated on the workgroup for the Congressional Black Caucus Emergency Taskforce on Black Youth Suicide & Mental Health which resulted in a report and legislation.

Tyler L. Renshaw

Tyler L. Renshaw, PhD, is an Associate Professor in the Psychology Department at Utah State University, where he is the Director of the School Psychology Program and the School Mental Health Lab. Dr. Renshaw’s research focuses on developing assessment and intervention approaches for prompting mental health in schools, with particular emphasis on screening and prevention. He is a past Editor-in-Chief of Assessment for Effective Intervention and contributes to the editorial boards of several other journals that serve the school mental health community.

Shane R. Jimerson

Shane R. Jimerson, PhD, is a Professor University of California, Santa Barbara and Nationally Certified School Psychologist. His scholarship addressing school violence and school safety includes 6 books. School Safety and Violence Prevention: Science, Practice, and Policy (2018, American Psychological Association); Supporting Bereaved Students at School (2017, Oxford University Press); The Handbook of School Violence and School Safety: International Research and Practice 2nd Edition (2012, Routledge), Best Practices in School Crisis Prevention and Intervention 2nd Edition (2012, National Association of School Psychologists), The Handbook of Bullying in Schools: An International Perspective (2010, Routledge), School Crisis Prevention and Intervention: The PREPaRE Model (2016, National Association of School Psychologists).