Child Suicide and the Schools

Abstract

To the Editor. Child death by suicide is a serious and growing problem. A steep rise in the rate of suicide now makes it one of the leading causes of death for adolescents and young adults, and the available data may be underreported if, as many experts believe, numerous “accidental” deaths are actually suicides.1 Since 1990, 72 children <19 years old have died by suicide in Cuyahoga County, Ohio,2 reflecting the fact that, like politics, child suicide is a very local problem.As early as 1990, the American Academy of Pediatrics Committee on School Health recommended that pediatricians work with local school personnel to implement suicide-reduction strategies. The Committee observed that successful prevention programs would have to involve community school personnel, physicians, students, and their parents.3 The recent suicide of a Cleveland school child who was under medical care for depression prompted the belated question as to why the physicians and mental health professionals who were treating the child for depression did not notify the school, and involve school professional personnel in surveillance of the child's behavior and performance.Should we, then, be notifying the schools when we recognize that a patients is at risk of suicide? Are the schools really willing and able to help? What are the pros and cons of school notification, and what are the patient privacy issues?In a recently published survey evaluating the acceptability of different types of school-based suicide prevention programs, high school principals rated curriculum-based programs presented to the students, and in-service presentations to teaching staff, as preferable to a school-wide student self-reporting program.4 These findings suggest that school administrators are not comfortable in active detection programs to identify pupils who might be self-destructive, and their reticence to do so is understandable. School administrators are not mental health professionals. Yet students spend a plurality of their waking hours in school, and the consequences of suicide are not limited to the individual student and his or her family. Invariably, the individual suicide becomes a problem for the extended school family, especially given the phenomenon of “cluster suicides” imitating the index case.Most of the respondents to another, randomized, nationwide survey of high school health teachers reported that the teachers believe that it is their role to recognize students at risk for suicide, that recognition can reduce the chance of a student committing suicide, and that preventing a student from committing suicide is one of the most important things they can do. Only 9% of the teachers, however, believed that they really could recognize a student at risk. Teachers at schools with staff in-service programs on adolescent suicide, with a curriculum that included teaching students about suicide prevention, and with a crisis intervention team expressed higher confidence in their ability to identify a student at risk of self-destruction.5What has not been reported in the literature is whether it is beneficial if physicians and mental health professionals inform school personnel when a child has been medically diagnosed with a condition that places him or her at heightened risk of self-harm. Pediatricians, child psychiatrists, psychologists, and social workers do diagnose and treat children with depression, adolescent adjustment reaction, chemical dependency, sexual identity problems, exposures to violence or abuse, and other conditions that put them into the at-risk category. Most of these at-risk youngsters are either attending or will be returning to school. We believe that schools can help if they are included as part of the team. School personnel can provide unique surveillance of day-to-day behavior, and detect early signs and symptoms that may be inapparent to family or physicians.We propose that pediatricians discuss with parents the pros and cons of informing their child's school when there is a recognized chance of suicide. Parents will need reassurance that involving school staff is unlikely to stigmatize their youngster, and that the potential for improved survival outweighs the small social risk. Written consent to release this information to the school would be very appropriate.The pediatrician can play an important role by proposing this idea to the child's family and to the child's mental health provider. It has been suggested that the initial call to the school be made either to the director of pupil services for the school system or to the psychologist, social worker, nurse, or principal at the child's school building. Clear lines of communication will need to be created so that school personnel can quickly notify health providers if disturbing behavioral changes or concerns are observed. On their part, the school will need to take measures to ensure privacy and to minimize the risk of stigmatization.Given the potential risks and benefits, the notion of deliberately involving the schools in this endeavor has a strong appeal, even in the absence of published studies. The Cleveland Public School system has already expressed an interest in participating in just this sort of team effort. We believe that other area school systems will be interested, too. We invite the readers of Pediatrics to consider this idea.In Reply. The recommendations of Feingold and Quilty are both excellent and timely. Pediatricians would play an important role in preventing suicide if they were to actively engage school personnel to become part of the early detection and prevention team. It should also be noted that pediatricians may also need to assess the ability of a school to handle sensitive information responsibly and assist those schools less apt to do so.There are federal laws that protect access to regular school programs for students with special needs, such as the law referred to by school personnel as “Section 504.” Students who need to have sensitive medical information shared with staff to protect their own safety may fall under this legal protection. Yet some schools, specifically those without a counselor, social worker, or nurse on site, will often need assistance with managing this information. When introducing information about suicidal ideation, we must be certain that we raise staff awareness without inducing fear or dread. Confidential medical information in schools is often kept sealed from the general academic cumulative record of students so that it is shared only with those with a “need to know.” But when no school health professionals are on site, there may be no system for handling such information. So that schools use information to prevent crises, not create them, pediatricians must also be prepared to work intimately with schools that lack internal capability. This may require visiting the school to help establish a plan, offering staff education, responding to questions from those staff who are part of the plan, and being proactively available each year when classes and staff change.