Adolescent Research Review

, Volume 3, Issue 2, pp 235–253 | Cite as

State Requirements for School Personnel Suicide Prevention Training: Where Do We Go From Here?

  • Elizabeth Kreuze
  • Tracy Stecker
  • Kenneth J. Ruggiero
Quantitative Review

Abstract

Suicide is a leading cause of death among youth and emerging adults in the USA. Because youth suicide imposes serious burdens and has profound implications, federal priorities include suicide prevention training among school personnel, in part, because school personnel can assume an important role in suicide prevention given their work with youth. Many states now have policies for school personnel suicide prevention training, in response to federal priorities encouraging the establishment of suicide prevention training requirements among school personnel. However, because federal priorities do not specifically define these training requirements, there is considerable variation in state-level policy and practice. Consequently, state-level youth suicide rates are examined in relation to variable state policies, to explore how suicide rates may differ as a function of variable policies, in order to determine if particular policies or practices are correlated with greater harm or benefit to youth. Statistical analyses suggest that state-level policies are not strongly correlated with rates of youth suicide, indicating that current policies have not had significant impact on youth suicide. Alternatively, statistical analyses suggest that rates of youth suicide are correlated with youth population percentages per state and rural areas. Five important policy and training considerations are discussed relating to training duration, training frequency, training content, application of skills, and inclusion of technology. These five policy and training considerations outline specific issues that should be considered when developing state requirements for suicide prevention training among school personnel, including the creation of precise definitions and rigorous standards, review of the evidence base around training approaches, and the creation of standards around evaluation of training programs. Further exploring these five particular policy and training considerations will increasingly unite federal priorities and state-specific youth suicide prevention efforts, which may more effectively moderate rates of youth suicide.

Keywords

Youth Suicide prevention School personnel State requirements Policy 

Introduction

This article addresses the need to examine the role of school-based suicide prevention training among school personnel to combat youth suicide, as well as the need to evaluate state policies and training curricula to inform best practices. Suicide is a leading cause of death among youth and emerging adults in the USA, resulting in both federal and state response (Condron et al. 2015; Godoy et al. 2016, 2015; Goldston et al. 2010; Office of the Surgeon General, National Action Alliance for Suicide Prevention, Department of Health and Human Services 2012; Rodi et al. 2012; Walrath et al. 2015). Federal priorities include community and school-based suicide prevention training; however, this general guideline is not specifically defined. Consequently, states have implemented variable training requirements in response to general federal priorities. Because states have enacted variable training policies in the absence of a defined national standard, state-specific youth suicide data and state-specific training requirements are outlined.

State school personnel suicide prevention training requirements are explored in relation to rates of youth suicide by state. Statistical analyses suggest that state policies and rates of youth suicide are independent and unrelated, indicating that current school personnel suicide prevention training policies are uncorrelated with rates of youth suicide. Statistical analyses instead suggest that rates of youth suicide are correlated with youth population percentages per state and rural areas.

Five important policy and training considerations are provided in response to the results of the statistical analyses, and in response to variable state requirements. These considerations relate to training duration, training frequency, training content, application of skills, and technology-oriented elements. More specifically, evaluation of training duration, training frequency, and training content are discussed in an effort to move toward establishing research-driven guidelines. Because the creation of policies to adopt evidence-based training practices should be prioritized, the state of the literature around evidence-based programs that are readily available for dissemination and implementation are also briefly described. Exploring how school personnel proactively translate knowledge into prevention behaviors by additionally evaluating application of skills is also discussed. Finally, opportunities to leverage technology to assist in cost-efficient dissemination and implementation of evidence-based training programs nationally are highlighted, particularly in smaller states and rural areas that are often restricted or isolated from traditional training resources, and that often have the highest rates of youth suicide.

Relevance and Significance of Prioritizing Youth Suicide Prevention

Age-adjusted suicide in the USA increased 24% between 1999 and 2014 [Centers for Disease Control and Prevention (CDC) 2016a]. The suicide rate for girls aged 10–14 years had the largest increase (200%), tripling from 0.5 per 100,000 in 1999 to 1.5 per 100,000 in 2014 (CDC 2016a). Suicide is the second leading cause of death for youth and emerging adults aged 10–24 years (CDC 2016b). However, death by suicide portrays only one part of this public health crisis, as more youth attempt suicide than die by suicide (CDC 2017). According to the most recently available data from the National Youth Risk Behavior Survey, in 2015, approximately 17.7% of high school students reported seriously considering attempting suicide, 14.6% made a suicide plan, and 8.6% attempted suicide one or more times in the year preceding the survey (CDC 2016d). Because youth suicide imposes profound individual, relationship, community, and societal burdens (CDC 2017), additional research addressing youth suicide is important to prioritize in order to moderate both morbidity (i.e., suicidal ideation, suicide attempts) and mortality (i.e., death by suicide).

Policymakers have long held that trained school personnel can assume an important role in suicide prevention due to their accessibility to and frequent interaction with youth. Most youth are exposed to numerous teachers and school personnel, most days per week, for three-quarters of each calendar year. In contrast, medical providers have more infrequent contact with youth; yet, health professionals are disproportionately relied upon to identify and address risk for self-harm and suicide. Because adolescents are increasingly independent from parents (CDC 2015a, b), and because youth spend a large portion of their days in school, schools are well positioned to promote the health and safety of students [American Foundation for Suicide Prevention (AFSP) 2016; CDC 2015c; National Action Alliance for Suicide Prevention (NAASP) 2014). Suicide prevention training programs for school personnel may assist in identification and referral of at risk youth, and may concurrently reduce stigma and address myths about suicide. Involving schools in suicide prevention is timely and relevant, given the profound impact imposed by youth suicide, as well as the need for collaborative approaches and novel solutions to suicide prevention. However, if school personnel are to assume their important role as gatekeepers, researchers, program developers, and policymakers have a duty to ensure effective training and effective policies that meet school personnel needs, which may increasingly moderate rates of youth suicide.

National Response to Youth Suicide

National priorities have focused, in part, on the need for suicide prevention training among school personnel (NAASP 2014). Specifically, The National Action Alliance for Suicide Prevention (NAASP 2014), a public–private partnership working to advance the national strategy for suicide prevention, engages in the following activities: conducting reviews of public and private research portfolios, performing targeted literature reviews, statistically simulating the effects of potential interventions to reduce morbidity and mortality, and gathering stakeholder input through repeated surveys. The Action Alliances National Research Prioritization Task Force, implemented in 2010, comprises representatives from 11 organizations that serve both public and private sectors in research, advocacy, and practice (NAASP 2014). In 2014, the Research Prioritization Task Force released the Prioritized Research Agenda, which outlines research areas demonstrating the greatest promise in helping to reduce rates of suicide attempts and suicide deaths in the next 5–10 years, if optimally implemented (NAASP 2014).

More specifically, the Research Prioritization Task Force and Prioritized Research Agenda summarize many applicable national priorities relating to suicide prevention training among school personnel, as these particular priorities demonstrate promise in reducing suicide attempts and suicide deaths. These relevant youth-specific goals include the need to: (1) use technology-based innovations to reduce suicide risk and intermediate outcomes within organizations such as schools (objective 5b); (2) maximize community program intervention effects (objective 5c); (3) increase the reach of suicide prevention training among community groups (objective 7.1); (4) ensure that community members are well trained in identifying individuals at risk (aspirational goal 7); (5) increase help-seeking and referrals by decreasing stigma (aspirational goal 10); and (6) integrate crosscutting themes, such as testing new technology and including technological enhancements; testing approaches to initiate and maintain healthy social connections and help-seeking behaviors (e.g., within organizations such as schools); using multi-disciplinary approaches to understand community values on individual behaviors; and adapting and testing appropriate components within systems that have responsibility for housing or managing at-risk populations (e.g., adolescents in schools).

State Response to Youth Suicide and the Prioritized Research Agenda

Several states have constructed policies that align with these national priorities in different ways. Specifically, 10 states mandate annual suicide prevention training for school personnel (i.e., AK, DE, GA, KS, KY, LA, NE, ND, TN, TX); 17 states mandate non-annual training (i.e., AR, CT, IL, IN, ME, MD, MA, MS, NJ, OH, PA, SC, SD, UT, WA, WV, WY); 15 states encourage but do not mandate training (i.e., AL, AZ, CA, CO, FL, MI, MN, MO, MT, NV, NY, OK, RI, VA, WI); and 3 states have unique school suicide prevention statuses only (i.e., ID, IA, NC) (AFSP 2016). In contrast, five states have no training mandates, no training recommendations, and no suicide prevention statuses (i.e., HI, NH, NM, OR, VT). This variability in state policies offers a unique opportunity to examine state-level suicide rates and how they may differ as a function of these policies.

State-Specific Youth Suicide Rates

Table 1 outlines states’ training recommendations. It presents the year training recommendations were adopted, youth suicide rates per state, youth death rates per state, percentage of adolescent deaths attributable to suicide per state, total youth population per state, weighted total youth suicides per state, and percentage of the total state population residing in rural versus urban areas. Further, Table 1 organizes states according to their respective training recommendations (i.e., mandate annual, mandate non-annual, encourage, prevention status, no policy). Within each of these training recommendation categories, states are presented according to their total youth population value, which are listed in ascending numerical order. Youth was operationalized for purposes of this report as individuals aged 10–18 years.

Table 1

Column three contains state-specific youth suicide rates; column four contains state-specific youth death rates; columns three and four were divided to calculate the percent of state-specific youth deaths attributable to suicide, and those results are presented in column five; column six includes state-specific youth population values; columns three and six were multiplied to calculate actual weighted youth suicides, and column seven represents the total number of youth that die by suicide per the state-specific population value in column six; finally, column eight contains percentages of the total state population residing in rural versus urban areas

State

Training recommendations and year recommendation was adopted (AFSP 2016)

Youth suicide rates per 100,000 (CDC 2013)

Youth death rates per 100,000 (CDC 2016c)

Percentage of youth deaths attributable to suicide (%)

Youth population per state (US Census Bureau 2016b)

Actual, weighted number of youth that die by suicide in each state annually

Percent of total state population residing in urban versus rural area (US Census Bureau 2016c)

ND

Mandate 2 annual professional development training hours. Originally adopted in 2013; updated in 2015 to include annual training requirements

10.57

44.8

23.6

81,000

8.6

Urban: 59.9%

Rural: 40.1%

AK

Mandate 2 annual training hours. Adopted in 2012

13.88

60.2

23.1

83,000

11.5

Urban: 66%

Rural: 34%

DE

Mandate 90 min of annual training; training materials must be evidence based and pre-approved. Adopted in 2015

2.52

37.1

6.8

103,000

2.6

Urban: 83.3%

Rural: 16.7%

NE

Mandate 1 annual training hour; training materials must be pre-approved. Adopted in 2014

5.82

40.4

14.4

232,000

13.5

Urban: 73.1%

Rural: 26.9%

KS

Mandate a minimum of 1 h of annual training. Adopted in 2016

4.35

41

10.6

342,000

14.9

Urban: 74.2%

Rural: 25.8%

KY

Mandate 2 annual self-study review hours. Adopted in 2010

3.99

44.6

8.9

473,000

18.9

Urban: 58.4%

Rural: 41.6%

LA

Mandate 2 annual in-service training hours. Adopted in 2008

3.88

56.2

6.9

502,000

19.5

Urban: 73.2%

Rural: 26.8%

TN

Mandate 2 annual in-service training hours. Originally adopted in 2007; updated in 2016 to include all school employees

3.41

47.2

7.2

745,000

25.4

Urban: 66.4%

Rural: 33.6%

GA

Training durations are not defined, but training is required annually. Adopted in 2015

2.62

40.6

6.5

1,283,000

33.6

Urban: 75%

Rural: 25%

TX

Training durations are not defined, but training is required annually; training must follow Department of State Health Services best practices. Originally adopted in 2013; amended in 2015 to include annual staff development requirements

3.58

38.8

9.2

3,498,000

125.2

Urban: 84.7%

Rural: 15.3%

WY

Mandate 8 training hours every 4 years; training materials must be pre-approved. Adopted in 2014

8.86

53.2

16.7

65,000

5.8

Urban: 64.8%

Rural: 35.2%

SD

Mandate a minimum of 1 h of training to obtain initial certification and to renew certification (though frequency is not specifically defined). Adopted in 2016

13.78

53.4

25.8

98,000

13.5

Urban: 56.7%

Rural: 43.3%

ME

Mandate a 1–2 h in-service every 5 years. Adopted in 2013

3.71

36.2

10.2

143,000

5.3

Rural: 61.3%

Urban: 38.7%

WV

Training durations are not defined, but are required as “routine education”, though the frequency is not specifically defined. Adopted in 2012

3.61

49.1

7.4

185,000

6.7

Rural: 51.3%

Urban: 48.7%

MS

Training durations are not defined, but training is mandated one time for newly licensed teachers and principals. Adopted in 2009

3.94

57.1

6.9

348,000

13.7

Rural: 50.7%

Urban: 49.3%

AR

Mandate 2 training hours every 5 years. Adopted in 2011

4.58

52.9

8.7

349,000

16

Urban: 56.2%

Rural: 43.8%

UT

Mandate 2 training hours, which repeats with the state licensure cycle. Adopted in 2012

5.4

35.1

15.4

431,000

23.3

Urban: 90.6%

Rural: 9.4%

CT

Training durations are not defined, but training is mandated one time. Adopted in 2011

2.64

25.5

10.4

464,000

12.2

Urban: 88%

Rural: 12%

SC

Mandate 2 training hours every 5 years. Adopted in 2012

3.58

47.1

7.6

529,000

18.9

Urban: 66.3%

Rural: 33.7%

MD

Mandates apply to certified school counselors specifically; training durations are not defined and training frequency is not defined. Adopted in 2015

2.95

38.3

7.7

693,000

20.4

Urban: 87.2%

Rural: 12.8%

MA

Mandate 2 training hours every 3 years. Adopted in 2014

1.97

24.1

8.2

753,000

14.8

Urban: 92%

Rural: 8%

IN

Training durations are not defined, but training is mandated one time in order to obtain an IN teaching license. Adopted in 2011

4.05

40.4

10

842,000

34.1

Urban: 72.4%

Rural: 27.6%

WA

Mandate 3 training hours an unspecified number of times. Adopted in 2013

3.9

32.3

12.1

866,000

33.8

Urban: 84%

Rural: 16%

NJ

Mandate 2 training hours each professional development period, also require a mental health trainer administer training. Adopted in 2006

2.08

26.8

7.8

1,032,000

21.5

Urban: 95%

Rural: 5%

OH

Training durations are not defined, but training is mandated every 5 years. Adopted in 2012

4.34

34.9

12.4

1,315,000

57.1

Urban: 77.9%

Rural: 22.1%

IL

Training durations are not defined, and the number of mandated training sessions is also undefined. Adopted in 2009

2.94

37.5

7.8

1,430,000

42

Urban: 88.5%

Rural: 11.5%

PA

Mandate 4 training hours every 5 years. Adopted in 2014

3.56

36.3

9.8

1,496,000

53.3

Urban: 78.7%

Rural: 21.3%

RI

Encourage training. Adopted in 2012

2.75

26.4

10.4

115,000

3.2

Urban: 90.7%

Rural: 9.3%

MT

Encourage training. Adopted in 2015

9.77

53

18.4

123,000

12

Urban: 55.9%

Rural: 44.1%

NV

Encourage training. Adopted in 2006

5.17

41.3

12.5

335,000

17.3

Urban: 94.2%

Rural: 5.8%

OK

Encourage training. Adopted in 2014

4.97

50.8

9.8

489,000

24.3

Urban: 66.2%

Rural: 33.8%

AL

Encourage training. Adopted in 2009

3.63

52.8

6.9

545,000

19.8

Urban: 59%

Rural: 41%

MN

Encourage training. Adopted in 2008

4.74

31

15.3

666,000

31.6

Urban: 73.3%

Rural: 26.7%

CO

Encourage training. Adopted in 2004

6.70

37.8

17.7

667,000

44.7

Urban: 86.2%

Rural: 13.8%

WI

Encourage training. Adopted in 2008

4.53

36

12.6

714,000

32.3

Urban: 70.2%

Rural: 29.8%

MO

Encourage training. Adopted in 2016

4.51

47.7

9.5

754,000

34

Urban: 70.4%

Rural: 29.6%

AZ

Encourage training. Adopted in 2015

5.61

44

12.8

877,000

49.2

Urban: 89.8%

Rural: 10.2%

MI

Encourage training. Adopted in 2006

3.94

37

10.6

1,035,000

40.8

Urban: 74.6%

Rural: 25.4%

VA

Encourage training. Adopted in 2004

3.44

34.3

10

1,044,000

35.9

Urban: 75.5%

Rural: 24.5%

NY

Encourage training. Adopted in 2013

2.10

27.8

7.6

2,205,000

46.3

Urban: 87.9%

Rural: 12.1%

FL

Encourage training. Original legislation repealed in 2011, and updated in 2016

2.78

39.3

7.1

2,231,000

62

Urban: 91.2%

Rural: 8.8%

CA

Encourage training. Adopted in 2009

2.44

32

7.6

4,594,000

112.1

Urban: 95%

Rural: 5%

ID

Prevention statuses only. Adopted in 2007

6.42

43

14.9

228,000

14.6

Urban: 71%

Rural: 29%

IA

Prevention statuses only. Adopted in 1989

5.7

35

16.3

389,000

22.2

Urban: 64%

Rural: 36%

NC

Prevention statuses only. Adopted in 2006

3.3

41

8

1,220,000

40.3

Urban: 66.1%

Rural: 33.9%

VT

No policies

4.8

33.5

14.3

64,000

3.1

Rural: 61.1%

Urban: 38.9%

NH

No policies

3.09

26.7

11.6

144,000

4.5

Urban: 60.3%

Rural: 39.7%

HI

No policies

4.2

28.7

14.6

161,000

6.8

Urban: 92%

Rural: 8%

NM

No policies

9.65

52.7

18.3

258,000

24.9

Urban: 77.4%

Rural: 22.6%

OR

No policies

3.39

32.8

10.3

449,000

15.2

Urban: 81%

Rural: 19%

It was anticipated that states that mandate or encourage training, or that have suicide prevention statuses, would lower rates of youth suicide than states without such guidelines in place. However, youth suicide rates appear to be weakly correlated with current training policies. In contrast, youth suicide percentages appear most strongly correlated with youth population per state (i.e., highest suicide rates in less populated states), and also appears strongly correlated with geographic location (i.e., youth suicide more pronounced in rural areas).

To evaluate the apparent correlations between rates of youth suicide and state youth population, Kendall’s tau non-parametric statistical tests were conducted using SPSS version 24 (IBM 2017), given the primary focus on state policies and the desire to explore additional associations within this principal focus. Kendall’s tau was selected because it is a preferred statistical test for intermediate samples when n < 30 (Daniel 1978; Polit 2010). Further, Spearman’s rank-order correlation is somewhat less accurate because the approximations to theoretical sampling distributions are imperfect, especially for intermediate samples, and Kendall’s tau provides more advantageous and reliable statistical properties (Daniel 1978; Polit 2010; Snedecor and Cochran 1980). However, because the minimum sample size required to perform Kendall’s tau is n = 4 (Daniel 1978), tests were performed on three of the five primary policy groups (i.e., n = 10 states that mandate annual training, n = 17 states that mandate non-annual training, n = 15 states that encourage training). Tests were not performed on the remaining two policy groups (i.e., n = 3 states with suicide prevention statuses, n = 5 states with no policies), because these sample sizes were too small to analyze meaningfully.

The correlation between the rates of youth suicide and a state’s youth population was corroborated statistically. Specifically, there was a significant negative correlation between rates of youth suicide and state youth population in the n = 10 states that mandate annual training (Kendall’s tau_b = − 0.556; p = 0.025), the n = 17 states that mandate non-annual training (Kendall’s tau_b = −0.353; p = 0.048), and the n = 15 states that encourage training (Kendall’s tau_b = −0.467; p = 0.015). Together, these findings suggest that less populated states have higher rates of youth suicide irrespective of state policies addressing suicide prevention training among school personnel.

Next, a 5 × 2 contingency table was constructed and a Chi-square non-parametric statistical test was conducted using SPSS version 24 (IBM 2017). The Chi-square test was selected because it allowed crosstabulations to make inferences about the existence of a relationship between state policy and youth suicide (Daniel 1978; Polit 2010; Snedecor and Cochran 1980). A significant Chi-square test would result in rejection of the null hypothesis (i.e., state policy and youth suicide are independent and not related), and acceptance of the alternative hypothesis (i.e., state policy and youth suicide are not independent and are related) (Daniel 1978; Polit 2010; Snedecor and Cochran 1980).

There were no significant relations between any of the five primary groups (i.e., mandate annual training, mandate non-annual training, encourage training, prevention status only, no policies) and rates of youth suicide. In the 5 × 2 contingency table, results were homogenous with respect to rates of youth suicide. Specifically, X2(9) = 3.4786; p = 0.95. As a result, it is appropriate to accept the null hypothesis (i.e., state policies and rates of youth suicide are independent and do not appear to be related).

To evaluate the apparent correlations between rates of youth suicide and rural areas, U.S. Census Bureau data was used to explore state-specific youth suicide rates within the context of rural versus urban states. In the Northeast region, Maine and Vermont represent the highest proportion rural states, with 61.3 and 61.1% of their populations defined as rural, respectively (US Census Bureau 2016a, c). In the Midwest region, South Dakota represents the highest proportion rural state, with 43.3% of its population classified as rural (US Census Bureau 2016a, c). In the Southern region, West Virginia represents the highest proportion rural state, with 51.3% of its population defined as rural (US Census Bureau 2016a, c). Finally, in the Western region, Montana represents the highest proportion rural state, with 44.1% of its population classified as rural (US Census Bureau 2016a, c). These particular high proportion rural states have high rates of youth suicide, as compared to low proportion rural states. Specifically, there were 3.61 youth suicide deaths per 100,000 in West Virginia; 3.71 youth suicide deaths per 100,000 in Maine; 4.8 youth suicide deaths per 100,000 in Vermont; 9.77 youth suicide deaths per 100,000 in Montana; and 13.78 youth suicide deaths per 100,000 in South Dakota (CDC 2013). Alternatively, California has the lowest proportion of population residing in rural areas (5%; US Census Bureau 2016a, c) and they also have lower rates of youth suicide (i.e., 2.44 youth suicide deaths per 100,000; CDC 2013).

States containing greater percentages of rural versus urban areas coincide somewhat with total state youth population values (i.e., high proportion rural states generally have less youth population). South Dakota represents the second smallest populated state among the 17 states requiring non-annual training; Maine represents the third smallest populated state among the 17 states requiring non-annual training; West Virginia represents the fourth smallest populated state among the 17 states requiring non-annual training; and finally, Mississippi (i.e., also containing greater percentages of rural versus urban populations; US Census Bureau 2016a, c), represents the fifth smallest populated state among the 17 states requiring non-annual training. Further, Montana represents the second smallest populated state among the 15 states encouraging training. Similarly, Vermont ranks first as the least populated state among the five states with no training policies. Thus, high proportion rural states and state youth population are distinct considerations, which may also be interconnected. When evaluating youth suicide prevention approaches used within states, it is important to consider both the proportion of a state defined as rural, as well as the total youth population per state.

Synthesizing these influential identified correlations, taken together, smaller states and rural areas are important to prioritize for improved suicide prevention efforts. New initiatives are needed to learn how to best address suicide prevention efforts in these particular areas, given the elevated rates of youth suicide identified in less populated states and rural areas. Further, because this analysis determined existing school personnel suicide prevention training policies are not significantly correlated with rates of youth suicide, it is imperative to also evaluate the training approaches used in a state. Because the analysis indicated youth suicide is correlated with less populated states and rural areas, evaluation of current programs and policies should occur alongside expansion efforts in small states and rural areas in particular, ensuring future training initatives are effective and ensuring they correlate with declines in youth suicide over time. Further, additional program and policy evaluation may also promote a more unified evidence-driven national standard, one from which all states may implement and benefit. Expanded program and policy evaluation increases the likelihood improved, evidence-based suicide prevention training standards for school personnel are adopted and implemented by all states.

Policy and Training Evaluation Considerations Stemming from the National Strategy and States’ Response to Youth Suicide

Several states have constructed policies that align with national suicide prevention priorities in different ways. Specifically, many states now have policies for school personnel suicide prevention training. However, there is considerable variation in policy and practice. Because the National Research Prioritization Task Force (NAASP 2014) indicates optimal implementation in particular is key to reducing morbidity (i.e., rates of suicide attempts) and mortality (i.e., death by suicide), it is important to further explore state variability in policy and practice. Rigorous evaluation of guidelines, programs, and practices is needed to understand characteristics that may relate to variability in suicide statistics by state. Further, additional evaluation of state variability is needed because the National Prioritized Research Agenda (NAASP 2014) describes the need for optimal implementation and standardized approaches.

Training Duration

Training duration is a characteristics that may be important to consider in establishing standardized approaches and optimal implementation, as it pertains to suicide prevention training among school personnel. Most states require 1–2 h of training; however, additional research is needed to determine if 1–2 h of prevention training is sufficient to affect competency and prevention behaviors. States requiring 1–2 h of training typically do not require program evaluation, such as changes in knowledge or trainee skills that may occur as a result of training. This is a significant missed opportunity. As a result, little is known about the optimal length of training necessary to produce lasting change, which is problematic, because producing lasting change is crucial in increasing opportunities to successfully identify and respond to suicide risk situations. Evaluation is needed to determine whether there is need to expand prevention curricula and/or allocate additional time to review and reinforce key concepts within existing training programs.

Training Frequency

Training frequency also may be a key characteristic important to consider in establishing standardized approaches and optimal implementation, in regards to suicide prevention training among school personnel. Frequent training may improve knowledge gains and skill maintenance over time. Training one time during a 5-year period, or one time during an entire career, for example, may not be as effective as annual training. Research is needed to understand whether more frequent re-training is associated with sustained improvements in risk identification. Training duration and frequency are interconnected. A one-time requirement of 1–2 h of training may be less effective than an annual requirement of 1–2 h of training, for example. The currently limited correlation between youth suicide rates and training duration and frequency may be the result of existing training guidelines that are unlikely to affect school personnel competency or behavior in managing suicide risk.

Training Content

Training content is also a characteristics that may be important to consider in establishing standardized approaches and optimal implementation, as it pertains to suicide prevention training among school personnel. Policy guidelines are needed to support training approach(es) that have significant reach and impact. Research is needed to inform policy. Identifying optimal training methods is, therefore, a major public health priority. Training needs may vary from state to state, but evaluation is needed to ensure significant deviations from evidence-based training content and evidence-based training approaches do not have adverse impact. Several programs have undergone significant evaluation and have shown benefits in the empirical literature. However, few states have adopted clear policies around the use of evidence-based training programs. Delaware is currently the only state requiring the use of evidence-based training materials. Texas indicates that training should be based on best practices recommended by the Department of State Health Services, but it is unclear if recommendations are based on expert opinion or on research evidence. Nebraska and Wyoming requires that training materials be “approved”, but it is unclear if decisions are guided by evidence-based standards. The remaining states omit language relating to the evidence base and do not require training materials follow evidence-based standards. This is also a significant missed opportunity.

Toward Establishing Research-Driven Training Content Guidelines

Guidelines are needed to inform state policy around training of gatekeepers in suicide prevention. Policymakers should consider a number of issues, including creation of precise definitions and rigorous standards, review of the evidence base around training approaches that are designated as acceptable, and creation of standards around evaluation of training programs.

The advantages and disadvantages of expanding prevention curriculum and incorporating additional risk factors for suicide is also an important consideration. Because existing training mandates do not appear to be strongly associated with rates of youth suicide, it will be important to gather evidence on a number of levels, including gathering and prioritizing evidence on factors that better predict future suicide, to improve resource allocation and understanding of the impact of prevention training. If evaluation is standardized and widely used across settings, there is tremendous potential to rapidly accelerate what is known about the impact of these programs and how state-level variability in training requirements may relate to suicide risk among youth. Because evaluations are not currently standardized and used across settings, this also represents a significant missed opportunity. Expanding prevention curriculum and standardizing evaluation may increasingly enable school personnel to identify youth at risk, in part, by including broader evidence-based risk factors for suicide, and thus offering additional opportunities for intervention. Further, standardizing implementation and evaluative procedures would also promote greater understanding of the impact of state-level policies.

To this end, one training content priority would be the creation of policies to adopt evidence-based programs. Resources for adopting evidence-based approaches currently are widely accessible and readily available, and considerable evidence exists to support these programs. As previously mentioned, because the vast majority of states do not require training content follow evidence-based standards, the significance of this missed opportunity is more fully realized, given the accessibility of evidence-based programs currently available to states. Specifically, the Substance Abuse and Mental Health Services Administration (SAMHSA 2017) National Registry of Evidence-Based Programs and Practices (NREPP) is a freely available, searchable online database that includes evidence-based school personnel suicide prevention training programs [i.e., Applied Suicide Intervention Skills Training (ASIST); Kognito At-Risk for High School Educators; Mental Health First Aid; Question, Persuade, Refer (QPR) Gatekeeper Training for Suicide Prevention]. SAMHSA’s (2017) NREPP also contains school-wide evidence-based suicide prevention programs, those that include training and resources for both school personnel and students [i.e., American Indian/Zuni Life Skills Development; Lifelines Curriculum; Linking Education and Awareness of Depression and Suicide (LEADS) for Youth; Model Adolescent Suicide Prevention Program (MASPP); Peer Assistance and Leadership (PAL); Reconnecting Youth (RY) A Peer Group Approach to Building Life Skills; Signs of Suicide (SOS) Middle and High School Prevention Programs; Sources of Strength; Strategies and Tools Embrace Prevention with Upstream Programs (STEP UP)]. Furthermore, the SAMHSA (2017) NREPP outlines resources for dissemination and implementation, enhancing states’ ability to adopt standardized evidence-based training approaches.

Additional SAMHSA NREPP Contextual Information

SAMHSA’s NREPP includes 22 suicide prevention programs; 17 are “Legacy Programs” (i.e., reviewed before September 2015), and five are “Newly Reviewed Programs” (i.e., reviewed after September 2015 using updated criteria; SAMHSA 2017). “Newly Reviewed Program” profiles differ slightly from “Legacy Program” profiles. “Legacy Programs” contain descriptive program information, quality of research information, quality of research ratings based on program outcomes, readiness for dissemination information, program costs, program replications, and program contacts (SAMHSA 2017). “Newly Reviewed Programs” contain program descriptions, evaluation of findings by outcome, study evaluation methodology, studies reviewed with supplemental and cited documents, detailed resources for dissemination and implementation information, program costs, and program contacts (SAMHSA 2017). One important difference between “Legacy” and “Newly” reviewed program profiles involves evidence ratings by outcome. Specifically, “Legacy Programs” contain quality of research ratings, which are based on a scale ranging from 0.0 to 4.0; whereas, “Newly Reviewed Programs” provide evidence ratings by outcome, identifying programs as having “effective outcomes”, “promising outcomes”, “ineffective outcomes”, or “inconclusive outcomes” (SAMHSA 2017).

SAMHSA NREPP Program Descriptions, Program Evidence, and Quality of Research Ratings

SAMHSA NREPP programs, and select studies evaluating these interventions, have been independently and rigorously evaluated (SAMHSA 2017). The NREPP includes Section I suicide prevention programs, which indicates these programs have produced at least one positive outcome related to suicide prevention during research (SAMHSA 2017). NREPP ratings reflect the strength of the conceptual framework, intervention effects on individual outcomes, ability of the intervention to achieve stated goals, degree to which implementation occurred as designed, quality of research examining the intervention, and resources available for dissemination and implementation (SAMHSA 2017). In studies containing school personnel samples in particular, evidence exists to support use of NREPP programs.

SAMHSA NREPP School Personnel Programs

Applied Suicide Intervention Skills Training (ASIST)

Training goals include helping gatekeepers develop suicide first aid skills and competencies, while empowering gatekeepers to assume a formal helping role in the creation of a safeplan, to increase the immediate safety of persons at risk of suicide (SAMHSA 2017). ASIST consists of five progressive components in which gatekeepers build comfort and understanding around suicide, suicide risk assessment, and suicide intervention (SAMHSA 2017).

Compared to pre-training, training significantly improved gatekeeper attitudes and self-efficacy (n = 126, Coleman and Del Quest 2015), gatekeepers reported significant increases in identification of at-risk youth (n = 434, Ewell Foster et al. 2016), gatekeepers were significantly more likely to ask at-risk youth about whether they were considering suicide (Coleman and Del Quest 2015; Ewell Foster et al. 2016), and gatekeepers experienced significant improvement in helping behaviors (i.e., asking about suicidal ideation and active listening; Ewell Foster et al. 2016). Gatekeeper preparedness was maintained at 6- (Coleman and Del Quest 2015) and 9-months (Ewell Foster et al. 2016), and the number of at-risk youth referred to treatment increased significantly from pre-test to 6- to 9-month follow-up (Ewell Foster et al. 2016).

ASIST is one of the five “Newly Reviewed” NREPP programs, having been identified by SAMHSA as a program with “promising outcomes” for increasing personal resilience and self-concept (Gould et al. 2013; SAMHSA 2017).

Kognito At-Risk for High School Educators

Training aims to prepare high school personnel gatekeepers to identify, approach, and refer students exhibiting signs of psychological distress to support services (SAMHSA 2017). Program goals include building knowledge, skills, and confidence, while also aiming to reduce stigma around mental disorders, and increasing protective factors by improving social connectedness (SAMHSA 2017).

Training significantly increased preparedness to recognize, approach, and refer distressed students; significantly increased the likelihood of approaching and referring students exhibiting psychological distress; and significantly increased confidence in one’s ability to help suicidal students accept help, compared to controls (n = unknown, Albright et al. 2011a, b, 2013; n = unknown; n = 216; n = 303, OSPF 2013; SAMHSA 2017). At 3-months, teachers reported a 71% increase in approaching at-risk students (Albright et al. 2013).

SAMHSA overall quality of research ratings were as follows: preparedness to recognize, approach, and refer students exhibiting signs of psychological distress 2.8/4.0; likelihood of approaching and referring students exhibiting signs of psychological distress 2.8/4.0; and, confidence in one’s ability to help suicidal students exhibiting signs of psychological distress 2.8/4.0 (Albright et al. 2011a, b; SAMHSA 2017).

Mental Health First Aid

Training aims to improve gatekeeper knowledge, while modifying gatekeeper attitudes and perceptions about mental disorders and related issues, including how to respond to individuals experiencing acute mental health crises and how to respond to individuals in the early stages of chronic mental health problems (SAMHSA 2017). Gatekeepers are taught to follow a five-step action plan when providing Mental Health First Aid to an individual in crisis (SAMHSA 2017).

Training significantly increased gatekeeper recognition of mental illness, significantly improved beliefs regarding treatment effectiveness so gatekeeper beliefs more closely mirrored mental health professional beliefs about treatment approaches, significantly reduced aspects of personal and perceived stigma, significantly improved intentions toward helping others, and significantly increased confidence in providing help, compared to controls (n = 327, Jorm et al. 2010) and compared to pre-test (n = 210, Kitchener and Jorm 2002; n = 458; Morawska et al. 2013). Further, teacher training provided indirect benefits to students, and students reported receiving significantly more mental health information from school personnel, compared to students with untrained teachers (Jorm et al. 2010). Significant gains in gatekeeper knowledge, beliefs about treatment effectiveness, and confidence in helping individuals with a mental health problem were maintained at 6-month follow-up (Jorm et al. 2010; Kitchener and Jorm 2002; Morawska et al. 2013).

SAMHSA overall quality of research ratings were as follows: recognition of schizophrenia and depression symptoms 2.7/4.0; knowledge of mental health support and treatment resources 2.6/4.0; attitudes about social distance from individuals with mental health problems 3.1/4.0; confidence in providing help, and provision of help, to an individual with mental health problems 2.3/4.0; and, mental health 3.3/4.0 (Kitchener and Jorm 2002, 2004; Jorm et al. 2004; SAMHSA 2017).

Question, Persuade, Refer (QPR) Gatekeeper Training for Suicide Prevention

Training goals include teaching gatekeepers the epidemiology of suicide, misconceptions about suicide prevention, the warning signs of a suicide crisis, and how to respond by leveraging three target gatekeeper skills—Question the individual’s desire or intent regarding suicide, Persuade the individual to seek and accept help, and Refer the individual to appropriate support resources (SAMHSA 2017).

Training significantly increased self-perceived knowledge and self-efficacy (n = 3,958, Cerel et al. 2012; n = 126; Coleman and Del Quest 2015; n = 170; Cross et al. 2011; n = 36; Johnson and Parsons 2012; n = 630; Keller et al. 2009; n = 238; Reis and Cornell 2008; n = 106; Tompkins et al. 2009, 2010; n = 106; n = 249; Wyman et al. 2008); significantly increased declarative knowledge (Cross et al. 2011; Johnson and Parsons 2012; Reis and Cornell 2008; Tompkins et al. 2009, 2010), knowledge of access to services (Johnson and Parsons 2012; Wyman et al. 2008), asking students about suicide (Coleman and Del Quest 2015; Cross et al. 2011; Johnson and Parsons 2012; Reis and Cornell 2008; Tompkins et al. 2009, 2010; Wyman et al. 2008), and self-reported referrals of students by school personnel (Coleman and Del Quest 2015; Cross et al. 2011; Reis and Cornell 2008).

SAMHSA overall quality of research ratings were as follows: knowledge about suicide 2.6/4.0; gatekeeper self-efficacy 2.6/4.0; knowledge of suicide prevention resources 2.9/4.0; gatekeeper skills 2.8/4.0; and, diffusion of gatekeeper training information 2.5/4.0 (Cross et al. 2011; Matthieu et al. 2008; SAMHSA 2017; Wyman et al. 2008).

SAMHSA NREPP Blended School Personnel/Student Programs

American Indian/Zuni Life Skills Development

The school-based suicide prevention curriculum aims to reduce suicide risk and improve protective factors among American Indian adolescents (SAMHSA 2017). The curriculum includes 28–56 lesson plans and is team-taught by school teachers working in conjunction with community resource leaders and representatives of local social services agencies, with students participating in lessons three times per week during the school year (SAMHSA 2017).

Students reported non-significant reductions in suicide probability, reported significantly less hopelessness, reported significantly greater anger management abilities, and demonstrated significantly greater levels of suicide intervention skills, compared to control students (n = 128, LaFromboise and Howard-Pitney 1995).

SAMHSA overall quality of research ratings were as follows: hopelessness 2.8/4.0; and, suicide prevention skills 2.3/4.0 (LaFromboise and Howard-Pitney 1995; SAMHSA 2017).

Lifelines Curriculum

The schoolwide suicide prevention program establishes administrative guidelines and procedures for responding to at-risk students, provides school personnel suicide prevention training, includes informational materials and a workshop for parents, and finally, includes curriculum for students that is taught by health teachers or school guidance counselors (SAMHSA 2017). Program goals include increasing identification of at-risk youth, ability to provide an appropriate intial response, and ability to obtain help for at-risk youth (SAMHSA 2017).

Students experienced significant increases in knowledge about suicide, positive attitudes toward talking about suicide, positive attitudes toward suicide intervention, positive attitudes toward obtaining help for troubled peers, and positive attitudes toward seeking adult help, compared to controls (n = 86, Haines 2007; n = 253; Kalafat and Elias 1994; n = unknown; Kalafat et al. 2007; SAMHSA 2017).

SAMHSA overall quality of research ratings were as follows: knowledge about suicide 2.9/4.0; attitudes about suicide and suicide intervention 2.9/4.0; attitudes about seeking adult help 2.0/4.0; and, attitudes about keeping a friend’s suicide thoughts a secret 2.9/4.0 (Kalafat et al. 2007; SAMHSA 2017).

Linking Education and Awareness of Depression and Suicide (LEADS) for Youth

The student curriculum aims to increase knowledge of depression and suicide, modify perceptions of depression and suicide, increase knowledge of suicide prevention resources, and improve intentions to engage in help seeking (SAMHSA 2017). School teachers implement the curriculum for 1 h per day, over a 3-day period, with in-school activities being supplemented by activities and homework completed outside of school (SAMHSA 2017).

At 3-months, students had significant increases in knowledge and perceptions of depression and suicide, and knowledge of suicide prevention resources, compared to controls (n = 730, Leite et al. 2011; SAMHSA 2017).

SAMHSA overall quality of research ratings were as follows: knowledge of depression and suicide 1.8/4.0; perceptions of depression and suicide 1.8/4.0; and, knowledge of suicide prevention resources 1.8/4.0 (Leite et al. 2011; SAMHSA 2017).

Model Adolescent Suicide Prevention Program (MASPP)

The program, originally developed for American Indian adolescents/emerging adults, aims to reduce the incidence of adolescent suicide attempts and suicide through education about suicide and related behavioral issues (SAMHSA 2017). As a community-wide initiative, the program includes school-based suicide prevention curriculum, community education, enhanced screening and clinical services, and extensive outreach provided through schools, social services programs, community events, and health clinics (SAMHSA 2017). Further, volunteers of various ages are recruited to serve as natural helpers/gatekeepers, and these individuals engage in personal and program advocacy (SAMHSA 2017).

After program implementation, there were steep, significant declines in suicidal gestures (i.e., behaviors that are not physically life-threatening, but require intervention because of self-destructive intent) over time, and suicide attempts (i.e., life-threatening, self-inflicted injuries that would result in death without medical intervention) also declined significantly over time (n = unknown number of individuals from one of the Athabaskan tribes residing in New Mexico; May et al. 2005). However, rates of death by suicide remained unaffected (May et al. 2005). Young adults aged 19–24 years experienced the greatest significant declines in combined suicide gestures and attempts, however, frequency of suicide gestures and attempts also declined significantly among youth aged 11–18 years (May et al. 2005). Finally, rates of self-destructive behaviors showed significant effects, and the frequency of total self-destructive acts declined 73% over the course of the entire program (May et al. 2005).

SAMHSA overall quality of research ratings were as follows: suicide attempts 2.0/4.0; and, suicide gestures 2.0/4.0 (May et al. 2005; SAMHSA 2017).

Peer Assistance and Leadership (PAL)

The peer helping program aims to build resiliency in youth, by pairing youth with peer helpers, who receive training and support from teachers participating in the program (SAMHSA 2017). Mentees are referred to the program if declining school performance, personal, or other problems and risk factors are present, and the mentee is assigned to a peer helper for peer-based assistance and mentorship (SAMHSA 2017). School teachers recruit, train, monitor, and evaluate the performance of peer helpers to ensure their mentees receive adequate support (SAMHSA 2017).

The PAL program addresses suicide risk factors more broadly, and after program implementation, students’ academic performance improved significantly, both PAL peer helpers and PAL mentees experienced significant decreases in school absences, and both PAL peer helpers and PAL mentees had significantly fewer discipline referrals, compared to pre-program (n = unknown; PAL Services 2000; SAMHSA 2017). Further, in the semester following PAL participation, PAL peer helpers reported significantly greater increases in perceptions of being important in school projects, praise received from their teachers for hard work, communication with their mothers, appropriate responses in dealing with peers, and perceptions that the school had positive communication with their parents (n = unknown; Landry 2005; SAMHSA 2017).

SAMHSA overall quality of research ratings were as follows: academic performance 2.0/4.0; classroom attendance 2.0/4.0; classroom behavior 2.0/4.0; and, relationships with family, peers, and school 2.3/4.0 (PAL Services 2000; Landry 2005; SAMHSA 2017).

Reconnecting Youth (RY): A Peer Group Approach to Building Life Skills

The school-based prevention program for students aims to build resiliency against risk factors and control early signs of substance abuse and emotional distress (SAMHSA 2017). Youth with poor school achievement and other risk factors are identified and referred to the program by school personnel (SAMHSA 2017). At-risk youth participate in group social support and bonding activities, which also includes parental involvement and a course curriculum taught by school personnel or partnering agencies (SAMHSA 2017).

The Reconnecting Youth A Peer Group Approach to Building Life Skills program also addresses suicide risk factors more broadly, and after program implementation, grade point averages and earned credits increased significantly (n = 264, Eggert et al. 1990, 1994; n = 259); self-esteem, perceived social support, and school bonding increased significantly (n = 105, Eggert et al. 1995, 1994), and school absenteeism decreased significantly (Eggert et al. 1990), compared to controls. Further, degree of drug use, drug involvement, and resultant adverse drug use consequences declined significantly from pre- to post- program implementation (Eggert et al. 1990), and drug involvement reductions were maintained at 10 months (n = 124, Eggert and Herting 1991; Eggert et al. 1994). Teacher social support independently and directly decreased student drug use (Eggert and Herting 1991), and teacher support also significantly improved peer group support (n = 106, Thompson et al. 2000). Finally, depression, hopelessness, perceived stress and anger declined significantly after participating in the program, and were maintained at 5 months (Eggert et al. 1995).

SAMHSA overall quality of research ratings were as follows: school performance 3.3/4.0; drug involvement 3.2/4.0; mental health risk and protective factors 3.3/4.0; and, suicide risk factors 3.3/4.0 (Eggert and Herting 1991; Eggert et al. 1990, 1994, 1995; SAMHSA 2017; Thompson et al. 2000).

Signs of Suicide (SOS) Middle and High School Prevention Programs

The school-based program aims to raise awareness of depression and suicide, and also includes a screen for depression and suicidal behavior, with the goal that students will recognize warning signs both in themselves and their peers (SAMHSA 2017). Program goals include decreasing suicide and suicide attempts by increasing knowledge and adaptive attitudes, encouraging personal and peer help seeking, reducing the stigma of mental illness, engaging parents and school personnel as partners in prevention through gatekeeper education, and encouraging schools to develop community partnerships to further support student mental health (SAMHSA 2017).

Students were 40% (n = 2100, Aseltine and DeMartino 2004; n = 4133; Aseltine et al. 2007) to 64% (n = 1046, Schilling et al. 2016) less likely to report a suicide attempt in the 3 months following intervention, compared to controls. Intervention students with pre-program suicidal ideation were 96% less likely to report suicidal behavior in the 3 months following intervention, compared to control students with pre-program ideation (n = 386, Schilling et al. 2014). Intervention students with suicide attempt history were 75% less likely to report suicidal planning in the 3 months following intervention, compared to control students with suicide attempt history (Schilling et al. 2016). Students experienced significantly greater knowledge of and more adaptive attitudes toward depression and suicide, compared to controls (Aseltine and DeMartino 2004; Aseltine et al. 2007; Schilling et al. 2016).

Compared to baseline, 30 days post-implementation, there were 60% increases in personal help seeking for depression and suicidal ideation (n = 92 schools, Aseltine 2003). Compared to baseline, there were no increases in personal help seeking among intervention and control students at 3 months (Aseltine and DeMartino 2004; Aseltine et al. 2007). Compared to baseline, 30 days post-implementation, there were non-significant increases in seeking help on behalf of troubled friends (Aseltine 2003). Compared to baseline, there were no increases in helping troubled friends at 3 months, among intervention and control students (Aseltine and DeMartino 2004; Aseltine et al. 2007).

Signs of Suicide is one of the five “Newly Reviewed” NREPP programs, having been identified by SAMHSA as a program with “promising outcomes” for suicidal thoughts and behaviors, as well as knowledge, attitudes, and beliefs about mental health (Aseltine et al. 2007; Schilling et al. 2014, 2016; SAMHSA 2017). However, the remaining two program outcomes, receipt of mental health and/or substance use treatment and social competence were identified by SAMHSA as having “ineffective outcomes” (Aseltine et al. 2007; Schilling et al. 2014, 2016; SAMHSA 2017).

Sources of Strength

The program aims to build socioecological protective influences among youth to reduce the likelihood that vulnerable students become suicidal (SAMHSA 2017). Students are trained as peer leaders, and student leaders connect with trained adult advisors at school and in the community (SAMHSA 2017). With support from advisors, peer leaders conduct well-defined messaging activities with the goals of changing peer group norms and influencing coping practices and problem behaviors (SAMHSA 2017).

Compared to untrained peer leaders, trained peer leaders reported significantly more positive expectations that adults at school should help suicidal peers, and peers should obtain adult help for suicidal friends despite peer requests for secrecy (n = 706, Petrova et al. 2015; n = 2675; Wyman et al. 2010). Compared to controls, help seeking norms and the number of identified trusted adults increased significantly (Petrova et al. 2015; Wyman et al. 2010), in addition to greater use of coping resources (Wyman et al. 2010). Trained peer leaders were significantly more engaged in school, increasing peer support, compared to untrained peer leaders (Wyman et al. 2010). Among students, perceptions of adult support for suicidal persons and acceptability of seeking help increased significantly, compared to controls (Petrova et al. 2015; Wyman et al. 2010). Students with past year suicidal ideation, relative to non-suicidal students, had greater perceptions of adult help (Petrova et al. 2015; Wyman et al. 2010), help-seeking acceptability, coping, and relationships with engaged adults (Petrova et al. 2015). Finally, trained peer leaders in metropolitan schools were 4-times more likely than untrained peer leaders to refer suicidal friends to engaged adults; referrals did not increase among trained peer leaders in smaller schools (Wyman et al. 2010).

SAMHSA overall quality of research ratings were as follows: attitudes about seeking adult help for distress 3.1/4.0; knowledge of adult help for suicidal youth 3.1/4.0; rejection of codes of silence 3.1/4.0; referrals for distressed peers 3.0/4.0; and, maladaptive coping attitudes 2.8/4.0 (SAMHSA 2017; Wyman et al. 2010).

Strategies and Tools Embrace Prevention with Upstream Programs (STEP UP)

The student curriculum includes social and emotional learning activities, and also incorporates skills of metacognition and mindfulness, with the goals of promoting positive mental health, building emotional competence, emphasizing the use of positive behavioral intentions and supports, and creating a safe school climate (SAMHSA 2017). Eight key concepts and skill sets are taught over 16, 25-min lessons and nine additional lessons are completed outside of school to reinforce program skills (SAMHSA 2017).

Training resulted in significant gains in teacher-rated social and emotional learning (i.e., self-regulation, social competence, and responsibility), compared to control students (n = 59, Fuller et al. 2015).

STEP UP is one of the five “Newly Reviewed” NREPP programs, having been identified by SAMHSA as a program with “effective outcomes” for self-regulation and social competence (Fuller et al. 2015; SAMHSA 2017).

Application of Skills

Application of skills is also a characteristics that may be important to consider in establishing standardized approaches and optimal implementation, as it pertains to suicide prevention training among school personnel. As outlined above, empirical research indicates several suicide prevention-training programs improve school personnel knowledge, efficacy, confidence, and preparedness, making adoption of evidence-based approaches an important consideration; however, it is also important to identify how best to encourage school personnel to apply this knowledge and training. States should fund evaluation and research around suicide prevention training initiatives, not only to track program impact, but also to improve knowledge in the field with respect to the application of skills among school personnel. States do not typically require evaluation of trainees’ application of skills that may occur as a result of training, which represents another significant missed opportunity and additional priority.

Exploring how best to empower school personnel to apply learned skills is a necessary consideration, because the most effective training curriculum will have little impact if school personnel are unable to translate learned skills into planned and purposeful prevention behaviors. Additional research initiatives evaluating application of skills is an important measure, with each consideration building on the previous. Implementing evidence-based adjustments to training duration, training frequency, and training content will have negligible effects if school personnel are unable to proactively apply learned skills.

Inclusion of Technology

Including technology may also be a characteristics that is important to consider in establishing standardized approaches and optimal implementation, in regards to suicide prevention training among school personnel. Leveraging technology may enhance the feasibility of aforementioned training evaluation processes and ensure that states have increased access to cost-effective resources to facilitate training on a large scale. The impact of sustainable technology-based resources as adjuncts or full drivers of these programs should also be researched. Technology could address training duration considerations feasibly, as technology permits convenient, self-paced and flexible learning experiences. Further, school personnel could complete the training when it fit their unique schedule, allowing trainees to remain focused and on-task. Technology certainly would address training frequency considerations, as training would be accessible virtually anytime and anywhere. School personnel could easily access the training as frequently as desired, or as frequently as mandated. Additionally, because technology increases the availability of resources and access to training content, school personnel would have access to additional depression awareness curriculum and other prevention programs that could supplement existing training. Researching utilization of technology to supplement or drive existing training may allow the feasible expansion of prevention training content. Further, it is likely more feasible to standardize a technology based program, and easier to provide high fidelity and optimal implementation, which would promote a more unified training standard. Therefore, inclusion of technology in particular may be one of the more important considerations in achieving optimal implementation of standardized approaches, which is a priority outlined by the National Research Prioritization Task Force and also described in the Prioritized Research Agenda (NAASP 2014).

More specifically, use of technology aligns with national goals (objective 5b; objective 7.1; crosscutting themes; NAASP 2014), in part, because technology provides opportunities to promote program standardization, optimal implementation, and standardized evaluation. Further, technology provides opportunities to increase reach (i.e., promote scalability) while controlling costs (i.e., maintain sustainability). Accordingly, several evidence-based suicide prevention programs for school personnel/students included in SAMHSA’s (2017) NREPP leverage technology for optimal sustainability and scalability [i.e., Kognito At-Risk for High School Educators; Linking Education and Awareness of Depression and Suicide (LEADS) for Youth; Lifelines Curriculum; Signs of Suicide (SOS); Sources of Strength; Strategies and Tools Embrace Prevention with Upstream Programs (STEP UP); Question, Persuade, Refer (QPR)].

In addition to leveraging technology to address previous considerations relating to training duration, training frequency, and training content, application of learned skills may also be greater with inclusion of technology, as school personnel can review training content as frequently as needed, referencing helpful reminders and prevention content. Further, with greater access to prevention resources, school personnel may increasingly connect to resources and other individuals through technology platforms, improving confidence and ability to act, while simultaneously promoting a strong prevention community. Additionally, technology may be an independent factor and important consideration when encouraging the five states without current legislation to implement suicide prevention training standards for school personnel as well, given the cost-effectiveness, feasibility, practicality, and accessibility technology-based training uniquely provides.

Further, Table 1 and the resulting statistical analysis reinforced that rural areas may benefit from targeted outreach, given the elevated rates of youth suicide identified in rural areas. Because rural areas in particular are potentially isolated from traditional suicide prevention training resources, leveraging technology is a practical and efficient way to reach school personnel in rural locations. Technology would also connect rural school personnel to one another and to additional resources. Several school personnel training programs included in the SAMHSA (2017) NREPP utilize technology, and these technology-oriented programs provide feasible and cost-effective opportunities to reach and train rural school personnel. Moreover, several blended student/school personnel programs included the SAMHSA (2017) NREPP also leverage technology, providing additional opportunities to include students in these rural areas as well, helping students simultaneously build peer support where connections may otherwise be limited due to physical distance.

Additionally, Table 1 and the resulting statistical analysis also indicated that less populated states experience the highest rates of youth suicide, and that these states lose a significantly higher percentage of their youth population to suicide per year when compared to more populated states. Therefore, less populated states would likely additionally benefit from targeted outreach. Because smaller states often have greater budgetary costraints than larger states, and may have more overall resource constraints, leveraging technology would increase opportunities to provide cost-effective training. Technology would increase reach and improve accessability to training and resources, while decreasing costs to maximize available financial resources. Moderating the higher rates of youth suicide in less populated states and rural areas requires innovative prevention activities, and technology can act as an adjunct or full driver of prevention initiatives in small states and rural areas especially, to maximize impact and reach while controlling costs.

Conclusion

Suicide prevention training for school personnel is a public policy priority (AFSP 2016; NAASP 2014) given the frequent interactions between school personnel and adolescents, as well as the need for collaborative approaches to suicide prevention (CDC 2015c; NAASP 2014). However, because existing state training mandates are highly variable and do not currently correspond with reduced rates of youth suicide by state, reviewing both policy and program evaluation initiatives is timely and relevant. Because policies should encourage states to adopt evidence-based approaches, evaluation of current training duration recommendations, training frequency recommendations, training content, application of skills, and technology-oriented programs are important considerations that should be prioritized. Currently, clear guidance addressing the impact of state-level policies is limited due to the lack of standard implementation and evaluation that occurs for these programs. This is a significant missed opportunity. Dissemination and implementation of existing evidence-based programs is also an important consideration, and there is opportunity to build the SAMHSA NREPP evidence base as well. Additional evaluation and research would promote a research-defined training standard, while also increasing the availability and visibility of evidence-based training approaches. Policy amendments should then reflect the latest research, increasing the ability of states to mandate effective evidence-based training requirements for school personnel.

Notes

Author contributions

All authors were responsible for the conception and direction of the article. EK created the first draft of the article, and KJR and TS provided substantive feedback on subsequent drafts. After several iterations where all authors contributed, all authors approved the final version of the article.

Compliance with Ethical Standards

Funding

There were no forms of financial support, funding, or involvement. There are no conflicts of interest.

Conflict of interest

The authors report no conflicts of interest.

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Copyright information

© Springer International Publishing 2017

Authors and Affiliations

  • Elizabeth Kreuze
    • 1
  • Tracy Stecker
    • 1
  • Kenneth J. Ruggiero
    • 1
    • 2
  1. 1.College of NursingMedical University of South CarolinaCharlestonUSA
  2. 2.Ralph H. Johnson VA Medical CenterCharlestonUSA

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