Suicide: Many Schools Fall Short on Prevention
All schools conduct fire drills, and many have detailed plans for coping with floods, hurricanes, or earthquakes. They employ nurses to vaccinate students against diseases. These days, some even practice for the one-in-a-million chance that an armed intruder will go on a shooting spree.
But most schools are unprepared to deal with a far more common threat to their students: Suicide is the third-leading killer of 10- to 19-year-olds in the United States, yet only one in 10 schools has a plan to prevent it.
Most schools that teach suicide prevention generally opt for quick units in health class or school assemblies. Typically, they show videos of healthy-looking adolescents who have survived a suicide attempt. But psychologists warn that such an approach can do more harm than good.
Whether owing to a lack of financial resources or to ignorance or denial of the problem, few schools are tackling suicide prevention in a comprehensive way that research suggests can save lives and help school districts avoid legal liability.
And there are lives to be saved. Youth suicide rates have tripled in the past 30 years, reaching an all-time high of 2,700 fatalities in 1997. On average, one out of every three districts loses a student to suicide each year—sometimes on their own campuses.
Last May, a 14-year-old girl hanged herself in the restroom of her New York City middle school. In March of last year, the 17-year-old captain of the football team in a small Connecticut town doused his body with gasoline and ignited himself on the practice field.
"It usually takes multiple deaths on school grounds to grab administrators' attention," said Scott Poland, the psychological-services director for the Cypress Fairbanks, Texas, public schools and the author of the book Suicide Intervention in Schools.
Some districts are paying dearly in court, Mr. Poland added. "Educators need to take this seriously," he said.
While the damage awards against school districts in student-suicide cases are up significantly, some district lawyers caution educators against undue alarm. "School districts shouldn't get the wrong impression that they should run around like chickens with their heads cut off and do suicide prevention when they have limited resources," said Land Leslie, who successfully defended the Springfield, Ore., school district in a suicide case last year.
A Family Matter
Many parents, meanwhile, argue that a child's emotional problems are a family matter, and that schools are inappropriate venues to broach the issues of life and death.
"Who are these people that they should assert their views on other people's children?" said Phyllis Schlafly, the president of the Eagle Forum, a conservative family-advocacy group, who calls class discussions of suicide "death education."
"School is for academic purposes, not psychological ones," she said.
Few would argue with the idea that an all-out suicide watch tests the principle of in loco parentis.
When the courts first held that public schools have special duties as stewards of the nation's young people for eight hours a day, they probably didn't envision principals patrolling their buildings to stop Jane from jumping off the roof.
But, then, there wasn't as much roof jumping back then.
The Latin term in loco parentis—literally, "in the place of parents"—was first used by Romans to refer to the Greek slaves whom they employed to tutor their children. So that the Roman children would respect their low-ranked teachers, the Roman masters delegated their parental power temporarily so the Greeks could discipline the pupils in their care.
The U.S. courts, having inherited the doctrine from English law, also applied the concept to help teachers keep students in their seats. Over the years, various courts conferred broad supervisory power on schools to control unruly students, using the doctrine at times to sanction paddling and other corporal punishment.
Along with the power to discipline students came certain responsibilities to protect students from harm. In recent years, the courts have taken this guardianship status further by holding schools liable for negligence if they fail to protect a child who is harassed or sexually abused by another student at school. In the past 20 years, several courts extended the surrogate parental obligation further still, finding that schools have a legal obligation to take "reasonable steps" to protect students from hurting themselves.
Whether a student kills himself in his bedroom or in the school's locker room, the courts are sending a message to schools that they can no longer stand on the sidelines, said Richard Lieberman, a psychologist with the Los Angeles public schools who has testified on behalf of districts.
The number of lawsuits filed against school districts claiming negligence in student suicides has multiplied tenfold in the past 20 years, Mr. Lieberman estimates. For every suicide case that goes to trial, at least 20 are settled out of court, he said. In the past two years especially, national publicity over a spate of school shootings has helped prompt a shower of legal claims against schools.
"Parents are now aware they can sue. Every one of the lawsuits from West Paducah, Kentucky, to Springfield, Oregon, has brought a national awareness that one can litigate against schools for their failure to provide a safe environment for children," Mr. Lieberman said, referring to shooting incidents during the 1997-98 school year.
Many school employees are now buying individual-liability insurance in case their districts' plans don't protect them. "It's sleep insurance," said Doug Kocher, a director of property and casualty at Forrest T. Jones Inc., a Kansas City, Mo., insurance broker that covers more than 150,000 teachers. "They want to have something to fall back on." ("Fearful Teachers Buy Liability Insurance," March 29, 2000.)
While federal law requires schools to report to authorities if they suspect a student is being abused by his or her parents, no state requires schools to notify parents if a student expresses suicidal thoughts.
When schools are found to be liable in a child's suicide, legal experts say, it's generally for negligence: They could have "foreseen the suicidal risk" of the student, or they knew of the student's intent to harm himself and failed to take "responsible" steps to prevent it. Among the cases addressing schools' liability:
- In a watershed case in 1995, a federal district court in Tampa, Fla., found the Polk County school board guilty of negligence in 13-year-old Shawn Wyke's death and awarded his mother $167,000. The day before Shawn's suicide in 1989, another student told the assistant principal that he had discovered Shawn trying to hang himself in the school restroom. But the administrator failed to notify the boy's mother about the incident. The next day, the 5th grader hanged himself from an oak tree in his back yard.(See Wyke v. The Polk County School Board.)
- In January 1997, a student at a Longview, Wash., high school told
her mother that her ex-boyfriend was talking about killing himself
and that he was standing in front of a mirror every night with a gun
to his head. That day, the girlfriend's mother told the school
counselor about Nick Shoff's comments.
But instead of notifying the boy's parents himself, which was the school's policy, or summoning the 15-year-old out of class for a psychological evaluation, the counselor asked the girlfriend's mother to call the Shoffs. She didn't call in time. That night, Nick went home and fatally shot himself. The school district settled out of court with his parents for $690,000, the parent's lawyer said.
- A 1991 case against the Montgomery County, Md., board of education stemmed from junior high school students' telling a counselor that their friend was making suicidal statements. When a counselor questioned Nicole Eisel about those comments, the 13-year-old denied that she was going to hurt herself, and the counselor chose not to notify her parents. A week later, the girl was killed in a murder-suicide pact. A state appeals court found the counselors negligent in their duty to warn the parents, arguing that the counselors should have been able to "foresee" the suicide despite her denials.(See Eisel v. Board of Education of Montgomery County 597 A.2d 447 (Md. 1991))
Whether such legal claims are well-founded or not, such lawsuits often are driven by parents' desire, or need, to assign blame, some experts say.
"Who else are you going to sue? You aren't going to sue yourself for not helping your child. You aren't going to sue your psychiatrist," said Julie Underwood, the general counsel for the National School Boards Association. "Schools can't be protectors of all children."
"A lot of this is misdirected grief," Mr. Lieberman, the psychologist, added. "Parents say Satan did it. Marilyn Manson did it. We simplify it and put it up on the shelf so we can understand it. People have to put that anger somewhere."
It's no simple task to detect a child's suicidal intent. Metal detectors and surveillance cameras may nab gun-toting teenagers, but they don't pick up inner turmoil.
Most U.S. schools—58 percent—discuss suicide prevention in some academic course during the school year, according to a 1995 survey of school health programs published in the Journal of School Health. Those units, which typically last three hours or less, usually include video docudramas of teenagers who survived a suicide attempt, use shocking statistics designed to get students' attention, and provide information on where teenagers should go for help.
Publications now on the market range from mail-order suicide-prevention kits at $6.65 apiece to higher-priced textbooks. To fulfill their suicide-prevention requirement, many schools hire lecturers to speak to large assemblies on the subject. Like the ubiquitous drug-awareness programs in which police officers try to "scare kids straight" with the gritty realities of addiction, many suicide-prevention programs now employ medical experts to deliver a similar jolt of shock therapy.
In his presentations to high school students, Dr. Victor Victoroff, the chairman emeritus of psychiatry at Huron Road Medical Center in Cleveland, shows slides of teenagers who attempt suicide and end up in emergency rooms: a girl who had her stomach pumped, a boy with his face blown off by a gunshot blast, a girl with her wrists carved up. "I'll use any means to cut through the romantic haze. I want them to know suicide is a painful experience," Dr.Victoroff said.
Working Toward Prevention
The general view among mental-health professionals is that talking about suicide can help prevent teenagers from doing it. But there is no evidence that short lectures in classrooms or heavily attended school assemblies, or even visits to the morgue have any measurable effect on preventing teenagers from killing themselves. And some of the approaches may actually aggravate the situation for the most vulnerable students.
In one of the most rigorous evaluations of suicide-prevention programs, Dr. David Shaffer, a professor of psychiatry at Columbia University, found that the most commonly used suicide-awareness programs in schools often did more harm than good.
In his 1987 study, Dr. Shaffer evaluated several widely used programs with 1,000 students in six New Jersey high schools. While there was no evidence that the didactic classroom discussions caused emotional distress among students as a whole, neither did the course alter the disturbing attitudes of those students who said that "in certain situations, suicide was a reasonable solution to one's problems."
Moreover, the study found, those students who were already contemplating suicide were more distressed after being exposed to the lessons. "At any one time in any classroom, there are going to be one in four kids who have thought about suicide," Dr. Shaffer said recently. "Talking about it might stimulate what has been bottled up, and that's not necessarily a good thing."
Such findings have provided support for critics who believe suicide-prevention courses ought to be dropped. "These death-and-dying courses can have dangerous consequences," said Ms. Schlafly of the Alton, Ill.-based Eagle Forum. "Some children may be tripped over the edge."
But schools can drive down the youth-suicide rate if they employ very specific methods, researchers say.
Preliminary findings from a study by University of Washington researchers suggest that students who practice solving difficult dilemmas in their lives though role-playing in group sessions with other students twice a week are less likely to be depressed or to exhibit suicidal behavior than those who do not take part in such programs.
The American Association of Suicidology, a nonprofit organization based in Washington dedicated to understanding and preventing suicide, suggests that one way to curb suicides is to train school personnel from bus drivers to custodians to teachers to recognize certain behavioral clues that a student is at risk:A sustained case of the blues, discarding valuable possessions, emotional volatility, or suicidal statements all hint at trouble.
Teachers might also read student essays for more than their literary value. A 1986 study of students' work in several schools found 500 poems that contained suicidal references but that were returned to students without comment or follow-up.
One of the students, an 11-year-old boy, turned in an essay titled "Suicide Mistake" in which he outlined his own death in detail. That night, he killed himself just as he'd described.
Teachers are often reluctant to talk to their colleagues about students for fear that they will violate a student's privacy rights, Ms. Underwood of the NSBA said: "Students' privacy gets so drilled into their heads, and unfortunately they sometimes get snagged by it."
If teachers detect morbid preoccupations, however, they should be discreet about revealing them, Mr. Poland said. In his book, Mr. Poland cites the case of a Denver teacher who intercepted a note written by a 12-year-old 7th grader and read the personal details about his melancholy state to the class. The boy committed suicide later that day.
Another way to put a dent in the youth-suicide rate is to persuade teenagers to tell adults when they know other students have such intentions, even though it might be seen as tattling.
The unwritten code of silence among students has to be broken, said Clark Flatt, whose youngest son shot himself in 1997. "In 70 percent of all teen suicides, another teen knew about it and did nothing," said Mr. Flatt who, through the Nashville-based Jason Foundation, named for his dead son, trains teenagers to take their friends' morbid musings seriously.
Though no formal research has been done, Mr. Flatt is encouraged by the results so far: Since he launched the Teens Helping Teens program three years ago, Mr. Flatt has received 42 letters from young people who said their friends' "snitching" had saved their lives.
Many experts say the subject is particularly difficult to teach about—even more sensitive than AIDS, sex, or drugs—because talking about suicide has long been considered taboo.
Greeks and Romans condemned suicide as an offense against the state because suicide deprived society of a productive member. Many religious denominations have held that suicide victims are condemned to hell, and have barred their burial in sacred ground and shrouded their memory in shame.
From Stigma to Support
A more compassionate view of suicide victims has emerged in recent years. For example, the Rev. Arnaldo Pangrazzi, a Roman Catholic priest in Italy, expressed the current official Catholic teaching in a 1984 newsletter article: "Churches should teach compassion toward those who take their own lives and judgment should be left to God."
But the overarching taboo remains, U.S. Surgeon General David Satcher said at a suicide-prevention conference in Nashville last fall. In a year in which 30,000 Americans would commit suicide and half a million would attempt it, Dr. Satcher argued that the country should see suicide as a public-health epidemic.
"It's time for us to move from shame and stigma to support," said Dr. Satcher, who is expected to unveil an ambitious plan this spring to increase federal financial support for mental-health services. Because a majority of teenagers who kill themselves suffer some type of diagnosable mental-health problem, Dr. Satcher said, the best way schools can ward off more suicides is to usher troubled children to the nearest mental-health professional. The dip in the teenage-suicide rate in the late 1990s is partly attributable to better screening of children for mental-health problems, some experts say.
In the Nurse's Office
One of the most promising places in this country to thwart a suicide may be the school nurse's office.
In a 10-month University of Washington study in 14 Seattle schools, students who were deemed at risk for dropping out were interviewed in two-hour sessions by a nurse or social worker who asked them a series of questions about their mood and called their parents or a hospital if they expressed suicidal inclinations.
Those who participated in the psychological-interview program were 54 percent less likely to have suicidal thoughts or act on them in the months following the session than those who did not participate, the study found.
The potential for preventing teenage suicide through screenings like those is huge, experts say, simply because of the volume of visitors to a school nurse's office.
Of all the children in the United States who seek mental-health services, half get them at school. But states spend less than 1 percent of their education budgets on mental-health services in schools. With limited funds to hire psychologists and social workers, most schools don't have staff members who are trained to diagnose mental-health conditions.
"You have to know the difference between a joking teen and one who has a knife under their bed or has already counted out the pills," said Leslie Kraft, who runs Columbia University's well-regarded Teen Screen program, in which social workers and nurses are trained to identify teenagers in four New York City high schools in the Bronx who are at risk for suicide. About a quarter of the more than 800 students identified as being at risk were referred for further evaluation last year. "We have kept a lot of these kids alive," Ms. Kraft said.
Experts say that in the best of all possible worlds, children's emotional deficits would be catalogued in kindergarten. Spotlighting and giving early treatment to children with short attention spans, school phobias, or short fuses could greatly reduce problems in later grades, they say.
In addition, advocates of smaller schools and classes say, responding to individual students' needs is harder when buildings and classrooms are packed.
"The larger you get, the harder it gets. You have to have numbers that are reachable," said Stephen Mulligan, a former counselor for the 9,000-student Smithtown, N.Y., public schools, who recently retired after 28 years. "If you have a teacher teaching 150 kids a day, you don't know them as well."
And not every suicide-prevention plan that works cost money: Just knowing how to react after a suicide can help prevent future ones, experts say.
The National Association of School Psychologists suggests that schools take certain steps immediately after a student kills himself: construct a "calling tree" to spread the news to school staff members, alert the parents of the friends of the deceased, assign a counselor to talk to students in his class, call the family to offer assistance, and keep the superintendent informed.
Another important rule is not to glamorize the act by constructing elaborate shrines to the dead. Experts advise that establishing a fund in the student's memory is preferable to even the most modest memorial.
Minimizing exposure to media reports of the tragedy can also reduce the chances of "copycat" suicides, some experts say. In the weeks after last April's highly publicized Columbine High School shootings in Colorado, in which the two assailants turned their guns on themselves after killing 13 others, suicide attempts peaked in several districts nationwide.
The Welcoming School
Schools can play a role in reducing youth suicide simply by making their schools as welcoming as possible, many educators say.
Most school employees may labor to provide happy environments for students, but some observers warn that many schools are places where bullying is rampant, cliques are ruthless, and teachers are too harried to care.
In a survey last year of 558 6th, 7th, and 8th graders at a suburban Indianapolis middle school, researchers from the University of Illinois at Urbana-Champaign found that 80 percent of the students reported they had bullied another classmate in the past 30 days. Children who are repeatedly harassed are more likely to kill themselves, studies have found.
The national push to raise academic standards and hold schools more accountable for their students' performance has also placed new pressures on children, some health educators say. Performing well on new, high-stakes tests can be just as stressful for some students as a verbal assault by the class bully.
"They don't give awards to the mediocre," Mr. Mulligan said.
Gifted students who are competing for slots at top colleges can just as easily be overwhelmed by pressures for them to succeed, said Mr. Lieberman, who points to a Los Angeles high school senior with a 4.0 grade point average who killed himself last fall after he was rejected by the University of California, Los Angeles.
In a survey of teenagers on the reasons why they attempted suicide, school pressures ranked in the top three, along with a romantic split and family problems. "You can't separate out students' emotional report card from their academic report card," said Dr. William Pollack, a professor of psychiatry at the Harvard Medical School and an expert on adolescent health.
Dr. Pollack and others suggest a fairly straightforward solution to improving students' mental health: expressing affection. Studies dating to the 1960s have shown that animals that are deprived of physical affection when they are young tend to exhibit more aggressive and violent behavior later in life.
Tiffany Field, a University of Miami researcher who runs the Touch Institute, applied that theory to the classroom in her study of interactions between teachers and students in France and the United States. Ms. Field found that the French students, whose teachers were more physical with them (whether to show discipline or affection), were better behaved and less aggressive than American students, who had less physical contact with their teachers.
Ms. Field laments reports that many U.S. teachers are reluctant to hug students for fear that their gestures will be misinterpreted as sexual. "We are less touchy-feely because there are more lawyers around," she said, "even though setting limits with affection is the best way to be a teacher or a parent."
Of course, suicide-prevention experts acknowledge, many measures that might reduce the youth suicide rate are out of educators' hands.
Researchers often cite a British study to show that reducing access to deadly means can greatly drive down the rate. In 1957, the carbon monoxide content of domestic cooking gas in Britain was 12 percent, and self-asphyxiation accounted for 40 percent of all suicides there. By 1971, a year after the introduction of natural gas reduced the carbon monoxide levels to 2 percent, asphyxiation accounted for less than 10 percent of suicides, and the overall suicide rate in Britain plummeted by 26 percent.
In the United States, two-thirds of people under 18 who commit suicide use a firearm.
Diagnosis and Treatment
Dr. Thomas Shires, a trauma surgeon and the head of the federally funded Suicide Prevention Research Center, advocates minimizing access to handguns. But he expresses doubt that such measures would make a serious dent in suicide rates. "If they don't do it with guns, they will do it with something else," he said.
What perturbs Dr. Shires most is what he sees as the medical profession's poor record at diagnosing and treating young patients' psychological pain.
Dr. Shires' research found that 70 percent of all people who attempt suicide have seen their family physician within the 30 days before they made the attempt. But many medical doctors are not well-versed in distinguishing between serious emotional distress and evanescent adolescent angst.
Dr. Shires prescribes a multipronged approach to fighting suicide: If physicians were better trained, more students had caring adults in their lives from infancy on, and schools were better prepared to identify and get troubled children the help they needed quickly, the youth-suicide rate would surely plummet, he said.
In light of the societal forces driving children to suicide, Linda Taylor says, schools that take up the challenge have to be warned that they can't save every child.
Ms. Taylor, a counselor at the Los Angeles public schools' well-respected mental-health clinic, tells the story of a rambunctious 10-year-old girl she was treating years ago for attention deficit hyperactivity disorder. One evening, the child's mother told the 5th grader to clean up her room and not to come out until it was clean. The girl hanged herself from a belt in her bedroom closet.
"Everyone was devastated," said Ms. Taylor, who added that though the girl's father had recently died, the family was close and there was no clear sign the child had serious emotional problems. "We felt, my God, what did we miss? How did we not see what was coming?"
Vol. 19, Issue 32, Pages 1,20-22