Mental health screening goes to school

Sarah Zephirin is one of four care coordinators at a public school district in Hillsboro, Ore., a Portland suburb, with more than 19,000 students. As a mental health professional, Zephirin is one of the adults trained to conduct a suicide screener when a student shows signs of being suicidal. As of mid-March, 282 Hillsboro students this year have said they have thought about suicide, according to Zephirin. Twenty-nine percent of these students are in elementary grades, which at Hillsboro includes sixth grade.

“I think there used to be a perception that we didn’t have to think about suicide prevention in elementary school,” Zephirin said. “We know just from recent data around mental health concerns, that’s not true: We are seeing warning signs in kids younger and younger.”

Suicides among U.S. children and teens have steadily increased over the past two decades. According to government data from 2020, suicide is now the second leading cause of death for children ages 10-14, and the 10th leading cause for children ages 5-9. In 2020, the latest year with available data, 20 children in the 5-9 age range died by suicide — up from 12 or fewer such suicides each year from 1999 to 2019.

Some evidence suggests the COVID-19 pandemic may have made things worse. A Centers for Disease Control and Prevention report last summer found that emergency room visits for suspected suicide attempts among adolescents ages 12 to 17 began to increase in May 2020, soon after coronavirus lockdowns and social distancing restrictions began. During a one-month period that ended March 20, 2021, suicide attempt–linked ER visits for girls were 51 percent higher than during the same period in 2019.

With these recent trends, some states are taking action to prevent suicides among youth. In some cases, they are requiring schools to train teachers on warning signs of suicide, to develop mental health plans that include suicide risk evaluation, or to include suicide hotline numbers on student IDs. Experts insist the growth of the problems shows that even the youngest students need trusted adults, including school staff, to broach the topic of suicide, even if the discussion looks different for different grade levels.

In 2020 and 2021, nine states passed legislation requiring suicide hotline numbers on student ID cards. Some of these states also instituted other prevention measures: Arizona law now mandates suicide awareness and prevention training for school employees, while Wisconsin lawmakers directed state education officials to implement a grant for high school peer-to-peer suicide prevention programs. Some state laws, notably in California, Oregon, and Illinois, require safety plans specifically addressing student groups that may experience higher suicide risk, including those who have lost a friend or family member to suicide, homeless or foster students, students with disabilities or mental health disorders, and students who identify as LGBT. According to the American Foundation for Suicide Prevention, over half of U.S. states require some form of suicide prevention training for school personnel.

Before 2018 at Hillsboro School District, Zephirin said about 175 students per year who were screened for suicidal thoughts confirmed they had thought about suicide. In the 2018-2019 school year, 396 students said they’d done so. In the 2020-2021 school year, the number dropped considerably, though Zephirin said that’s likely because students learned virtually instead of in school with teachers present for much of that year.

In 2019, Oregon lawmakers passed Adi’s Act, requiring districts to have a suicide prevention plan in writing. Zephirin said Hillsboro already trained teachers on warning signs for suicide, and it already provided direct lessons about suicide to middle and high school students. But since the passage of the new law, named after a transgender-identifying teen who died by suicide in 2017, the school has also implemented direct lessons for sixth graders on suicide prevention and increased the lessons for higher grades.

Zephirin said that for younger students, major behavioral changes are one of the biggest warning signs. But in some cases, young children do explicitly talk about not wanting to live. When Zephirin or another trained adult conduct a suicide screener, they directly ask the student whether he or she has thought about suicide. “I’d rather ask and be wrong, than not ask and it’s there, and I missed it,” Zephirin said. If the student says yes, they probe further about means and access to means.

For the youngest students, the prevention conversation is different. “We’re not going into a kindergarten class and teaching them specifically about what to do if someone tells you they want to die,” Zephirin said. “But we are teaching things about, like, if someone’s not safe, what do you do?” By fourth to sixth grade, Zephirin said more direct conversations are needed, and students often already have exposure to ideas about suicide through social media. For a struggling child, she said, having an adult asking directly about suicide can show him there are people ready to help him work through his difficulties.

“I think suicide can still for people be this scary, taboo subject,” Zephirin said. “But wow, to have somebody ask me that question … and let me know that it’s OK, and we’re gonna figure it out and that there’s help and I don’t have to feel this way.”

April Bordeau is the director of Care to Change, a faith-based counseling center in the Indianapolis area that receives weekly school referrals for suicide risk screenings. “We get 6-year-olds, 8-year-olds, 10-year-olds,” she said. She points to child depression, increased access to social media (with exposure to bullying or stories about suicide), higher numbers of suicides among adults, and pandemic isolation as potential reasons for the increase.

As a Christian, Bordeau worries that Christian schools are less likely to seek outside help for students struggling with thoughts of suicide. She wants to see more people trained in how to recognize signs of suicidal ideation and respond to someone who may need help: “The church is in a position to offer hope. So I feel like it’s our responsibility as Christ-followers to do something about this issue.”

—If you or someone you love is struggling with suicidal thoughts, call the National Suicide ­Prevention Lifeline at 1-800-273-8255, or text RemedyLIVE at 494949.