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Accurate Language and Concepts About SuicideBy changing the way we talk about suicide, we change the way we think of it. In general the language used forany other illness-based death or sudden loss (such as a heart attack or car accident) is a guiding principle.Died of suicide (Also ‘Died by suicide’) - Suicide is death due to brain illnesses. In a suicidal statethought processes become distorted because of biological, psychological, social, cultural and/orsituational reasons. Suicidal people are not thinking clearly. They are in fact struggling with a kind ofillness in their thinking processes. The term “Committed suicide” does not describe accurately what hasoccurred. Committed implies a crime or immoral act. Suicide is no longer seen as a crime or sin but isrecognized to be the result of a mental health condition with a medically treatable cause at least 90% ofthe time. Often a person with lived experience of suicide will say choice was not involved but insteadthey were overwhelmingly “compelled” to attempt to kill themselves.Person with lived experience - A person with the lived experience of suicide has struggled withsuicidal thoughts or behaviors and may be an attempt survivor. Resilience is a skill that can bedeveloped - one is not “permanently fragile” when they are an attempt survivor.Bereaved by suicide - Someone who has been exposed to the suicide of another person andexperiences a high level of psychological, physical and/or social distress for a considerable length oftime. In the U.S. the term “loss survivor” is often used. This loss can cause PTSD, complicated grief orother deleterious physical and mental consequences. Everyone grieves differently and on their owntimeline. Incorporating such a loss into one’s life requires work and support.Fatal or Non-fatal Attempt— Applying the general principle of speaking about suicide using illnessbased language, fatal and non-fatal is language in line with a fatal or non-fatal heart attack or otherillness. It is not advised to add a value statement to suicide such as calling an attempt failed, successful,or botched, etc. Also the term “completed” suicide is not advised. Completing something implies success.Suicide is a complex phenomenon. It does not have to do with an individual’s willpower. There is no simpleexplanation for any suicide. Though an immediate precipitating event may occur, that is not the “reason”someone has died.People often ask what to say to a person who has lost someone to suicide. Generally, it is advised to think ofwhat one would say or do if the person had lost their loved one suddenly in a fatal car crash or a heartattack - then do and say that.vi

KEY TO TOOLKIT ACRONYMSAACIAsian Americans for Community InvolvementACSAdolescent Counseling ServiceAFSPAmerican Foundation for Suicide PreventionARAdministrative RegulationASISTApplied Suicide Intervention Skills TrainingCDCCenters for Disease Control and PreventionCRTCrisis Response TeamERMHSEducationally- Related Mental Health ServicesFERPAFamily Educational Rights and Privacy ActHEARDHealth Care Alliance for Response to Adolescent DepressionHIPAAHealth Insurance Portability and Accountability Act (Privacy and Security Rules)IRPIndividualized Re- Entry PlanLPCH/SMHT Lucile Packard Children’s Hospital/School Mental Health TeamMYSPPMaine Youth Suicide Prevention ProgramNIMHNational Institute of Mental HealthPBISPositive Behavioral Interventions and SupportPSNProject Safety NetPTSDPost Traumatic Stress DisorderQPRQuestion, Persuade, Refer - Gatekeeper TrainingSAMHSASubstance Abuse and Mental Health Services AdministrationSBP or BPSchool Board PolicySPRCSuicide Prevention Resource CenterUFSUplift Family ServicesUSFUniversity of South Floridavii

TABLE OF CONTENTSINTRODUCTION . 1SECTION I: PROMOTION OF MENTAL HEALTH AND WELLNESS . 4A. EDUCATION . .41. STAFF EDUCATION . . 42. STUDENT EDUCATION . . . 43. PARENT/COMMUNITY EDUCATION . . 5MEANS RESTRICTION . . . . 6HEALTHY ADOLESCENT SLEEP . . . . 6B. SAFE AND CARING SCHOOL CLIMATE . . 10CONNECT STUDENTS WITH CARING ADULTS . 10SOCIAL EMOTIONAL LEARNING . . 11MINDFULNESS . 30ATTACHMENTS FOR SECTION I: PROMOTION . .451.1 THE IMPERATIVE OF COMPASSIONATE SELF-CARE 461.2 TRANSITIONING – PRIMARY SCHOOL THROUGH LIFE AFTER HIGH SCHOOL . 511.3 SOCIAL MEDIA . 661.4 CULTURE, MENTAL ILLNESS AND STIGMA . 721.5 SAMPLE SEL ACTIVITIES AND STRATEGIES 801.6 MINDFULNESS AND SCHOOL CLIMATE: ONE EXAMPLE 811.7 TYPES OF STUDENT PROGRAMS INFORMATION SHEET, SAMHSA Toolkit .821.8 GENERAL GUIDELINES FOR TEACHERS AND STAFF, LA County Youth Suicide Prevention Project . 841.9 RISK FACTORS FOR YOUTH SUICIDE, SAMHSA Toolkit . 861.10 PROTECTIVE FACTORS AGAINST YOUTH SUICIDE, SAMHSA Toolkit . 891.11 RECOGNIZING AND RESPONDING TO WARNING SIGNS OF SUICIDE, SAMHSA Toolkit 911.12 RED FOLDER INITIATIVE (for administrators and school staff as well) .921.13a QPR AS A UNIVERSAL INTERVENTION 971.13b QPR GUIDELINES . 1001.14 INCLUDING SUICIDE PREVENTION IN OTHER EFFORTS TO REACH PARENTS, SAMHSA Toolkit 1011.15 IDEAS FOR MAXIMIZING PARENTAL RESPONSE RATE, SAMHSA Toolkit 1021.16 SUICIDE PREVENTION: FACTS FOR PARENTS, SAMHSA Toolkit . 103SECTION II: INTERVENTION IN A SUICIDAL CRISIS . 104A.B.C.D.E.F.CRISIS RESPONSE TEAM (CRT) MEMBERS AND ROLES . . . . 105IDENTIFY AND MONITOR AT-RISK STUDENTS . . . 110LOW RISK LEVEL OF SUICIDE 111MODERATE TO HIGH RISK LEVEL OF SUICIDE . 111EXTREMELY HIGH (IMMINENT) RISK LEVEL OF SUICIDE . 112PROCESS FOR RE-ENTRY TO SCHOOL AFTER EXTENDED ABSENCE OR HOSPITALIZATION . 114ATTACHMENTS FOR SECTION II: INTERVENTION 1152.1 SELF-INJURY AND SUICIDE RISK INFORMATION SHEET, SAMHSA Toolkit . 1162.2 SUICIDE PREVENTION AWARENESS SESSION APPROPRIATE FOR ALL SCHOOL PERSONNEL 1172.3a SUICIDE RISK ASSESSMENT FORM . 1232.3b CONCERN FORM FOR ELEMENTARY LEVEL . 125viii

2.4 CRISIS INTERVENTION PROTOCOL CHECKLIST AND FLOW CHARTS . . 1302.5 GUIDELINES FOR NOTIFYING PARENTS, SAMHSA Toolkit . 1342.6 PARENT CONTACT ACKNOWLEDGEMENT FORM, SAMHSA Toolkit . . 1362.7 GUIDELINES FOR STUDENT REFERRALS, SAMHSA Toolkit . . 1372.8 REFERRAL PROCESS FOR SPECIAL EDUCATION MENTAL HEALTH ASSESSMENT . . 1382.9 REFERRAL, CONSENT, AND FOLLOW-UP FORM . 1392.10 HEALTH AND EDUCATION PLAN – PHYSICIAN REPORT . 1402.11 SAFETY PLANNING GUIDE: A QUICK GUIDE FOR CLINICIANS, WICHE & SPRC . 1412.12 SAMPLE PERSONAL SAFETY PLAN (to be used with attachment 2.11) . . 1432.13 STUDENT SUICIDE RISK DOCUMENTATION FORM, SAMHSA Toolkit . . 1452.14 GUIDELINES FOR FACILITATING A STUDENT’S RETURN TO SCHOOL, SAMHSA Toolkit . 1462.15 GUIDELINES FOR WHEN A STUDENT RETURNS TO SCHOOL FOLLOWING ABSENCE FOR SUICIDAL BEHAVIOR .1482.16 OTHER ISSUES AND OPTIONS SURROUNDING A STUDENT’S RETURN TO SCHOOL, MYSPP 1492.17 CHILD AND ADOLESCENT PSYCHIATRIC HOSPITALS .1512.18 MEANS RESTRICTION . 1522.19 SUICIDE CONTAGION AND CLUSTERS . . 156SECTION III: POSTVENTION RESPONSE TO SUICIDE OF A SCHOOL COMMUNITY MEMBER . . 158A. STEPS TO TAKE IN THE IMMEDIATE AFTERMATH . . . 152B. STEPS TO TAKE IN THE LONG- TERM AFTERMATH . . 162ATTACHMENTS FOR SECTION III: POSTVENTION 1653.1 POSTVENTION PROTOCOL FLOW CHART . 1663.2 SAMPLE POSTVENTION TELEPHONE TREE . 1673.3 GUIDELINES FOR WORKING WITH THE FAMILY, SAMHSA Toolkit . 1683.4 SAMPLE SCRIPT FOR OFFICE STAFF, SAMHSA Toolkit . . 1693.5 GUIDELINES FOR NOTIFYING STAFF, SAMHSA Toolkit . 1703.6 SAMPLE LETTER TO FAMILIES, SAMHSA Toolkit . . 1713.7 SAMPLE DEATH NOTIFICATION STATEMENT FOR PARENTS, AFSP &SPRC Toolkit .1723.8 SAMPLE AGENDA FOR INITIAL ALL-STAFF MEETING, AFSP &SPRC Toolkit . 1753.9 SAMPLE ANNOUNCEMENTS, SAMHSA Toolkit . . 1763.10 TALKING ABOUT SUICIDE, AFSP &SPRC Toolkit . . 1813.11 TALKING POINTS FOR STUDENTS AND STAFF AFTER A SUICIDE, SAMHSA Toolkit . 1833.12 SAMPLE GRIEF DISCUSSION WITH STUDENTS, KARA . . 1843.13 FACTS ABOUT SUICIDE AND MENTAL DISORDERS IN ADOLESCENTS, AFSP &SPRC Toolkit 1853.14 MEMORIALIZATION, AFSP & SPRC Toolkit . . . 1883.15 STUDENT SUICIDE RISK DOCUMENTATION FORM, SAMHSA Toolkit . . . 1933.16 WORKING WITH THE COMMUNITY, AFSP &SPRC Toolkit . . . . . 1943.17 GUIDELINES FOR ANNIVERSARIES OF A DEATH, SAMHSA Toolkit . . . . 1973.18i GUIDELINES FOR WORKING WITH THE MEDIA, SAMHSA Toolkit . . 1983.18ii FRAMEWORK FOR SUCCESSFUL MESSAGING – POSITIVE NARRATIVE . . . 1993.19 MEDIA, AFSP &SPRC Toolkit . . . . .2003.20 SAMPLE MEDIA STATEMENT, AFSP &SPRC Toolkit . . . 2023.21 KEY MESSAGES FOR MEDIA SPOKESPERSON, AFSP & SPRC Toolkit . . . 2043.22 RECOMMENDATIONS FOR REPORTING ON SUICIDE, AFSP . . . 2053.23 AT A GLANCE: SAFE REPORTING ON SUICIDE, SPRC . . . 2073.24 CONTAGION AND CLUSTERS . . . . 2103.25 GRIEF FOR CHILDREN AND TEENS AFTER SUICIDE . . . . 212APPENDIX A: SCHOOL SUICIDE PREVENTION POLICY, LAW & EDUCATIONAL STANDARDS . .215APPENDIX B: STAFF, PARENT AND STUDENT RESOURCES . 222APPENDIX C: KARA GRIEF SUPPORT RESOURCES . . 257BIBLIOGRAPHY . 275ix

INTRODUCTION2017“No matter where we live or what we do every day, each of us has a role in preventing suicide. Our actions canmake a difference.”Regina M. Benjamin, MD, MBA VADM, U.S. Public Health Service Surgeon General2012 National Strategy for Suicide eports/national-strategy-suicide-prevention/full report-rev.pdfThis Toolkit was created in 2013 in response to a need for schools to address student mental and emotionalwellness to prevent suicide and, in particular, how to respond after a suicide loss. California law AB 2246,enacted in 2016, requires that all public schools have a “Pupil Suicide Prevention Policy.” This documenthas been updated to reflect both this need and this policy requirement.The 2013 Toolkit quoted SAMHSA’s 2012 “Preventing Suicide: A Toolkit for High Schools”. It states,“Schools have an essential role to play in preventing suicide and in promoting behavioral health amongAmerica’s young people”. Through the promotion of youth behavioral health, the ability of students to learnand thrive is enhanced. The tools and resources provided in this updated Toolkit are meant to complementwhat schools may already have in place and to help initiate the implementation of a “Pupil SuicidePrevention Policy”.Statistics tell us many things.In California the rate of youth mental health hospitalizations has risen by 50% between 2007 and2015.In 2011-13 nearly one fifth (19%) of California public school students in grades 9 and 11 seriouslyconsidered attempting suicide in the past year.In 2013-14 21% of California youth ages 12-17 reported needing help for emotional or mentalhealth problems (“Hospitalizations for Mental Health Issues”, 2016).Fifty percent of all lifetime cases of mental illness begin by age 14 and seventy five percent by age 24(“Mental Health Facts,” 2014).Suicide is the second leading cause of death for youth and young adults ages 10 to 24 (“Ten LeadingCauses of Death,” 2014).Though data informs about a great deal it does not paint the entire picture. It cannot quantify the grief,anguish, confusion, guilt and devastation felt by the family, friends and community of an adolescent whodies by suicide. It does not inform about the increased risk youth face for PTSD, other mental healthproblems or even their own suicide after the loss of a peer to suicide. It does not reveal the uncomfortablereactions evoked by suicide; the fear, blame, isolation, stigmatization, silence and secrecy that surroundssuicide.Suicide is a major, preventable public health problem. Reducing the number of suicides requires theengagement and commitment of people in many sectors including education. This Toolkit containsinformation schools need to further the goals of emotional health promotion and suicide prevention foryouth. Some actions schools can take include these delineated in Lucile Packard Foundation Kids Data.Setting school policies that foster a positive, supportive environment and promote studentengagement in school, and supporting comprehensive K-12 education for social-emotional learning,including communication skills, problem-solving skills, and stress management1

Ensuring adequate funding and training for a range of school staff to recognize signs of mentaldistress and refer students to services; such training also should focus on how to promote a safe andsupportive environment for all students, including LGBT youth (“Hospitalizations for Mental HealthIssues”, 2016).Tools to accomplish these actions are found in the sections of this document; Promotion of Mental Healthand Wellness, Intervention in a Suicidal Crisis, Postvention Response to Suicide and Appendices. Eachsection is related to the others. None functions entirely on its own. Though one area may apply in aparticular situation all are meant to work together. For instance, when a student is noted to be struggling,actions described in the “Intervention in a Crisis” section may need to be activated and as the student issupported through the crisis mental wellness promotion actions may become more applicable. Or, should astudent death due to suicide occur, students may experience a crisis and part of postvention may involveactions described in the intervention section. All parts are necessary and all function together.The goal of this document is to ensure that schools can participate fully in the broader community effort topromote youth emotional and mental health and prevent youth suicide. It is our intention and hope that thefull participation by schools in student behavioral health promotion will lead to more fulfilling andproductive lives for all their students.Cultural Issues in Mental Health Promotion and Suicide PreventionThe students and families that school personnel and child mental health professionals interact withcomprise an increasingly diverse group with unique needs. The acceptability of children’s mental healthservices is highly influenced by attitudes, beliefs, and practices from their families’ cultures of origin.(Pumariega, et al. 2010a)This Toolkit has been written and compiled under the presumption of multiculturalism, with a broaddefinition of culture that has been chosen, not limited to ethnic or racial makeup, but ratherone that embraces the variable values, attitudes, beliefs, and behaviors shared by a people, and that is oftentransmitted between generations. Multiculturalism assumes that no single “best” way exists toconceptualize human behavior or explain the realities and experiences of diverse cultural groups.Rather, it is more useful to assume that everyone has a unique culture, and that cultural influences arewoven into personality like a tapestry (McDermott, 2002). From this perspective, three of the major tasksfor school professionals include (1) developing a broad knowledge base about cross-cultural variations inchild development and childrearing; (2) integrating this knowledge in a developmentally relevant way tomake more informed assessments and interventions; and (3) developing a culturally sensitive attitude andtherapeutic stance in all interactions with students and their families, including those of the samebackground as the school staff (Pumariega, 2010; Joshi, 2015).For additional resources that may be helpful for specific cultural populations, please see Attachment 1.4.2

SUMMARYSchools have special reasons for taking action to help prevent the tragedy of suicide: A student’s mental health can affect their academic performance. Depression and other brainconditions can interfere with the ability to learn. Maintaining a safe environment is part of a schoolʼs overall mission. A student suicide can significantly impact other students and the entire school community.Knowing what to do following a suicide is critical to helping students cope with the loss andpreventing additional tragedies that could occur. Although this is a school- based toolkit, there is an understanding that children and teens arepart of a community and that any comprehensive intervention includes not only members ofthe school, but also the family and selected members of the child’s extended community (suchas trusted adults, therapist, primary care, etc.).Experts recommend that schools use an approach to suicide prevention that includes the following:1. Provide training and suicide awareness education for key staff, administrators, and site- basedpartners2. Educate parents regarding suicide risk and mental health promotion3. Educate and involve students in mental health promotion and suicide prevention efforts4. Screen students for suicide risk, as appropriate5. Identify students at possible risk of suicide and refer them to appropriate services6. Respond appropriately to a suicide deathSuicide Prevention: A Toolkit for High Schools, SAMHSAThis toolkit addresses suicide prevention and responses to suicidal behaviors in three irrevocablyinterconnected and interdependent areas:1. Promotion of Mental Health and Wellness2. Intervention in a Suicidal Crisis3. Postvention Response To a Suicidal DeathEach staff member takes responsibility for the part they can play in keeping students safe by becomingfamiliar with those aspects of this Toolkit that are pertinent to their role in student safety. Parents andthe larger school community will be made a

Roni Gillenson, LMFT Adolescent Counseling Services On--‐Campus Counseling Program Director George Green, PhD Psychologist, Gunn High School Tom Jacoubowsky Assistant Principal, Gunn . Ohlone and Palo Verde Elementary Schools Selene Singares Counselor, Palo Alto High School Stephanie Sheridan, .