Application 4
LDots01
School-BasedSuicidePrevention.pdf
School-Based Suicide Prevention With African American Youth in an Urban Setting
Melanie M. Brown and Julie Goldstein Grumet Government of the District of Columbia
Youth in urban settings are at significant risk for suicide and other mental health issues, but little is known about the utility or outcomes of suicide prevention programs with this population. This article reviews the outcomes of a grant-funded initiative to provide suicide screening to urban, African American youth. Columbia TeenScreen was implemented at 13 middle and high schools in Washington, DC, to 229 Black or African American students. Forty-five percent of students screened positively for previous suicide attempt or ideation, symptoms of depression or anxiety, and/or other emotional problems. Twenty percent of all youth screened endorsed current or previous suicidal ideation or attempts. Over 90% of youth endorsed at least some problem with depression or irritability. Early detection of risk factors through universal screening can lead to earlier treatment, thwarting a suicidal crisis. Implications for conducting screening in an urban setting and how psychologists can engage in screening are explored.
Keywords: suicide, prevention, African American, screening, schools
Mental health problems in youth are more common than gen- erally recognized. Studies show that at least 1 in 5 children and adolescents have a mental health disorder and at least 1 in 10, or about 6 million youth, have an emotional disturbance serious enough to warrant immediate clinical intervention (U.S. Depart- ment of Health and Human Services, 2003). In addition, as many as 80% of children in the United States who are in need of mental health services do not receive treatment (Kataoka, Zhang, & Wells, 2002), even among those who possess private or public medical insurance.
Untreated mental illness, especially depression, is associated with a host of negative outcomes including suicide. Although not all depressed individuals consider suicide, unrecognized or un- treated depression can lead to suicidal gestures. Suicidal gestures include a variety of lethal and nonlethal behaviors ranging from thoughts of suicide to self-injury. Risk factors for suicidal behavior are known to include the presence of major depression, a previous
suicide attempt, a history of disruptive behavior or abuse, and substance use (Gould, Greenberg, Velting, & Shaffer, 2003).
Racial and ethnic disparities are long-standing factors affecting access to and utilization of mental health services. African Amer- ican and Latino children have the greatest unmet mental health needs (Ringel & Sturm, 2001) and are also more likely to live in a low-income household, which is associated with increased risk for mental health problems (Howell, 2004).
Nationwide, suicide is the third leading cause of death for youth between the ages of 10 and 19 with youth ages 15–19 being six times more likely to commit suicide than their younger aged peers (Heron, 2007). Suicide is also the third-leading cause of death for African American youth ages 15–24 years (Centers for Disease Control and Prevention, 2004). Historically, African American youth have had lower rates of suicide than Whites and Latinos, but the difference between these two groups has decreased in the past 20 years primarily because of the increasing rate of suicide among African American males. Goldsmith (2001) suggested that the lower rate of suicide among African Americans can be attributed to greater religiosity, greater social support, and larger extended families, which may act as protective factors.
The majority of the more than 70,000 children and adolescents attending Washington, DC (DC) public schools are of ethnic minority descent. Approximately 85% are African American (Dis- trict of Columbia Public Schools, 2005). Given the high rates of suicide among adolescents, they have been the recent target of many suicide prevention programs; however, few studies to date focus exclusively on suicidal behavior among African American youth. Therefore, this study will examine an evidence-based screening program for suicidality among urban African American youth.
The Youth Risk Behavior Survey (YRBS; Eaton et al., 2006) conducted in DC public schools found that 21.8% of high school students felt sad or hopeless almost every day for at least 2 weeks
Editor’s Note. This is one of eight accepted articles received in response to an open call for submissions on interventions for suicidal persons across the life span.—MCR
MELANIE M. BROWN received her MPH from the Johns Hopkins Bloomberg School of Public Health. She is the project evaluator of the STOP Suicide Program (School-Based Teen Outreach Program for Sui- cide) at the District of Columbia Department of Mental Health. Her research interests include injury prevention and children’s mental health. JULIE GOLDSTEIN GRUMET received her PhD from George Washington University in clinical psychology. She is the project director of the STOP Suicide Program at the District of Columbia Department of Mental Health. Her areas of professional interest include youth suicide prevention and school-based mental health. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Julie Goldstein Grumet, 64 New York Avenue Northeast, 4th Floor, Washing- ton, DC 20002. E-mail: [email protected]
Professional Psychology: Research and Practice © 2009 American Psychological Association 2009, Vol. 40, No. 2, 111–117 0735-7028/09/$12.00 DOI: 10.1037/a0012866
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(compared to 28.5% of high school students nationally), 12.3% actually attempted suicide one or more times during the past year (compared to 8.4% of high school students nationally), and 8.7% made a suicide plan (compared to 13% nationally). Although DC students were less likely to feel sad or hopeless, or make a suicide plan than the national cohort, they were more likely to attempt suicide. Furthermore, the YRBS data indicate that girls in DC are more likely than African American girls in the national sample to report having made a suicide attempt (15.1% vs. 9.8% nationally) and to have required medical attention as a result of an attempt (3.9% vs. 2.6% nationally; Eaton et al. 2006).
Rates of suicidal ideation, suicide planning, and suicide attempts are even higher for middle school youth in DC than for senior high school youth. In 2007, 23.9% of middle school students reported suicidal ideation, increasing from 20.6% in 2005; 13.1% of middle school youth reported making a plan; and 13.4% reported ever trying to kill themselves (District of Columbia Public Schools, n.d.). A study by Ialongo et al. (2002) of urban, African American youth found that most first attempts of suicide were when youth were 11–15 years old and that few attempters ever received mental health treatment for their attempts.
All of these factors suggest that DC middle and high school students are more likely than typical high school students to attempt suicide, even if they are reporting lower rates of planning for suicide. While suicide is not among the leading causes of death for 15- to 19-year-olds in DC, higher than average rates of suicide attempts suggest that youth in DC may lack appropriate coping mechanisms for dealing with emotional stressors. Their suicidal behaviors may be a more impulsive act and a first-line coping mechanism. With the high rate of self-reported suicide attempts among DC youth, there is a pressing need to identify at-risk youth early so adults can teach them alternative coping strategies and link them to supportive services.
School-based prevention approaches that utilize an intensive assessment of youth identified as at risk for suicide or mental illness in conjunction with a direct case finding strategy such as confidential surveys have received considerable support (Shaffer & Pfeffer, 2001). Two of the more widely used school-based screening programs that are also evidence based are Columbia TeenScreen and Signs of Suicide (S.O.S.). Both programs are listed on the Substance Abuse and Mental Heath Services Admin- istration’s National Registry of Effective Programs (Substance Abuse and Mental Health Services Administration, 2008a, 2008b). The President’s New Freedom Commission on Mental Health (United States Department of Health and Human Services, 2003) recognized TeenScreen as a model program, and it is supported by 34 national organizations including the American Academy of Child and Adolescent Psychiatry and the American Federation of Teachers. TeenScreen has trained over 450 sites in 43 states, and it is currently in use at numerous schools across the country (United States Department of Health and Human Services, 2003). Signs of Suicide (S.O.S.) is designed by Screening for Mental Health, Inc. It has been widely adopted and has been used in more than 675 schools across the country. It is endorsed by 15 national organizations specializing in youth mental health services and suicide prevention (Aseltine, James, Schilling, & Glanovsky, 2007). In spite of their widespread use, little research has been conducted to date into the feasibility or efficacy of using either program with African American youth.
Few studies, in fact, have explored the utility and efficacy of implementing a school-based screening program solely in poor urban schools. The studies that have been conducted have focused largely on middle-class urban or suburban populations, and none to date have focused exclusively on African American youth. Psy- chologists, especially in outpatient practices, are in a unique po- sition to provide school-based screening. They have the clinical knowledge, screening expertise, and often flexibility of time to partner with schools to screen youth. Additionally, they can take referrals from the screening days since most schools do not have adequate school-based mental health services to accommodate the numbers of youth in need of services.
This article reports outcomes from a school-based suicide pre- vention program in 13 middle and high schools in DC and high- lights how psychologists can carry out such a program.
Method
Sample and Setting
The STOP Suicide Program (School-Based Teen Outreach Pro- gram for Suicide) is funded by a grant from the Substance Abuse and Mental Heath Services Administration and is housed in the DC Department of Mental Health. The 13 schools that were identified for screening were typically brought to the attention of the STOP Suicide staff by a clinician with the School Mental Health Program (SMHP; an affiliated program administered by the DC Department of Mental Health that provides prevention and early intervention programming in DC public and public charter schools). The in- clusion criteria for schools included having a student enrollment that consisted of junior, middle, or senior high school (6th–12th grade) students; having approval from the school’s principal; and being able to identify a school staff member (typically the SMHP clinician or other school-based mental health clinician) who would be responsible for assisting the STOP Suicide Program staff with implementing the screening program.
SMHP clinicians are in 48 of the 264 total DC public and public charter schools. Clinician assignment to a school is determined jointly by DC Department of Mental Health and DC public school administrators. SMHP clinicians offer suicide and mental health screening to their principals as one of many primary prevention programs they can conduct. Clinicians are not required to offer this screening in their schools; however, they are mandated to run at least two evidence-based programs in their school during the year. There have been no other specific suicide prevention activities offered in most of the DC public schools for many years.
Measures
Columbia TeenScreen. Students were screened using the Co- lumbia Health Screen, a screening tool available through the Columbia University TeenScreen Program (McGuire & Flynn, 2003). The Columbia Health Screen is a 14-item Likert format paper and pencil questionnaire designed for youth ages 11 to 18 years that asks a student to report on his/her subjective experience in the past 3 months of depression and low mood, anger/irritability, substance abuse, anxiety or worry, as well as any thoughts of suicide. The student rates his/her self-perception of this symptom
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from 1 (no problem) to 5 (very bad problem). Criteria for being a positive screen are any or all of the following: (a) endorsing three or more symptoms as bad problem or very bad problem; (b) indicating wanting help with any symptom; (c) any suicidal ideation within the past 3 months or having made a previous suicide attempt; (d) appearing distressed to the examiner; and/or (e) asking to meet with someone to talk more.
The TeenScreen program recommends that individuals admin- istering the screen should have a bachelor’s degree or be currently enrolled in college, preferably with a major in psychology or social work. All clinical interviews should be completed by licensed master’s- or doctoral-level individuals or under the supervision of licensed personnel with experience in clinical and suicide risk assessment. SMHP clinicians are mental health specialists (typi- cally a clinician with a master’s degree in counseling or psychol- ogy), social workers, and psychologists. Some are licensed, while others work under supervision.
The Columbia Health Screen has been shown to be a valid screening instrument (Shaffer et al., 2004). Researchers examined the psychometric properties of the Columbia Suicide Screen (CSS; a precursor to the Columbia Health Screen) an 11-item, self-report questionnaire that includes items on lifetime suicide attempts and the 3-month prevalence of suicidal ideation, negative mood, and substance abuse (Shaffer et al., 2004). This study screened 1,729 high school students using the CSS (56% White, 18% African American, 13% Hispanic, and 13% other ethnicity) and also had the students complete the Beck Depression Inventory (Beck & Steer, 1993). A smaller subsample of these youth, some who scored positively and some who scored negatively, completed the Diagnostic Interview Schedule for Children (Shaffer et al., 1996) to assess for validity. The study found a trade-off between sensi- tivity and specificity; although the CSS has the potential for higher (0.88) sensitivity, the value was reduced to 0.75 when an optimum specificity of 0.83 was used. This allows for identifying those students who are at high risk for suicide, while not overburdening the system with too many false positives. Test–retest reliabilities of individual CSS items were in the good to excellent range. Addi- tionally, the CSS compared favorably to the Beck Depression Inventory, which had slightly higher test–retest reliability but was both less sensitive and less specific against the suicide validity criterion.
Although a fidelity scale is not available for the Columbia Health Screen, model integrity is strived for by offering full training and materials on all elements of screening. The developers provide all sites with recommendations and best practices guide- lines as well as ongoing technical assistance.
In the present study, active parental consent was required, and parental consent forms were typically sent to parents of all 6th- to 12th-grade students on multiple occasions prior to the screening date. Consent forms were also distributed as part of the registration process, at back-to-school nights, on parent/teacher conference days, and were handed out directly to youth in classrooms. School principals or other staff determined whether to screen entire schools or to focus on a class or grade. Most schools offered screening to the entire school (6th grade and above); however, in some cases they believed they could increase the number of consents returned by working with a particular grade. If youth from other grades turned in signed consent forms, obtained on parent/teacher night or some other means, those youth were still screened.
Procedure
Screening took place over the course of 1 day at each school. Screening occurred during class time, and students were retrieved from class to come to the designated screening area (such as a cafeteria or library). Arrangements were made with the school ahead of time to minimize the disruptions to the school day. The Department of Mental Health SMHP provided clinicians to assist on screening days. Typically, seven to eight clinicians were used on screening days. Each school designated several rooms for screening and clinical interviewing.
The parental consent form allowed parents to opt in or opt out of screening. All youth who returned signed consent forms re- ceived an incentive—typically an AMC movie card. On the day of the screen, youth had to sign an assent form to participate. The assent form was read out loud to them and included information on the screening program and informed them that parents would be called if their screen suggested the need for an additional evalua- tion. After completing the screen, all students met with a screener briefly, who scored the survey and debriefed with the student one on one. The students were then allowed to return to class if no concerns emerged. The screen itself took about 20 –30 min. For students who screened positively, the clinical interview typically took another 30 – 40 min. Parents of all youth who screened positively were notified of the results of screening and were given recommendations for an additional evaluation. The mental health clinician who conducted the clinical interview determined the appropriate referral resource—a school-based resource, a commu- nity mental health agency or immediate referral to a hospital. As per the TeenScreen protocol, youth are referred for an additional evaluation, not for a specific type of treatment such as therapy or medication. The STOP Suicide case manager helped link the families to the appropriate agency. A youth was considered “linked” when he/she went to at least one appointment for an additional evaluation or intake.
Results
Screening
Signed parental consent forms were returned by a total of 387 students across the 13 schools. Sixty-three (17%) of these students were absent on screening days. Forty-six parents (12%) refused to allow their child to participate in the screening program, and an additional 11 students (3%) declined to participate, leaving a final sample of 229 Black or African American students and 38 non- Black or African American students who were screened between March 2006 and September 2007. The female:male ratio among these students was nearly 2:1 (60% vs. 40%) with a mean age of 14 years (SD � 1.9 years) and an age range of 11–18 years. Two hundred twenty-nine (86%) students were African American, 19 (7%) were Hispanic, 11 (4%) were of mixed race, and 3% were of Caucasian, Asian, Native American, or other ethnicity. This article focuses only on the screening results of the African American youth. All youth and their families in this study were English speaking.
This sample is similar to the population of DC youth attending public and public charter schools with respect to race. The DC Public Schools Web site reports that approximately 84% of stu- dents enrolled are African American, 9% are Hispanic, 5% are
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White, 2% are Asian American, and less than 1% are of other ethnicity (District of Columbia Public Schools, 2005). The DC Web site does not provide information on the sex ratio of students enrolled in the DC public and public charter schools, so it is not possible to determine whether the larger number of female respon- dents is typical of enrollment at DC Public Schools.
There was significant variation in the screening rates across sites with an overall screening rate of 14% of the total number of consents that were distributed for all schools. The mean screening rate for all schools was 23% (SD � .15) of the number of consent forms that were distributed at each school, with a range of 3%– 48%. We typically received more consents back in schools with smaller enrollment.
Of those who took the screen, 45% (n � 102) of students screened positively for any reason including endorsing a previous suicide attempt or suicidal ideation, endorsing symptoms of de- pression or anxiety, or other emotional problems. Twenty percent (n � 45) of all students screened endorsed current or previous suicidal ideation or a previous suicide attempt, while 3% (n � 6) of all students screened required immediate hospitalization due to being at imminent risk for suicide. The majority of youth endorsed at least some problem with depression or irritability (57% and 77%, respectively).
Suicidal Ideation or Attempt, Depression, and Irritability
Similar to the findings of previous studies on youth suicidal behavior, girls in our sample were more likely than boys to report suicidal ideation or a previous suicide attempt (odds ratio [OR] � 2.75, 95% confidence interval [CI] � 1.29 –5.89). Girls were also significantly more likely to endorse feeling unhappy or sad within the past 3 months (OR � 3.97, 95% CI � 2.27– 6.94). In contrast, girls and boys were equally likely (OR � 1.04, 95% CI � 0.55–1.95) to endorse feeling angry or irritable in the past 3 months, a common symptom of depression in youth. There was no significant variation in the likelihood of endorsing one of these variables between age groups for the same sex; however, there was significant variation between 10- to 14-year-old boys and girls (OR � 4.42, 95% CI � 2.12–9.23) as well as between 15- to 19-year-old boys and girls (OR � 3.25, 95% CI � 1.34 –7.88) in the likelihood of reporting depressive symptoms in the past 3 months. Table 1 reports the prevalence of the students’ endorse- ment of each risk item by sex and age group.
Linkages
Sixty-two percent of youth were linked (went to at least one appointment) to a mental health services provider within 1 month of screening, and 70% of youth were linked by 6 months after screening. Almost 60% of all referrals were to SMHP clinicians or other school-based providers such as the social worker, psychol- ogist, or guidance counselor. The overall linkage rate for youth referred to school-based services was 86%; however, for youth referred to non-SMHP or non–school-based providers such as a community agency, the overall linkage rate was just 41% at 6 months after screening.
Discussion
Our findings suggest that there is a great need to address suicide-related mental health problems in urban schools, as well as
mental health problems in general. Few studies have examined universal screening as a mechanism for early detection for suicide and other mental health issues even though early detection could greatly reduce later suicidal behaviors. One study found that re- ports of depression from African American youth as early as 4th grade predicted later suicide attempts, particularly for girls (Ia- longo et al., 2004).
Students in our sample were more likely (45% vs. 39%, respec- tively) to screen positively for any reason than students in the validation sample of the screening instrument (Shaffer et al., 2004). Youth in our sample were less likely to report a previous suicide attempt than students in the TeenScreen validation sample (11% vs. 17%, respectively) but were more likely to report having experienced suicidal ideation in the past 3 months (15% vs. 11%, respectively). The TeenScreen validation sample was predomi- nantly White suburban youth as opposed to the present study, suggesting that African American youth, often understudied and underrepresented in validation samples, are also at great risk for suicidal behaviors and should not be ignored by researchers or practitioners. A review of the literature reveals that although researchers include minority youth in their samples when validat- ing suicide screening instruments, ethnic minority youth never make up the majority of the sample (Pena & Caine, 2006). As research and screening on suicide in African American youth is limited, there is a dearth of knowledge of the best instruments to use with this population. This can make it difficult to choose a culturally appropriate screening tool. Although the TeenScreen instrument appeared to be valid for detecting suicide and other mental health concerns in the present sample, more research should be done with screening minority youth.
There are virtually no studies to date on screening minority youth by private practitioners and yet these clinicians are well suited to provide this service. Graduate students, when supervised, can administer the screen, and referrals can be made back to a clinic or private office. By meeting the students on a screening day in a nontraditional, nonthreatening setting such as the school, practitioners can begin building rapport, and mental health stigma can be reduced.
Table 1 Students’ Endorsement of Risk Items by Age and Sex
Risk item Girls Boys
10- to 14-year-olds (n � 131)
Unhappy 70% 35% Suicidal ideation 23% 10% Attempted suicide 15% 3% Irritability 73% 78%
15- to 19-year-olds (n � 98)
Unhappy 70% 42% Suicidal ideation 18% 3% Attempted suicide 16% 3% Irritability 82% 74%
All ages (n � 229)
Unhappy 70% 37% Suicidal ideation 20% 8% Attempted suicide 16% 3% Irritability 78% 77%
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Other studies also suggest that African American youth in DC have higher rates of suicide attempts than what is observed na- tionally among both African American youth and overall when compared to the results of the 2005 YRBS. Results of our study found that 11% of youth reported ever making a suicide attempt, while according to the YRBS, only 7.6% of African American youth and 8.4% overall report attempting suicide. Our data reflect youth’s responses about having ever made an attempt compared to the YRBS, which asks about suicide attempts in the last 12 months, so it is possible that our numbers reflect higher percent- ages due to the different timeframe. Our results, though, are consistent with those found in the local YRBS in which 10.7% of middle school students and 11.2% of senior high school students reported making a suicide attempt in the last 12 months.
Although suicidal behaviors among youth ages 15–19 years are often the target for screening and intervention, our research sug- gests that urban middle school youth, ages 10 –14 years, are also at high risk for suicidal behaviors. One study found that suicidal ideation was reported in 14.5% of African American children 9 –10 years old, particularly among those youth with an exposure to violence, suggesting this is an age group that should not be overlooked when performing school-based screening or prevention (O’Leary, Frank, Grant-Knight, & Beeghly, 2006). Questions about thoughts of suicide and exposure to violence should also be included in all standard intakes by psychologists when working with urban African American youth of any age.
More of the youth in our study reported feeling irritable (77%) than sad (57%) in the past 3 months. Additionally, the YRBS found that more youth in DC reported making suicide attempts than the national sample, but fewer reported planning for suicide. This suggests that youth may not recognize anger as an internal state associated with depression and that their suicidality may stem from not knowing how to cope with strong feelings of anger. It is likely that their suicidality is more impulsive, less planned, and an immediate response to overwhelming feelings of anger and frustration.
The majority of the youth in our sample did not report making objectively “lethal” suicide attempts. Some of their reported sui- cide attempts included things such as “held a pillow over my face” and intentionally staying outside late in a dangerous neighborhood. Although the risk of death from these incidents is low, it speaks to the degree of distress and lack of coping skills possessed by many of the youth in our sample. Additionally, suicide attempts are often recurrent, suggesting that youth who report some suicidal behavior are at increased risk for future, perhaps more lethal behaviors (Bridge, Goldstein, & Brent, 2006). For those youth in mental health treatment, it is the responsibility of the psychologist to assess suicidality continuously among patients and to take all threats or pronouncements about attempts seriously.
One way in which psychologists can contribute to youth suicide prevention would be by offering prevention programs that focus on risk factors known to contribute to suicidality such as substance abuse, bullying, or depression. Joe (2006) found that African American families are more comfortable focusing on decreasing self-destructive behaviors such as substance abuse rather than on something as stigmatizing as suicide. Therefore, prevention pro- grams that target related risk factors may be more palatable to youth, families, and schools. In building relationships with fami- lies by providing treatment or exposure to topics that are less
threatening such as anger management, the groundwork can be laid for future referrals for other mental health matters.
Barriers and Limitations
The need for mental health screening in this population seems evident, but there are substantial barriers to implementation of universal screening in urban settings. One of the greatest chal- lenges has been obtaining active parental consent. Both Teen- Screen and the grant that funds this program require active con- sent. We also believe active consent is important as it begins to establish a relationship with the parent should a referral be neces- sary. However, only about 15% of any school’s student enrollment is screened despite many efforts to reach out to all youth and parents. Our difficulty in obtaining active parental consent and relatively small sample size are significant limitations to our study as these issues limit the generalizability of our results. It seems likely that the 15% of students who returned the consent form represent those students whose parents are most aware of and open to mental health services, which raises the question of whether our sample may represent a healthier segment of the population of urban African American youth. Given that the proportion of youth screening positively for any reason was higher in our sample than in the validation sample, this would seem to give more credence to our position that there is a greater need for screening in this population.
It should be noted that while our findings indicate a slightly higher parental refusal rate than what was observed in the Teen- Screen validation study (7% vs. 12%, respectively), the validation study utilized a passive consent process in which parents were only required to notify the school if they objected to screening. Since then, the TeenScreen program has begun requiring all sites to use active parental consent. There is no public data available yet on the rates of consent return being observed by other TeenScreen sites utilizing an active parental consent process. This issue needs to be studied further to determine whether active parental consent strikes the appropriate balance between ensuring that parents are properly involved in the screening of their children and that the consent process does not unnecessarily impede participation.
Only 3% of the youth offered the screen declined to participate, suggesting that when parental consent can be obtained, screening is a good mechanism to reach these youth. This is considerably lower than the 12% of youth who declined to participate in screening observed in the TeenScreen validation study. In contrast, the absentee rate observed among our sample was similar to that observed in the TeenScreen validation study (16% for our sample vs. 13%). The chronically absent youth are a subsample of high- risk youth that it is very difficult to reach and was beyond the scope of this school-based program. Community-based programs, juvenile justice, and employment services may be better partners to access some of these hard to reach youth.
One school-related barrier we experienced was principal turn- over. In DC, the turnover rate for school principals from year to year is as high as 40%. With such lack of continuity among leadership, it is hard to establish ownership and cohesiveness of the program. In discussions with the principals, they reported that they believed screening is important and attention to mental health is necessary, but they do not have the staff resources to devote to assisting with consent distribution nor did they want students to
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miss academic time to take the screen. Principals tend to prefer curriculum-based and staff in-service training over screening (Gould et al., 2003). Many also were concerned about uncovering a high degree of youth needing services and a paucity of in-school providers to see those youth. Community-based psychologists could fill a gap in resources by providing in-service training and/or seeing those youth who screen positively.
There would be specific barriers, however, to private practitio- ners trying to screen in schools. It is hard to gain access to schools. A psychologist could try to establish relationships with the mental health staff of a school to offer screening, but there are often delays and obstacles, even when the mental health staff sees this as an important initiative. Many urban schools are faced with the chal- lenges of meeting the standards set by the No Child Left Behind Act of 2001 and are struggling to raise youth’s academic progress. Teachers feel pressure to focus on learning and may not want to take time out for a prevention program or to distribute consents. For one lucky enough to partner with a school that is open to screening, he/she should still expect that youth will be absent, sick, not in class, on field trips, and may just not want to take the screen on the day the practitioner is there. An alternative might be to look for community health fairs or to partner with a faith-based group to provide screening in those settings.
Parents are also important stakeholders in screening programs. Several strategies were employed to reach parents such as attend- ing Back to School Nights, including consent forms in school registration packets, holding information sessions with food and babysitting, and holding discussions at local churches to talk about screening and mental health in the African American community. Many parents expressed fear and mistrust of the screening program at first. The basis of this fear seemed to be rooted in the fact that the screening program was offered by the school in conjunction with a governmental organization. Parents felt that by granting permission for anyone affiliated with the government or school to speak with their child about personal matters, that this could create an opportunity for the government/child protective services to become involved in their lives and the parent would ultimately lose control of their family.
Another barrier that parents have reported is the pervasive social stigma associated with suicide and mental illness in the African American community (Poussaint & Alexander, 2000). Many par- ents felt this is an issue to be addressed at home or through faith communities and not to be addressed by outsiders such as the school. Pursuing parental engagement and investment is perhaps the most important component of successful implementation of universal screening programs. This includes understanding the barriers to treatment such as lack of transportation, lack of child care, inability to navigate the health care system, and long waiting lists. A psychologist familiar with these barriers would be far more effective at engaging families and keeping youth in treatment. Community-based psychologists could also offer evening groups and partner with other groups such as housing and employment services to offer topics of relevance to these families—such as health and safety of their children and/or stress management.
We did find some activities that enhanced our ability to more effectively implement this screening. Targeting smaller groups for screening (e.g., one class rather than an entire school) resulted in substantially higher consent return rates because usually in these
cases there was a particular individual who took greater ownership of the screening program.
Providing incentives was also an important component to effec- tive implementation. This may be harder for private practitioners to offer; however, there are many local and national businesses that may be willing to donate merchandise such as coupons to fast-food chains or sports memorabilia from local teams. Principals can also offer incentives such as credit for class participation for turning in signed consent forms.
One essential caveat to be presented when considering screening for mental health issues in schools is the ability to follow up with at-risk youth. It is critical that positively screened youth be linked to some additional evaluation or treatment and that this is not left up to the parents alone. This could be a huge benefit of outpatient settings offering the screening and enlisting the support of multiple community-based providers. Many of the parents with whom we spoke dismissed reports that their children screened positive stat- ing that the child disclosed those things because he/she does not always get his/her own way, can be manipulative, or made it up to get out of class. Many of the parents in our sample needed a lot of support, encouragement, and education on mental health issues. Outpatient providers would be able to establish a long-term rela- tionship with the families from screening through treatment.
In conclusion, urban African American youth are at great risk for suicidal behaviors. They have many of the risk factors: poverty, exposure to violence, high rates of depression and irritability, and substance abuse. Suicidal ideation appears to be a frequent coping mechanism for these youth. Universal screening is one option for identifying youth who may not otherwise disclose these thoughts to anyone, but it will be essential to work closely with their families and schools to overcome some of the barriers experienced here. Community-based psychologists are in a position to screen and treat this underserved population. School-based screening provides excellent opportunities for clinicians and students in training to be exposed to a relatively new and rewarding venture, to contribute to a limited research base, and to provide a much- needed service to local, urban communities.
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Received November 30, 2007 Revision received May 8, 2008
Accepted May 14, 2008 �
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