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Some Secrets SHOULD be Shared…. SOS Signs of Suicide ® Prevention Programs for Middle & High Schools Candice Porter, MSW, LICSW Screening for Mental Health, INC. Screening for Mental Health, Inc.

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Some Secrets SHOULD be Shared…

SOS Signs of Suicide®

Prevention Programs for Middle & High Schools

Candice Porter, MSW, LICSW

Screening for Mental Health, INC.

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Screening for Mental Health, Inc.

  • Screening for Mental Health, Inc. (SMH) is a non-profit 501(c) (3) organization that develops evidence-based mental health education and screening programs for use by members of the public.

  • The mission of Screening for Mental Health is to promote the improvement of mental health by providing the public with education, screening, and treatment resources.

  • Programs Include: SOS Signs of Suicide® Prevention Programs Signs of Self Injury Prevention Program CollegeResponse® National Depression Screening Day® National Alcohol Screening Day® National Eating Disorders Screening Program® WorkplaceResponse® HealthcareResponse® Military PathwaysTM

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Prevalence of Suicide Among Young People

  • Nationally, suicide is the 3rd leading cause of death among children ages 15-24 (4,405 deaths in 2006) (CDC, 2004). Only accidents and homicides occurred more frequently.

  • Whereas suicides accounted for 1.4% of all deaths in the U.S. annually, they comprised 12% of all deaths among 15-24-year-olds.

    • Each year, there are approximately 10 youth suicides for every 100,000 youth.

    • Each day, there are approximately 11.5 youth suicides.

    • Every 2 hours and 5 minutes, a person under the age of 25 completes suicide.

  • Adolescent suicidal behavior is deemed to be underreported because many deaths of this type are classified as unintentional or accidental (World Medical Association, 2004).

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Depression & Youth

  • In 2007, 8.2% of adolescents (an estimated 2 million youth aged 12 to 17) experienced at least one major depressive episode in the past year (SAMHSA, 2009).

  • What is a Major Depressive Episode?

    • DSM-IV: a period of 2 weeks or longer in which there is either depressed mood or loss of interest or pleasure AND at least 4 of the following:

      • Increase or decrease in appetite

      • Problems with sleeping

      • Fatigue or energy loss

      • Feelings of worthlessness or excess guilt

      • Diminished ability to think or concentrate

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Depression & Youth

  • In children & adolescents, an untreated depressive episode may last between 7 to 9 months, potentially an entire academic year!

  • Overall, 20% of youth will have one or more episodes of major depression by the time they become adults (NAMI, 2003).

  • Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44 (WHO, 2003).

  • More than 90% of people who complete suicide have a diagnosable mental disorder, most commonly a depressive disorder or a substance abuse disorder (NIMH, 2009).

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National Longitudinal Survey of Youth, 1997

  • Based on data from a sample of adolescents that followed them from 1997 (15-17 years old) into young adulthood, through 2005 (23-25 years old)

  • 8% of the youth were designated as experiencing depression/anxiety

    • These youth engaged in more risky behavior during adolescence

    • Over a third (35%)did not earn a high school diploma, less likely to obtain a degree from a 4-year college (13% vs. 27% of the no depression/anxiety sample)

    • Less then half (43%) consistently connect to school and/or labor market between the ages of 18 to 24 (compared to 61% of no depression/anxiety sample)

      Source: Urban Institute estimates of the National Longitudinal Survey of Youth 1997

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Consequences of Untreated Mental Illnesses in Children

  • Suicide – 3rd leading cause of death in youth.

  • Imprisonment – 80 percent of youth entering the juvenile justice system have a diagnosable mental illness.

  • Foster care - It is estimated that 85 percent of children in foster care have an emotional disorder or substance abuse disorder.

  • Dramatically higher rates of school failure and drop-out

  • Custody relinquishment - Families are often forced to

    give up custody of their child to the state to secure services.

  • Substance use as self-medication.

  • Social isolation from their peers.

    Source: NAMI, 2003

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State, Territory, Tribal, and District Participation Map 2009

Weighted results mean that the overall response rate was at least 60%. The overall response rate is calculated by multiplying the school response rate times the student response rate. Weighted results are representative of all students in grades 9–12attending public schools in each jurisdiction. With weighted data, it is possible to say, for example, "X% of students in state Y never or rarely wore a seat belt when riding in a car driven by someone else." Unweighted data represent only the students who completed the survey.

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By the numbers… 2009

  • 2009 Youth Risk Behavior Survey found that:

    • 26.1% felt so sad or hopeless for 2+ weeks that they stopped doing some usual activity.

    • 13.8% seriously considered attempting suicide.

    • 10.9% made a suicide plan.

    • 6.3% attempted suicide.

      • 1.9% of those who made an attempt required medical attention

        Find the data for your city/state:

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Illinois Student Health Survey 2009

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Why do people want to end their lives? 2009

Situations that might contribute to a feeling of hopelessness include:


Family problems

Sexual, physical or mental abuse

Drug or alcohol addiction

Mental illness, including schizophrenia, bipolar disorder and depression

The death of a loved one

School or work problems

Unemployment or being unemployed for a long time

Feeling like you don't belong anywhere

Any problem that seems hopeless.

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Suicide – Risk Factors… 2009

  • Risk factors are not necessarily causes.

  • Suicidal distress can be caused by psychological, environmental and social factors.

  • The first step in preventing suicide is to identify and understand the risk factors.

  • The strongest risk factors for suicide in youth are depression, substance abuse and previous attempts (NAMI, 2003).

  • Mental Illness is the leading risk factor for suicide.

  • Over 90 percent of children and adolescents who die by suicide have a least one major psychiatric disorder (Gould et al., 2003).

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Psychiatric IllnessCo-morbidity


Personality Disorder/Traits


Substance Use/Abuse


Severe Medical



Family History

Access To Weapons


Psychological Vulnerability

Life Stressors



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What do prevention programs aim to do? 2009

  • Enhance awareness and increase information among students, staff, family, and community

  • Change environments and systems – with particular concern for diversity

  • Enhance identification of those at risk and build capacity of school, family, & community to help

  • Enhance competence/assets related to social and emotional problem solving (e.g., stress management, coping skills, compensatory strategies)

  • Enhance Protective Buffers (Resiliency Factors)

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Why should schools play a role? 2009

  • Schools cannot achieve their mission of educating the young when students’ problems are major barriers to learning and development. As the Carnegie Task Force on Education has stated: School systems are not responsible for meeting every need of their students. But when the need directly affects learning, the school must meet the challenge.

  • Schools are at times a source of the problem and need to take steps to minimize factors that lead to student alienation and despair.

  • Schools also are in a unique position to promote healthy development and protective buffers, offer risk prevention programs, and help to identify and guide students in need of special assistance.

    Center for Mental Health in Schools at UCLA (

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SOS Signs of Suicide® 2009Program Goals

  • Decrease suicide & attempts by increasing knowledge and adaptive attitudes about depression

  • Encourage individual help-seeking and help-seeking on behalf of a friend

  • Link suicide to mental illness that, like physical illness, requires treatment

  • Engage parents and school staff as partners in prevention by educating them to identify signs of depression and suicide and provide information about referral resources

  • Reduce stigma associated with mental health problems

  • Encourage schools to develop community-based partnerships

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SOS: Student Goals 2009

  • Help youth understand that depression is a treatable illness

  • Educate that suicide is not a normal response to stress but rather, a preventable tragedy that often occurs as a result of untreated depression

  • Inform youth of the risk associated with alcohol use to cope with feelings

  • Increase help-seeking by providing students with specific action steps to take if they are concerned about themselves or others and identifying resources

  • Encourage students and their parents to engage in discussion about these issues

  • Encourage peer-to-peer communication about the ACT help-seeking message

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A 2009cknowledge

Acknowledge that you are seeing the signs of depression or suicide in a friend and that it is serious


Let your friend know you care about them and that you are concerned that he or she needs help you cannot provide


Tell a trusted adult that you are worried about your friend

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Inputs 2009

School administration support for SOS program implementation

School clinical staff and other program implementers (nurses, teachers, etc.) are trained on program use.

Stakeholders provide program support i.e.

- Parents provide

active consent for

student participation

- Community mental

health resources

provide treatment


- Schools provide


classroom environment

for students to learn

about and discuss mental


Program provides Spanish and other language resources


Distribute consent forms to parents, provide screening forms and an opportunity to view educational video

Show educational video to students.

Conduct educator -facilitated discussion with students about issues surrounding depression and suicide

Discuss and model ACT and encourage students to seek help for themselves or their friends

Distribute and collect student self- administered screening forms

Clinical staff follow-up on screening results and make further assessment for students screened + for depression/suicide

Clinical staff contacts parents to make treatment referrals for their children.

Staff complete follow-up surveys

Short-Term Outcomes

↑ Knowledge of school staff, parents and students about suicide and depression.

↑ Attitudes of staff, students and parents, towards the importance of actively helping teens dealing with suicide and depression

↑ Teen knowledge and attitudes around suicide and depression and how they are related

Intermediate Outcomes

↑ Teen help seeking

behavior (ACT)

↓ Suicide ideation

↓ Suicidal attempts

↑ Adolescent access to clinical mental health intervention and treatment services.

↑ Self-efficacy of students who either want to seek treatment or want to help a friend do so.

Long-Term Outcomes

↓ Long-term suicidal behavior

↑ Self-efficacy of students and families who identify symptoms of suicide and depression and want to seek treatment in the future.

↓ Incidence of untreated depression in adolescent population

↑ Access to mental health services for students and families.

Program Logic Model for SOS


Through staff and student training, schools provide a de-stigmatizing and safe environment for students to come forward and engage in help-seeking behavior around concerns about mental illness.

Parents are educated on depression, suicide and the use of the SOS program so that they may take the initiative at home to openly discuss this topic with their children.

Area mental health services, through program awareness and support, thoughtfully discuss service and treatment options and their use with students and family.

Dissemination of results helps ensure an adequate system of service delivery to future students benefiting from the SOS program in their area schools.

  • Theoretical Methods

  • Students learn help seeking behavior through the modeling of easily replicable behaviors (CBT).

  • Self-risk assessment helps students become aware of their own mental health status, their risk associated with this status and their need for adopting help-seeking behaviors. A sense of risk precipitates the adoption of the desired health behavior (HBM)

  • A supportive environment promotes the practice of healthy behavior.

  • Partnering with parents reduces barriers to follow-up treatment.

  • Peer intervention is developmentally appropriate for adolescents.

  • Normalizing depression as just another treatable medical condition helps reduce the stigma and stereotypes normally

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SOS Program Components 2009

High School Program

Middle School Program

  • Implementation Guide

  • Educational DVD & Discussion Guide

  • Staff training DVD

  • Brief Screen for Adolescent Depression (BSAD) - parent & student version

  • High School Student Newsletter

  • Customizable Wallet Cards

  • Posters

  • Educational Materials for Staff, Students & Parents

  • Postvention Guidelines

  • Implementation Guide

  • Educational DVD & Discussion Guide

  • Center for Epidemiological Studies Depression Scale for Children (CES-DC)

  • Student & Parent Newsletters

  • Customizable Wallet Cards

  • Posters

  • Educational Materials for Staff, Students & Parents

  • Postvention Guidelines

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Identify & Train Your Team 2009

  • Review program goals, assign roles/responsibilities

  • Review kit, video and discussion guide

  • Review screening form and scoring

  • Designate time and date for program implementation

  • Review school policies for handling suicide disclosure, parental consent, record keeping, etc.

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Decide on Format 2009

●Provide program school-wide or select target student group based on grade level, class enrollment, or special need

Screening Implementation Options

  • Anonymous

  • Anonymous with Response Card

  • Non-anonymous

  • Anonymous with number ID

  • Eliminate (do not screen)

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Demonstrate the Program 2009

Staff Training Suggestions

  • Show the video and facilitate a discussion

  • Review the signs of depression and suicide

  • Answer questions, dispel myths

  • Review the school policy for handling students who disclose suicidal intent

  • Review school and community mental health resources

  • Review the Screening form

  • Distribute protocol for what to do when approached by students asking for help

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Prepare for Follow-Up 2009

  • Contact local mental health facilities and advise them of your program dates and times

  • Verify their referral procedures, wait lists, insurance details, etc.

  • Create a Referral Resource List to send with parent letter

  • Use SAMHSA’s Find Treatment Locator to identify additional referral resources

  • Have copies of the student follow-up form available

  • Review school’s emergency procedures and parental notification

  • Identify in advance who will be handling emergencies

  • Notify the nearest crisis response center about the program in advance to facilitate referrals

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SAMHSA’s Find Treatment Locator 2009

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Benefits of Community Partnering… 2009

  • Can help if a school does not have adequate staff

  • Students may feel more comfortable speaking with an outsider

  • As an introduction to community-based mental health resources

  • Enhance referral network for the school

    Allowing these agencies into the building educates and familiarizes students with their services and how to access them.

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  • Communication with Parents/Guardians 2009

  • Send parents a letter stating the goals of the program (template provided) and Parent Screening Form (reproduce Spanish materials, if needed)

  • Decide between Active Consent vs. Passive Consent (templates provided)

  • Hosting a Parent Night: Show the video, distribute the Parent Screening Form, answer questions, dispel myths, provide referral resources

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  • Parents/Guardians as Partners in Prevention 2009

  • Studies have shown that as many as 86% of parents were unaware of their child’s suicidal behavior.

  • The percentage of parents who are involved in the student’s activities is very small.

    • -Doan, et al, 2003

  • By raising parental awareness, schools can partner with parents to watch for signs of these problems in their children and instill confidence for parents seeking help for their child, if needed.

  • Involving parents may increase cooperation in prevention efforts and broaden community support

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    The Day of the Program 2009

    • Introduce Program

    • Show video

    • Facilitate discussion

    • Students complete and score screening forms and Response Card

    • Set expectation about when follow-up can be expected – Provide referral information

    • Follow up with students requesting help

    • Respond to requests for help – track students seeking help using the Student Follow-Up form

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    Make sure to review with students… 2009


    • Depressed mood (can be sad, down, grouchy or irritable)

    • Change in sleeping patterns (too much, too little or disturbed)

    • Change in weight or appetite (decreased or increased)

    • Speaking and/or moving with unusual speed or slowness

    • Loss of interest or pleasure in usual activities

    • Withdrawal from family and friends

    • Feelings of worthlessness, self-reproach or guilt

    • Feelings of hopelessness or desperation

    • Diminished ability to think or concentrate, slowed thinking or indecisiveness

    • Thoughts of death, suicide, or wishes to be dead


    • Extreme anxiety, agitation or enraged behavior

    • Excessive drug and/or alcohol use or abuse

    • Neglect of physical health

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    □ I need to talk to someone …

    □ I do not need to talk to someone …



    HOMEROOM SECTION:_________________________ TEACHER:_____________________________________


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    Evaluation of the SOS Program 2009

    • SOS is the only universal school-based suicide prevention program for which a reduction in self-reported suicide attempts has been document with a randomized experimental design.

    • Based on evidence from the first year of a 2 year study involving over 2100 students in 5 schools (Aseltine, 2004), the SOS program was added to SAMHSA’s National Registry of Evidence-Based Programs and Practices.

    • Study published in BMC Public Health, 2007 found SOS to be associated with significantly greater knowledge, more adaptive attitudes about depression and suicide, and most importantly, significantly fewer suicide attempts among intervention youths relative to untreated controls.

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    Reducing Liability – 2009Common Themes in Lawsuits

    • The institution ignored warning signs of suicide.

    • The institution provided the tools that the student used for suicide.

    • The institution took insufficient steps to address the warning signs.

    • The institution failed to notify the family about the student’s condition.

      -United Educators, “The Suicidal Student: Issues in Prevention, Treatment, and Institutional Liability” Roundtable Discussion, 2003

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    Student Mental Health Screening: 2009A Risk Management Perspective

    • United Educators actively encourages schools to provide a safe environment for students and reduce the institution’s liability. They believe that the SOS Suicide Prevention program can serve as an important risk management tool for schools.

    • A record of prevention programs is important. Many causes of serious student injury and death relate to mental health concerns.

    • Screening efforts and counseling services help show that the school takes student mental health issues seriously

      Constance Neary, Vice President for Risk Management, United Educators Insurance

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    Reducing Liability 2009

    • Prompt disclosure of a suicide threat to a parent is both legal and prudent

    • Document steps taken by the school, including parental follow-up and clinical care status

    • Joint decision making and good documentation help justify decisions should they later be challenged

    • Confidential materials should be stored under lock and key

    • Always consult with the school legal department for questions regarding policies

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    Reducing Liability 2009

    • It is important to convey to students and parents that the screenings being conducted in your school are informational, not diagnostic. Diagnoses, treatment recommendations and second opinions should not be given.

    • Faculty, staff, parents and students should be informed that the program is primarily for educational purposes and is not a substitute for a diagnostic examination. Program team members will recommend that students seek complete evaluations if their symptoms are consistent with depression and/or suicidality.

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    Common Objections & Talking Points 2009

    • Suicide is not a problem in our school

      • No school is immune to adolescent suicide

    • Schools are not appropriate for suicide prevention programs

      • Student problems with academics, peers, and others are more apt to be evident in school. The majority of parents are unaware of their child’s suicidality.

    • The program may introduce the idea to students

      • There has been no harm seen in screening teens for suicide risk (Gould, M., et al, 2005)et al, 2005

    • I don’t agree with labeling youth

      • The screenings are not diagnostic

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    Common Objections & Talking Points 2009

    • I don’t have enough staff/time

      • The program can be implemented in one class period using existing resources and partnerships with community providers.

    • There are no referral resources in my area

      • Identifying the need for resources can help justify the need for funding.

    • We cannot conduct mental health screenings

      • Screenings can be done confidentially or not at all

    • We already have a suicide prevention program

      • SOS is the only evidence-based that addresses suicide risk and depression, while reducing attempts.

      • It can also compliment other programs (QPR)

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    For more information, contact: 2009Diane Santoro, MSW, [email protected]

    Screening for Mental Health, Inc.

    One Washington Street, Suite 304 Wellesley Hills, MA 02481

    Phone: 781.239.0071 Fax: 781.431.7447

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    References 2009

    American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, D.C.: Author.

    Aseltine, R., et al. (2007). Evaluating the SOS suicide prevention program: A replication and extension. BMC Public Health 7(161).

    Centers for Disease Control and Prevention. (2008). Suicide: Facts at a glance. Atlanta, Georgia: U.S. Department of Health and Human Services Centers for Disease Control and Prevention.

    Center for Disease Control and Prevention. (2008). Web based injury statistics query and reporting system (WISQARS). Retrieved June 11, 2009, from

    Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth suicide prevention school-based guide. Tampa, FL: Department f Child and Family Studies, Division of State and Local Support, Louis de la Parte Florida Mental Health Institute, University of South Florida.

    Gould, M., et al. (2003). Youth suicide risk and preventive interventions: A review of the

    past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (4), 386-405. 

    Guild, M., Marrocco, F., Kleinman, M, Graham, J., Mostkoff, K, Cote,J. & Davies, M. (2005). Evaluation iatrogenic risk of youth suicide screening programs: a randomized controlled trial. Journal of the American Medical Association, 293 (13).

    Kalafat, J., Ryerson, D., and Underwood, M. Lifelines ASAP - Lifelines

    Adolescent Suicide Awareness and Response Program. Piscataway, NJ: Rutgers University.

    Grossman, D., et al. (2005). Gun storage practices and the risk of youth suicide and unintentional firearm injuries. Journal of the American Medical Association, 293 (6), 707-714.

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    References 2009

    Kerr, M. Suicide Prevention in Schools: Best practices and questionable practices [PDF document]. Retrieved from STAR-Center Online Website:

    Litts, D. (August 2, 2004). USAF Suicide Prevention Program: Lessons for Public Health Prevention in Non-military Communities. Retrieved June 2, 2009 from

    National Adolescent Health Information Center. (2006). Fact sheet on suicide-Adolescents and young adults. San Francisco, CA: Author, University of California, San Francisco.

    National Institute of Mental Health. (2009) Suicide in the U.S., statistics and prevention. Retrieved June 15, 2009, from

    National Alliance of Mental Illness (NAMI). (2003). Depression in Children and Adolescents. Retrieved on June 16, 2009 from

    Office of Applied Studies. (2006). Results from the 2005 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 06-4194, NSDUH Series H-30). Rockville, MD: Substance Abuse and Mental Health Services Administration.

    Shenassa, E., Rogers, M., Spalding, K. (2004). Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample. Journal of Epidemiology and Community Health, 58, 841-848.

    UCLA Center for Mental Health in Schools. School community partnerships: a guide. Retrieved from

    World Health Organization. (2000). Preventing suicide: A resource for teachers and other school staff. Geneva, Switzerland: Mental and Behavioral Disorders, Department of Mental Health.