Without mental health screenings, school officials miss many suicide risks

After the examDo you really know who are your most troubled students? According to a recent study in the American Journal of Public Health, school officials do, in fact, know who many of them are, but they are missing a significant number of students flagged by mental health screenings, including many who are at high risk for suicide.

In a study conducted with students at 7 New York metropolitan area high schools, researchers found that school officials identified roughly two-thirds of students at high risk for suicide, but they missed one-third of students that a school-based screening (Columbia Suicide Screen) identified as having the following risk factors:

  • Suicide attempt in the preceding 6 months
  • Suicidal ideation
  • Current mood, anxiety or substance use disorder.

School officials often believe that school-based screenings for mental health are somewhat redundant because clinical and administrative staff already know who troubled students are, researchers write. But, this study shows that screenings identify a significant number of students who are not identified by staff.

“The value of universal screening would be greatly reduced if school-based screening programs detected students already identified by school staff,” the authors write.

“Both screening and evaluations of school professionals are imperfect methods of identifying students with mental health problems,” the authors write. “Given the multiple demands on school administrative and clinical professionals, it would be impossible for these individuals to identify all students with mental health needs.”

School officials, in fact, missed a majority of students with some risk factors for suicide. Screening accurately identified 62.7% of students withsignificant mental health problems while school professionals accurately identified 36.5%, the researchers report.

For this study, researchers screened 1729 students at 7 high schools with the CSS. Of the 1729 students screened, 489 had positive results. The clinical status of those students and of 23% of those who screened negative were assessed with modules from the Diagnostic Interview Schedule for Children. School professionals who were unaware of students’ diagnostic status were asked to indicate whether they were concerned about the emotional well-being of each participating student. School professionals used in this study were nominated by principals because they were most likely to be aware of students’ emotional and behavioral problems.

The CSS is an 11-item self-report questionnaire embedded within a health survey. The questionnaire was administered during regular school hours in English class only. Within 14 days of screening, students with positive screening results completed the mood, anxiety and substance use modules of the Diagnostic Interview Schedule for Children, version 2.3 (DISC 2.3).

One concern about school-based screenings are that they over-identify students as having problems, researchers write. In other words, one reason school officials are reluctant to use them is that a high proportion of students will be false positives or will not have the “condition of interest,” they write.

In fact, the study found school officials identified far more false positives than the CSS. About 37% of students who screened positive on the CSS did not have a significant mental health problem while about 64% of students identified by school officials had no such problem. The researchers note that school professionals were asked to make very broad assessments about the students while CSS is specifically geared toward assessment of suicide risk.

About 18% of students were identified neither through screening nor by school professionals. Researchers note that the CSS questions focus on the previous 3 months while school staff were asked about students who were of current concern to them. This time lag may have resulted in students reporting on a transient diagnosis that resolved itself during the time lag.

Approximately 34% of students with significant mental health problems were identified only through screening, 13% only by school professionals and 34.9% though both screening and school professionals. School professionals are likely to be the most aware of the types of externalizing problems that disrupt classrooms such as aggression and disruptive conduct. These types of problems are not assessed by CSS, the authors report.

One lesson to be learned from the study is that even screenings are unlikely to identify all students who may need help and that they should be only 1 component of a school’s mental health initiative, the authors write. Even when screenings are conducted, school officials need to be engaged in identifying troubled students.

Another concern raised by the study is that school professionals indicated that they planned to refer or had already referred 65% of students to an agency for services. However, few students had obtained those services; 40% of referred students had obtained services in the last year and only 17% had obtained services in the previous 3 months.

“School-Based Screening to Identify At-Risk Students Not Already Known to School Professionals: The Columbia Suicide Screen,” by Michelle Scott, et al., American Journal of Public Health, February 2009, Volume 99, Number 2, pp. 334-339.

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