SOS Signs of Suicide®
Prevention Programs for Middle & High Schools
Candice Porter, MSW, LICSW
Screening for Mental Health, INC.
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
National Depression Screening Day®
National Alcohol Screening Day®
National Eating Disorders Screening Program®
Small Group Activity
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
Each day, there are approximately 11.5 youth suicides.
Every 2 hours and 5 minutes, a person under the age of 25
Adolescent suicidal behavior is deemed to be underreported because
many deaths of this type are classified as unintentional or accidental
(World Medical Association, 2004).
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
Depression & Youth
In children & adolescents, an untreated depressive episode
may last between 7 to 9 months, potentially an entire
Overall, 20% of youth will have one or more episodes of
major depression by the time they become adults (NAMI,
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).
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
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
Less then half (43%) consistently connect to school and/or labor
market between the ages of 18 to 24 (compared to 61% of no
Source: Urban Institute estimates of the National Longitudinal Survey of Youth 1997
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
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 9–12
attending 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.
By the numbers…
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
Find the data for your city/state:
Illinois Student Health Survey
Behaviors that Contribute to Illinois US Illinois
Unintentional Injuries and Students Students Students Are
Violence % % At:
Seriously considered attempting 14.5 13.8 Equal Risk
suicide (During the 12 months
before the survey.)
Attempted suicide 8.9 6.3 Higher Risk
(One or more times during the 12
months before the survey.)
Why do people want to end their lives?
Situations that might contribute to a feeling of hopelessness include:
Sexual, physical or mental abuse
Drug or alcohol addiction
Mental illness, including schizophrenia, bipolar disorder and
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.
Suicide – Risk Factors…
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,
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).
SUICIDE: A MULTI-FACTORIAL EVENT
Access To Weapons Psychodynamics/
Life Stressors Suicidal
What do prevention programs aim to do?
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)
Why should schools play a role?
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 (http://smhp.psych.ucla.edu)
SOS Signs of Suicide®
Decrease suicide & attempts by increasing knowledge and adaptive
attitudes about depression
Encourage individual help-seeking and help-seeking on behalf of a
Link suicide to mental illness that, like physical illness, requires
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
SOS: Student Goals
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
Inform youth of the risk associated with alcohol use to cope with
Increase help-seeking by providing students with specific action steps
to take if they are concerned about themselves or others and
Encourage students and their parents to engage in discussion about
Encourage peer-to-peer communication about the ACT help-seeking
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
Program Logic Model for SOS
Inputs Activities/Outputs Short-Term Outcomes Long-Term
School administration support Distribute consent forms to ↑ Knowledge of school staff,
for SOS program parents, provide screening parents and students about ↓ Long-term suicidal
implementation suicide and depression. ↑ Teen help seeking
forms and an opportunity to behavior
view educational video
School clinical staff and other ↑ Attitudes of staff, students ↑ Self-efficacy of
program implementers (nurses, and parents, towards the ↓ Suicide ideation
Show educational video to students and families
teachers, etc.) are trained on students. importance of actively helping who identify symptoms
program use. teens dealing with suicide and ↓ Suicidal attempts
of suicide and
Conduct educator -facilitated depression depression and want to
Stakeholders provide program ↑ Adolescent access to
discussion with students seek treatment in the
support i.e. ↑ Teen knowledge and attitudes clinical mental health
about issues surrounding future.
- Parents provide around suicide and depression intervention and treatment
depression and suicide
active consent for services.
and how they are related ↓ Incidence of untreated
student participation Discuss and model ACT and depression in
- Community mental ↑ Self-efficacy of students
encourage students to seek adolescent population
health resources who either want to seek
help for themselves or their
provide treatment treatment or want to help a
friends ↑ Access to mental
services friend do so.
health services for
- Schools provide Distribute and collect students and families.
de-stigmatizing/safe student self- administered
classroom environment screening forms
for students to learn Environment
about and discuss mental Clinical staff follow-up on
illness screening results and make Through staff and student training, schools provide a de-stigmatizing and safe
further assessment for environment for students to come forward and engage in help-seeking behavior
Program provides Spanish and students screened + for around concerns about mental illness.
other language resources depression/suicide
Parents are educated on depression, suicide and the use of the SOS program so
Clinical staff contacts that they may take the initiative at home to openly discuss this topic with their
parents to make treatment children.
referrals for their children.
Area mental health services, through program awareness and support, thoughtfully
Staff complete follow-up 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.
•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
SOS Program Components
High School Program Middle School Program
Implementation Guide Implementation Guide
Educational DVD & Discussion Educational DVD & Discussion
Staff training DVD Center for Epidemiological
Brief Screen for Adolescent Studies Depression Scale for
Depression (BSAD) - parent & Children (CES-DC)
student version Student & Parent Newsletters
High School Student Newsletter Customizable Wallet Cards
Customizable Wallet Cards Posters
Posters Educational Materials for Staff,
Educational Materials for Staff, Students & Parents
Students & Parents Postvention Guidelines
Identify & Train Your Team
Review program goals, assign
Review kit, video and discussion guide
Review screening form and scoring
Designate time and date for program
Review school policies for handling suicide
disclosure, parental consent, record
Decide on Format
●Provide program school-wide or select target
student group based on grade level, class
enrollment, or special need
Screening Implementation Options
• Anonymous with Response Card
• Anonymous with number ID
• Eliminate (do not screen)
Student Screening Forms
Demonstrate the Program
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
Prepare for Follow-Up
• Contact local mental health facilities and advise them of
your program dates and times
• Verify their referral procedures, wait lists, insurance
• 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
• Identify in advance who will be handling emergencies
• Notify the nearest crisis response center about the
program in advance to facilitate referrals
SAMHSA’s Find Treatment Locator
Benefits of Community Partnering…
• 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
• Enhance referral network for the school
Allowing these agencies into the building
educates and familiarizes students with their
services and how to access them.
Communication with Parents/Guardians
• 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
Parents/Guardians as Partners in Prevention
• 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
The Day of the Program
• 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
Make sure to review with students…
SIGNS (SYMPTOMS) OF DEPRESSION
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
OTHER INDICATIONS OF DEPRESSION
Extreme anxiety, agitation or enraged behavior
Excessive drug and/or alcohol use or abuse
Neglect of physical health
BASED ON THE VIDEO AND/OR SCREENING, I FEEL
□ I need to talk to someone …
□ I do not need to talk to someone …
ABOUT MYSELF OR A FRIEND.
IF YOU WISH TO SPEAK WITH SOMEONE, YOU WILL
BE CONTACTED WITHIN 24 HOURS. IF YOU WISH
TO SPEAK WITH SOMEONE SOONER, PLEASE
APPROACH STAFF IMMEDIATELY.
Evaluation of the SOS Program
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
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.
Reducing Liability –
Common Themes in Lawsuits
• The institution ignored warning signs of
• 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,
Student Mental Health Screening:
A 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
Constance Neary, Vice President for Risk Management, United Educators Insurance
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
Always consult with the school legal department for
questions regarding policies
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
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.
Common Objections & Talking Points
Suicide is not a problem in our school
No school is immune to adolescent suicide
Schools are not appropriate for suicide prevention
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
Common Objections & Talking Points
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
It can also compliment other programs (QPR)
For more information, contact:
Diane Santoro, MSW, LICSW
Screening for Mental Health, Inc.
One Washington Street, Suite 304 Wellesley Hills, MA 02481
Phone: 781.239.0071 Fax: 781.431.7447
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 http://www.cdc.gov/injury/wisqars/index.html
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
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.
Kerr, M. Suicide Prevention in Schools: Best practices and questionable practices [PDF document]. Retrieved from STAR-Center
Online Website: http://www.starcenter.pitt.edu/suicidepreventionresources/56/default.aspx
Litts, D. (August 2, 2004). USAF Suicide Prevention Program: Lessons for Public Health Prevention in Non-military Communities.
Retrieved June 2, 2009 from http://www.sprc.org/traininginstitute/disc_series/disc_1.asp
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
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.