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School psychologists involvement and perceived preparedness in the provision of suicide-related services :

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Title:
School psychologists involvement and perceived preparedness in the provision of suicide-related services : a comparison of practitionars serving different school levels
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English
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Cunningham, Jennifer
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University of South Florida
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Subjects / Keywords:
Crisis intervention
Preparation
Elementary school
Children
Suicide prevention
Dissertations, Academic -- Psychological & Social Foundations -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: While the manifestation of suicidal thoughts and/or behavior is more common among adolescents, children are capable of, and do experience, suicidal ideation as well as demonstrate suicidal behaviors. Suicide is the sixth leading cause of death among children aged 5-14 years (Center for Disease Control CDC, 2008). However, children may not always be referred or brought to the attention of the school psychologist, as their threats may be considered immature and unfounded. The purpose of this study is to provide data that clarifies the need for the provision of suicide-related services for children in elementary school. An archival dataset of 226 National Association of School Psychologist (NASP) practitioners was analyzed. In regards to referrals for potentially suicidal youth, within a two year period, practitioners who served elementary schools received an average of 1.64 referrals, practitioners who served middle/junior high schools received 2.95 referrals, and practitioners at the high school level received 3.95 referrals. Within the same time period, practitioners who served elementary schools experienced an average of .05 completed suicides, middle/junior high school practitioners experienced .07 completed suicides, and practitioners at the high school level experienced .16 completed suicides. Results indicated that overall, practitioners felt "moderately prepared" to provide suicide-related services to youth. School psychologists who predominantly served high schools perceived themselves to be significantly more prepared to engage in suicide-related roles than their elementary school colleagues. School psychologists who predominantly served middle/junior high schools were similar to their colleagues who served either elementary or high schools on three out of four professional roles. Implications for future research, training, and practice are discussed.
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Thesis (Ed.S.)--University of South Florida, 2010.
Bibliography:
Includes bibliographical references.
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by Jennifer Cunningham.
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Title from PDF of title page.
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Document formatted into pages; contains X pages.

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ABSTRACT: While the manifestation of suicidal thoughts and/or behavior is more common among adolescents, children are capable of, and do experience, suicidal ideation as well as demonstrate suicidal behaviors. Suicide is the sixth leading cause of death among children aged 5-14 years (Center for Disease Control [CDC], 2008). However, children may not always be referred or brought to the attention of the school psychologist, as their threats may be considered immature and unfounded. The purpose of this study is to provide data that clarifies the need for the provision of suicide-related services for children in elementary school. An archival dataset of 226 National Association of School Psychologist (NASP) practitioners was analyzed. In regards to referrals for potentially suicidal youth, within a two year period, practitioners who served elementary schools received an average of 1.64 referrals, practitioners who served middle/junior high schools received 2.95 referrals, and practitioners at the high school level received 3.95 referrals. Within the same time period, practitioners who served elementary schools experienced an average of .05 completed suicides, middle/junior high school practitioners experienced .07 completed suicides, and practitioners at the high school level experienced .16 completed suicides. Results indicated that overall, practitioners felt "moderately prepared" to provide suicide-related services to youth. School psychologists who predominantly served high schools perceived themselves to be significantly more prepared to engage in suicide-related roles than their elementary school colleagues. School psychologists who predominantly served middle/junior high schools were similar to their colleagues who served either elementary or high schools on three out of four professional roles. Implications for future research, training, and practice are discussed.
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School Psychologists Involvement and Perceived Preparedness in the Provision of Suicide Related Services: A Comparison of Practitioners Serving Different School Levels by Jennifer M. Cunningham A thesis submitted in partial fulfillment of the requirements for the degree of Education Specialist Department of Psychological and Social Foundations College of Education University of South Florida Major Professor: Shannon M. Suldo, Ph.D. Linda Raffaele Mendez, Ph.D. Julia A. Ogg, Ph.D Richard B. Weinberg, Ph.D. Date of Approval : March 26, 2010 Keywords: crisis intervention, preparation elementary school children, suicide prevention Copyright 2010 Jennifer M. Cunningham

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Acknowledgement s I would like to thank my Major Professor, Dr. Shannon Sul do, for her unwavering support and invaluable guidance throughout this research project. Without her, this project would have never come to fruition. I would also like to thank my commit tee members, Dr. Linda Raffaele Mendez, Dr. Julia Ogg, and Dr. Richard Weinberg, for their assistance and insight throughout this project. Special thanks to Allison Friedrich, for allowing me to access her dataset. Finally, I would like to thank my family, for their continual love and support in all that I do.

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i Table of Contents List of Tables i v Abstract v i Chapter One: Introduction 1 Statement of the Problem 1 Purpose of the Current Study 3 Definition of Key Term s 4 Suicide 4 Suicidal 4 Suicide P r evention 4 Sui cide Assessment and Intervention 5 Postvention 5 Elementary Age Children 5 Middle/Junior High School Age Adolescents 5 High School Age Adolescents 5 Research Questions 5 Re search Question 1 5 Research Question 2 6 Research Question 3 6 Research Question 4 6 Research Question 5 6 Research Question 6 6 Contributions to the Literature 7 S ignifica nce of the Current Study 7 Chapter Two: Review of the Literature 9 Phenomena of Suicide Among All Youth 9 Suicidal Behavior 9 Prevalence Rates and Trends 10 Specific to Elementary Age Children 12 Risk and Protective Factors 13 Risk Factors 14 Prior Suicide Attempts 14 Psychopathologies 14 Substance Abuse 14 Familial 15 Situational 15 Specific to Elementary Age Children 16 Protective Factors 16

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ii Interpersonal 17 Restricted Access to Firearms 17 Indivi dual 17 Specific to Elementary Age Children 18 Warning Signs 18 Specific to Elementary Age Children 19 Developmental Differences Unique to Elementary Age Children 19 Suicide Related Services for Youth in Schools 22 Prevention 22 Specific to Elementary Age Children 25 Assessment and Intervention 26 Specific to Elementary Age Children 27 Postvention 31 Specific to Elementary Age Children 32 Role of the School Psychologist 33 Provision of Mental Health Services 33 Crisis Intervention 34 Suicide Related S e rvices in Schools 37 Training in Suicide Related S e rvices for School Psychologists 40 Conclusions 43 Chapter Three: Methods 45 Participants 45 Participant Selection 46 Instrument 49 Procedure 50 Overview of Proposed Data Analysis 50 Research Question 1 50 Research Question 2 51 Research Question 3 51 Research Question 4 52 Research Question 5 52 Research Question 6 53 Chapter Four: R e sults 55 Data Screening 55 Data Analysis 56 Research Question 1 56 Frequency of Referrals for P otentially Suicidal C h ildren at the Elementary S chool Level 57 Frequency of Referrals for P otentially at the Middle/Junior High S chool Level 57 Frequency of Referrals for P otentially Suicidal Adolescent s at the High S chool Level 58

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iii Research Que stion 2 61 Frequency of Referrals for Potentially Suicidal Students in Elementary Schools vs. Middle/Junior High Schools 62 Frequency of Referrals for Potentially Suicidal Students in Middle/Junior High Schools vs. High Schools 62 Frequency of Referrals for Potentially Suicidal Students in Elementary Schools vs. High S chools 62 Research Question 3 63 Frequency of Completed Suicides at the Elementary School Level 63 Frequency of Completed Suicides at the Middle/Junior High School Level 64 Frequency of Completed Suicides at the High School Level 64 Research Question 4 66 Frequency of Completed Suicides in Elementary Schools vs. Middle/Junior High Schools 66 Frequency of Completed Suicides in Middle/Junior High Schools vs. High Schools 6 7 Frequency of Completed Suicides in Elementary Schools vs. High S chools 67 Research Question 5 68 Research Question 6 71 Chapter Five: Discussion 75 Dis cussion of Results 75 Frequency of Referrals for Suicidal Students 75 Frequency of Completed Suicides by Students 79 Perceived Preparedness for Professional Roles Relevant to Youth Suicide by Proportion of Time Spent in Elementary Sch ool 81 Perceived Preparedness for Professional Roles Relevant to Youth Suicide by School Level Served 82 Implications of the Results for School Psychologists 88 Delimitations of the Current Study 90 Limitations of the Current Study 90 Impact of Memory on Recall 93 Directions for Future Research 94 Conclusions 95 References 98 Appendices 107 Appendix A: Content Items of Interest 108 Appendix B: Cover Letter 110

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iv List of Tables Table 1. Comparison of Demographic Characteristics of School Psychologists in Archival Database and a National Sample of NASP Members 4 7 Table 2. Professional Characteristics of School Psychologists in Archival Archival Database 4 8 Table 3. Frequencies of Referrals at the Elementary School Level 57 Table 4. Frequencies of Referrals at the Middle/Junior High School Level 58 Table 5. Frequen cies of Referrals at the High School Level 59 Table 6. Means, Standard Deviations, and Ranges of Referrals for Potentially Suicidal Youth Received in the Past Two Years by School Level 60 Table 7. Frequencies of Completed Suicides at the Elementary School Level 63 Table 8. Frequencies of Completed Suicides at the Middle/Junior High School Level 64 Table 9. Frequencies of Completed Suicides at the High School Level 64 Table 10. Means, Standard Devi ations, and Ranges of Completed Suicide Experiences in the Past Two Years by School Level 65 Table 11. Elementary School Psychologist Subgroups 69 Table 12. Mean Levels of Preparedness for Professional Roles by Proportion of Time Spent Serving Elementary Schools 69 Table 13. ANOVA Summary Table for Perceived Preparedness for Professional Roles by Percent of Time Spent Serving Elementary Schools 7 0

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v Table 14. ANOVA Summary Table for Perceived Preparedn ess for Professional Roles by School Level Predominantly Served 7 2 Table 15. Mean Levels of Preparedness for Professional Roles by School Level Predominantly Served 7 3

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vi School Psychologists' Involvement an d Perceived Preparedness in the Provision of Suicide Related Services: A Comparison of Practitioners Serving Different School Levels Jennifer M. Cunningham ABSTRACT While the manifestation of suicidal thoughts and/or behavior is more common among adol escents, children are capable of and do experience suicidal ideation as well as demonstrate suicidal behaviors. Suicide is the sixth leading cause of death among children aged 5 14 years (Center for Disease Control [CDC], 2008 ). However children may not always be referred or brought to the attention of the school psychologist, as their threats may be considered immature and unfounded. The purpose of this study is to provide data that clarifies the need for the provision of suicide related services for ch ildren in elementary sc hool. An archival dataset of 226 National Association of School Psychologist (NASP) practitioners was analyzed. In regards to referrals for potentially suicidal youth, within a two year period practitioners who served elementary sch ools received an average of 1.64 referrals, practitioners who served middle/junior high schools received 2.95 referrals, and practitioners at the high school level received 3.95 referrals Within the same time period, practitioners who served elementary sc hools experienced an average of .05 completed suicides, middle/junior high school practitioners experienced

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vii .07 completed suicides, and practitioners at the high school level experienced .16 completed suicides. Results indicated that overall, practitioners related services to youth. School psychologists who predominantly served high schools perceived themselves to be significantly more prepared to engage in suicide related roles than their elementary school coll eagues. School psychologists who predominantly served middle/ junior high schools were similar to their colleagues who served either elementary or high schools on three out of four professional roles. I mplications for future research, training, and practice are discusse d

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1 Chapter One Introduction Statement of the Problem Completed suicides during childhood remain a relatively rare phenomenon. However, suicide is the sixth leading cause of death among children aged 5 14 years (Center for Disease Control [CD C], 2008). This is an increase from years past, such as 1991, when suicide was the seventh leading cause of death among this age group (Milling, Campbell, Davenport, & Carpenter, 1991). Nevertheless, the dearth of completed suicides among children may lead school psychologists who work primarily with elementary age children to dismiss the need for skills related to prevention, assessment, and intervention with suicidal youth. Administrato rs and other school personnel also may tend to doubt the importance of such a skill set. However, research suggests that professional practices relevant to suicide prevention and intervention are pertinent to all school psychologists, including those who work with elementary age children due to (a) the prevalence of suicida l thoughts and harm related statements made by elementary age students (CDC, 2008), and (b) the impact of prevention related activities delivered to children on later suicide related thoughts and behaviors (Greening et al., 2008). The value of proactive pr ofessional practices with children as young as first grade is supported by results of recent outcome studies in which elementary school students who participated in universal interventions geared towards socializing children

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2 for the student role and reduci ng aggressive disruptive behavior experienced reduced suicidality (less suicide ideation and fewer suicide attempts) during young adulthood (Wilcox et al., 2008). Specific risk and protective factors exist for children that are particularly predictive of l ater suicidality (Greening et al., 2008). School psychologists must be cognizant of these factors, so that early intervention efforts can be implemented if necessary. Additionally, factors such as age, developmental level, cognitive ability, and death or s (Mishara, 1999). As such, the expression of their risk factors or warning signs may differ from older children or adolescents. Due to the numerous differences between children and ado lescents, existing suicide assessment procedures must be modified to accommodate this developmentally unique population (Hunter & Smith, 2008; Merrell, 2008). Appropriate modifications to clinical interviewing techniques, as well as use of developmentally appropriate assessment instruments, is crucial in ensuring that an accurate assessment of the threat to self harm is conducted. Thus, school psychologists who work with young children need to be equipped with a unique skill set to work effectively with thi s population. Despite the research supporting the need for the provision of services to suicidal children (Greening et al., 2008; Wilcox et al, 2008), there are few empirically supported school based prevention, intervention, or postvention programs that address the developmental differences in children. Further, there is a lack of training opportunities and literature specifically geared towards preparing school personnel, namely school psychologists, to work with potentially suicidal children. To inform practice and

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3 professional development efforts, information is needed regarding (a) the frequency with which school psychologists who serve young children encounter suicidal youth in their ce in their abilities to work effectively with this population in relation to suicide risk. Purpose of the Current Study The primary purpose of the current study was to encounters with suicidal children and adolescents in thei r school based practice. The study aimed to provide concrete figures regarding the frequency of both referrals for and completed suicides among students at different school levels (i.e., elementary school, middle/junior high school, high school). A specifi c focus of the study also was to provide data that clarifies the need for the provision of suicide related services for children in elementary school, by determining the frequency with which elementary referrals received by school psychologists are referre d potentially suicidal children in schools (relative to the school psychologists who work in middle/junior high schools and high schools) as well as the frequency with which school psychologists who work in elementary schools experience the occurrence of a completed suicide (relative to school s among middle/junior high and high school students ) The final purpose of the study was to determine whether practitioner perceived preparedness to engage in professional roles relevant to youth suicide (i.e., prevention, assessment, counseling/support, postvention) differed as a function of school level predominantly served.

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4 Definition of Key Terms Suicide life or engaging in intentional self injurious behavior that ultimately results in death (Mazza & Reynolds, 2008). Suicidal The term suicidal refers to a range of thoughts, behaviors, and/or deliberate actions that can result in potentially life threat ening consequences (Mazza & Reynolds, 2008). An individual is identified as suicidal when he or she is actively thinking about and/or engaging in behavior with the intent of taking his or her own life. Suicide p revention Prevention is an overarching ter m that is comprised of many activities that seek to reduce the prevalence of suicidal thoughts, behaviors, attempts, and ultimately completed suicides (Kalafat & Lazarus, 2002). Such activities include, but are not limited to: general suicide awareness an d education, screenings, crisis and/or mental health team coordination, collaboration with community services, reliance on evidence based strategies to guide prevention activities and detailed intervention and postvention protocols aimed at preventing sub sequent suicide attempts (Lieberman, Poland, & Cowan, 2006). Suicide a ssessment and intervention Assessment and intervention activities are geared towards preventing suicide among youth that have demonstrated warning signs, or possess risk factors, assoc iated with suicidal behaviors (Kalafat & Lazarus, 2002). While these specific activities may vary, the general components include: detecting suicidal students, assessing suicidal intent, parental notification, initiating referrals for necessary mental heal th services, and providing follow up care (Kalafat & Lazarus, 2002).

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5 Postvention Postvention activities commence after the occurrence of a completed suicide, and the ultimate goal of these procedures is to take purposeful steps to prevent another suicid e (Poland & Lieberman, 2002). Such activities include: having a trained crisis response team, verifying that the death was a suicide, releasing only truthful and relevant information to students and parents, and offering grief counseling for students affec ted by the death (Brock, 2002). Elementary a ge c hildren Children who are currently in grades Kindergarten through fifth are referred to as elementary age youth or children. These children are typically from 5 to 10 years of age. Middle/ j unior h igh s ch ool a ge a dolescents. Adolescents who are currently in grades six through eight are referred to as middle/junior high school adolescents. These adolescents are typically 11 to 14 years of age. High s chool a ge a dolescents. Adolescents who are currently in g rades nine through twelve are referred to as high school adolescents. Typically, these adolescents are between the ages of 14 and 18. Research Questions To generate information regarding practitioner experiences with and preparedness for the provision of suicide related services to children, the following research questions were addressed by analyzing a dataset consisting of responses from mail out surveys that current practicing school psychologists were asked to complete. Research Q uestion 1 : What is the frequency with which school psychologists who work in different school levels receive referrals for potentially suicidal youth?

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6 Research Question 2 : Does the frequency of referrals for potentially suicidal youth differ as a function of school level serve d ( i.e ., elementary, middle, high)? Research Question 3 : What is the frequency with which school psychologists who work in different school levels experience the occurrence of a completed suicide? Research Question 4 : Does the frequency of occurrences of completed suicides differ as a function of school level served ( i.e., elementary, middle, high)? Research Question 5: Does the perceived level of elementary school functio n of the proportion of time they spend serving that population with respect to: a. Prevention? b. Intervention/assessment? c. In school counseling or support? d. Postvention? Research Question 6 : Does the perceived level of practitioner preparedness fo r professional roles relevant to suicide differ as a function of school level served ( i.e., elementary, middle, high) with respect to: a. Prevention? b. Intervention/assessment? c. In school counseling or support? d. Postvention?

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7 Contributions to the Literature The current study augment s the extant literature by underscoring the need for specific suicide related services (i.e., prevention, intervention, and postvention) for young children by providing data that support the notion that even young chil dren evidence suicidal thoughts. This study also contribute s to the literature by providing the first examination of school psych ologist s perceptions of preparedness in the provision of suicide related services as a function of school population served. F indings may provide implications for training programs regarding the need to more fully prepare practitioners to deal with potentially suicidal children. Significance of the Current Study The results from this study provide concrete evidence supporting n ot only the need for school psychologists serving all school levels to be trained in the provision of suicide related services, but also for those practitioners employed in elementary school settings to be trained in how to provide suicide related services to children. The fact that the majority of practitioners employed by public schools practice in elementary schools (Curtis, Hunley, Walker, & Baker, 1999), further illustrates the need to inform professional practices relevant to this specific population of school psychologists. Further, this study can provide evidence for school psychology training programs that practitioners should receive training in suicide related services specific to developmental levels of students (i.e., children, adolescents). The results from the current national study also provide baseline data specific to school psychologists current average perceptions of confidence in the provision of

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8 suicide related services to young children. Systemic efforts to provide needed trainin g in t his area to practitioners can be evaluated in part by examining mean levels of practitioners perceptions of preparedness to the results obtained in the current study.

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9 Chapter Two Review of the Literature This chapter reviews literature relevant to th e current study. Specifically, this chapter examines the literature in three main areas: the phenomenon of s uicide among all y outh s uicide related services for youth in schools and the role of the school psychologist relevant to the provision suicide rel ated services. When available, information within these areas that is specific to young children is highlighted. An understanding of pertinent literature in these three areas provides the relevant background information necessary in order to put the aim of the current study into context. Phenomena of Suicide Among All Youth Suicidal Behavior When discussing suicide, it is important to differentiate between the terms e, while suicidal behavior involves any deliberate action that can result in potentially life threatening consequences (Mazza & Reynolds, 2008). The phenomenon of suicide involves a continuum of behaviors, which ranges from suicidal ideation at one end, fo llowed by suicidal intent, suicidal attempt, and finally death at the other end of the continuum (Mazza & Reynolds ) Along the continuum of behaviors, the frequency of each behavior decreases, but its lethality increases. Mazza and Reynolds defined suicida l ideation ; suicidal ideation is the first domain on th e suicidal behavior continuum ( p.

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10 216). Example of suicidal ideations can be wishes of never being born to more specific thoughts, such as a suicide plan. Suicidal intent is the second domain along the al intent behaviors include giving away prized possessions, engaging in minor self destructive behaviors, and making subtle or overt threats (Mazza & Reyonlds). A suicidal attempt is the most lethal form of suicidal behavior. A suicide attempt is defined a injurious intentional self injurious behavior that results in de ath (Mazza & Reynolds ). This domain is the most rare. Prevalence Rates and Trends Across the United States, approximately 30,000 people take their own lives each year, and about another 650,000 receive emergency care after attempting to take their own liv es (U.S. Department of Health and Human Services [DHHS], 2001). As the eleventh overall leading cause of death in 2006, suicide accounted for 32,185 deaths (Heron et al., 2008). Suicide and suicidal behaviors are not restricted to just adults. In fact, acc ording to the National Vital Statistics Report for 2006, suicide rates were the highest for the 15 24 year old age group being the third leading cause of death, followed by ages 25 44, for which suicide ranks as the fourth leading cause of death (Heron et al., 2008). Over the past few decades, suicide rates for adolescents have been on the rise (Kalafat & Lazarus, 2002). Between 1960 and 1990, suicide rates for teens ages 15 19 more than tripled, from 3.6 to 11.3 per 100,000 deaths. Similar trends were obs erved for

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11 youth ages 10 14 years, increasing over 120% between 1980 and 1996. During the for youth ages 10 19 was observed, unt il an 18% increase between 2003 and 2004 occurred (Bridge, Greenhouse, & Weldon, 2008). In speculating as to what may contribute to this increase factors such as increase d use of and access to media, internet, and specifically online social networking sites should be considered. In 2006, suicide was the third leading cause of death for adolesc ents and young adults ages 10 24 years (National Adolescent Health Information Center [NAHIC] 2006). Adolescent and young adult males ages 10 24 have a consistently higher suicide rate than their female peers, averaging more than five times the rate of sa me age females ( NAHIC 2006). Between 1981 and 2003, 84.1% of 10 to 24 year olds who committed suicide were male (NAHIC, 2006) However, while adolescent males typically complete suicide at a higher rate than their female peers, females are more apt to at tempt suicide at a higher rate and report more suicidal ideation (Center for Disease Control [CDC], 2006 ; Mazza and Reynolds, 2008 ; NAHIC, 2006) When broken down by ethnicity, American Indian /Alaskan Native, non Hispanic males and females ages 10 24 have the highest suicide rate, 31 deaths per 100,000, which is over two times higher than rates for White non Hispanic adolescents (15.1 deaths per 100,000 in 2003; NAHIC, 2006) The suicide rate f or African American youth is 10.1 deaths per 100,000, while Hispanic/Latino youth average 9.6 deaths per 100,000. Finally, the suicide rate for Asian American and Pacific Islander youth was 8.9 per 100,000 deaths ( NAHIC, 2006).

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12 The three methods of self ha rm most often used in suicides of young people include firearms, hanging or suffocation, and poisoning (CDC, 2006). In 2005, the leading suicide method for both males and females ages 10 14 was suffocation (63.7%), followed by firearms (31.1%), and poisoni ng (3.0%). For males and females ages 15 24, the top three methods of suicide involve firearms (46.6%), suffocation (37.3%) and poisoning (8.6%; CDC, 2006). Specific to elementary a ge c hildren Completed suicides during childhood remain a relatively rare phenomenon. While suicides have been verified among children younger than age 10, it is a very rare occurrence (Mazza & Reyonlds, 2008). However, in 2006, suicide was the sixth leading cause of death among children ages 5 14 years accounting for 3.4% of a ll deaths in that age group (Heron et al., 2008). This is an increase in position from years past, when suicide was the seventh leading cause of death among 5 14 year olds (Milling et al., 1991). The trend in methods used by children has followed a simila r pattern to that of youth ages 15 to 19 years. Since 1993, suicides by suffocation among children ages 10 to 14, and youth ages 15 19 have increased, while suicide by firearms has decreased. Since 1999, suicide by suffocation has occurred more frequently than those by firearms (American Association of Suicidology [AAS], 2008). Notably, Mishara (1999b) found that many coroners are often reluctant to classify that th ey are often hesitant to rule even obvious self inflicted injuries as suicide, due to the belief that children do not fully understand the consequences of their actions. As a

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13 result, it is probable that the actual number of children that commit suicide is underreported, or deaths are erroneously classified as accidental. In sum, recent trends seem to indicate that while youth suicide rates decreased in in subsequent years the number of completed suicides has risen Stable trends include that ma les commit suicide at a significantly higher rate, while more females attempt suicide and demonstrate suicidal ideations. This is attributed to the methods utilized by each; males tend to select more lethal and immediate methods, such as firearms, while fe males tend to utilize hanging or poisoning methods ( NAHIC, 2006) Findings are also consistent regarding the frequency of completed suicides among children; although it was the sixth leading cause of death in 2006 for children ages 5 14, completed suicides in children younger than 10 years old remain rare. Risk and Protective Factors It is rare for an individual to commit suicide without warning. Rather, most suicides tend to be the result of increased risk factors and a lack of protective factors (Brock, Sandoval, & Hart, 2006). Additionally, a suicidal individual typically displays factors and the absence of protective factors do not definitively predict suicidal be havior, they do signal the need to be more vigilant of warning signs. There is general agreement in the research regarding what constitutes significant risk and protective factors, as well as warning signs. The most salient risk factors, protective factors and warning signs are summarized below.

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14 Risk Factors Risk factors may be defined as leading to or being associated with suicide; more specifically, individuals "possessing" the risk factor or factors have a greater potential for demonstrating suicida l behavior (DHHS, 2001). Prior suicide attempts The most significant predictor of a future suicide attempt is a previous attempt (Brock et al., 2006). It is estimated that 26 33% of adolescent suicide victims have made at least one previous attempt (Polan d & Liberman, 2005). Therefore, individuals who have made a previous attempt should be closely monitored for future risk. Psychopathology According to Poland and Lieberman (2005), over 90% of individuals who engage in suicidal behaviors have a psychiatri c disorder or a history of psychopathology. Mood disorders, depression in particular, are typically the most common mental illnesses that place individuals at increased risk for suicide (Brock et al., 2006; Mazza & Reynolds, 2008). According to the AAS (20 07), the risk of suicide among individuals with major depression is 20 times greater than individuals in the greater population. In addition, the feelings of hopelessness or helplessness that are commonly associated with depression are risk factors on thei r own, separate from the presence of a diagnosed mental illness. Other psychiatric disorders that are considered to be risk factors for suicide are substance abuse, anxiety disorders, and disruptive behaviors (Brock et al., 2006). Substance abuse Substa nce abuse plays an important role in suicide and individuals who abuse substances are considered to be at high risk for suicide The main reason that this risk factor is so critical is because the use of substances (i.e., illicit drugs

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15 and alcohol) decrea ses inhibition, thus increasing impulsivity and dissociation, and increasing the chance of making an attempt (Sommers Flanagan & Sommers Flanagan, 2008). Furthermore, if substance abuse is associated with depression, social isolation, or other risk factors the level of risk is exacerbated further. For example, i ndividuals with a history of alcohol abuse are six times more likely to die by suicide than those in the general population (Poland & Lieberman, 2002). Familial There are several risk factors rela ted to the family that have been significantly associated with suicidal ideation and behaviors, such as low levels of parental support or involvement, the presence of maternal or paternal mental illness, family history of suicide, and the presence of abuse (e.g., emotional, sexual, and/or physical; Brock et al., 2006; DHHS, 2001). Additionally, restricted access to mental health treatment, cultural or religious beliefs that condone suicide, easy access to lethal means (such as a firearm in the house), stigm a associated with help seeking behavior, and exposure to media that sensationalizes suicide, are all associated with suicidal ideation and behavior (Brock et al., 2006; DHHS, 2001). Situational Several situation specific risk factors have also been correl ated with suicidal ideation and behaviors. Most of these factors can be divided into the following categories: loss (e.g., loss of a loved one, loss caused by family relocation, loss of self esteem, loss of friends/social isolation), stressful life events (e.g., poverty, relationship break parental arguments, abuse, lack of social support at home), suicidality of others (e.g., exposure to the suicidal behavior of a peer, c ompleted suicide in the community) (Brock et al., 2006; Poland & Lieberman, 2002). However, one situational risk factor stands

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16 alone as it is the strongest situational risk factor: the presence of a firearm (Poland & Lieberman, 2002). In situations where a firearm is present, other risk factors are exacerbated, or place increased stress on the individual. Specific to elementary age children While the presence of any of the aforementioned risk factors should be taken seriously, the presence of depression, impulsivity, and aggression in children are particularly important as they are empirically identified risk factors for later suicidality as adolescents or adults (Greening et al, 2008). If these risk factors are identified in young children, their chances for experiencing feelings of suicidality and/or engaging in suicidal behaviors increase dramatically. Furthermore, demonstration of suicidal behaviors or suicide attempts in childhood predicts future suicide attempts in adolescents or adulthood, and such d isplays should be considered extremely serious (Greening et al., 2008). Of additional importance are other risk factors particularly predictive of suicide among children, such as the presence of psychiatric disorders, poor social adjustment, abuse (emoti problems or familial suicide, chronic health problems, and poor coping strategies (Centre for Suicide Prevention, 2000). While these risk factors may be applicable to older ad olescents the presence of the aforementioned risk factors in children places them at an increased risk for suicide and/or suicidal behaviors. Protective Factors Opposite of risk factors, protective factors reduce the likelihood of suicide. They enhance r esilience and may serve to counter risk factors (DHHS, 2001). According to the DHHS (2001), there are several important protective factors that can reduce the

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17 likelihood of a suicide attempt or completion. Effective clinical care for mental, physical and substance use disorders, in addition to easy access to a variety of clinical interventions and support for help seeking, are factors that can alleviate distress caused by mental illness. Interpersonal The most influential protective factors involve inter personal systems, specifically family and peer networks. Strong connections to family members and friends, good communication among family members, parental involvement and engagement, and ties to the community, as well as peer support and close social net works, all act as strong protective factors as long as they are present and functional (Brock et al., 2006; DHHS, 2001). Cultural and religious beliefs that discourage suicide are also considered to be essential interpersonal protective factors. Restrict ed access to firearms Another important protective factor is restricted access to highly lethal means of suicide, such as firearms or poisons (Brock et al., 2006; DHHS, 2001). The availability of firearms in the home is associated with increased suicidal ideation, and the presence of a gun in the home is associated with a five time greater risk of completed suicide (Brock et al., 2006). As a result, the absence of these weapons or any other potentially lethal means acts as a protective barrier against suic idal ideation and behaviors. Individual Several additional protective factors relate to attributes within an individual. Specifically, good problem solving and conflict resolution skills, adaptive coping skills, and nonviolent methods of handling dispute s are linked to reduced suicidality. Also, general satisfaction with life, high self esteem, and feeling that one has a purpose in life are considered to increase resiliency (Brock et al., 2006).

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18 Specific to elementary age children While all of the afore mentioned protective factors are pertinent to children, perhaps the most important protective factors for children are within the control of their parents (Ash, 2006). The most significant protective factor that parents have control over is removal of leth al means from the home. Especially if parents suspect suicidal ideation, it is of utmost importance that they be vigilant in keeping the home safe. In addition, parents can play a role in fostering resiliency in their children by reducing disruptive or str essful family patterns or events and increasing familial support and cohesion (Ash, 2006). Warning Signs Warnings signs are the ways in which an individual communicates distress, and signals the possibility of suicidal ideation (Brock et al., 2006). A c ommon mnemonic ands for purposelessness, when an individual sees no reason for living or no sense of purpose in which can manifest as agitation, being unable to sleep or re is no way out of stands for anger, which can look like rage or revenge see king behaviors for a perceived taking behaviors dramatic changes in mood can signal distress.

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19 Speci fic to elementary age children A review of the literature did not yield any warning signs that were specific to young children. However, it is important to note that elementary age children do not generally refer themselves, and therefore their behaviors are often the first sign of their intentions (Poland & Lieberman, 2005). Therefore, presence of any of the above warning s igns should be taken seriously. Developmental Differences Unique to Elementary A ge C hildren Perhaps the largest difference between chi ldren and older adolescents in regards to suicide is the concept of death. In order for children to understand and fully grasp the concept of suicide, they must understand the concept of death. This is important for school psychologists to be cognizant of, from that of adolescents, teenagers, and adults (Mishara, 2003). There are four aspects of death that adults and children view differently: irreversablity, nonfunctionality (finality), universality, and in evitability (Hunter & Smith, 2008; Mishara, 2003; Willis, 2002). The first stage is irreversability, in which young children liken death to sleep. This association is impacted largely by portrayals of death in fairytales and cartoons, in which characters t hat die can be reawakened or brought back to life if one has special knowledge or a magical potion (Cox, Garrett, & Graham, 2005; Mishara, 2003). This finding has provoked much research into the portrayal of death in fairytales, cartoons and movies (i.e. C ox et al., 2005), as those are the specific mediums to which younger children are frequently exposed. Second, children do not fully grasp the concept that once a person dies, his or her biological functioning ends. In other words, children do not understan d that death is final. Third, universality refers to the stage in which children come to understand that all people die; young children tend to believe that not all people die (Hunter & Smith, 2003; Mishara, 2003). Finally, most

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20 young children do not under stand that death is unavoidable. They hold the misconception that people can avoid death/dying if they know how to. Children must acquire knowledge of each of these sub concepts en route to gaining a mature understanding of death. According to Hunter and S mith (2008), formulation of a mature understanding of death seems to suggest that children hold an immature view of death until about the age of 9 or 10 years old, at which age they begin to develop a mature understanding of death. However, one salient finding from Hunter concepts of death at an earlier age ( M = 6.25 years) than reported in previous studies. This finding, which is not consistent with previous research, suggests that there might not be definitive guideline s as research suggests that mature death concepts are related to age, cognitive ability, and death experiences. Findings also implied that recent events in the United States, such as September 11 th and the war in Iraq, have played major roles in facilitating Children learn about death through many different contexts, such as school, media, and conver sations with adults (Mishara, 2003). For example, talking with parents about family members or pets that have died, memorial holidays for those who have died in wars, and depictions of death and dying on television or in movies are all ways that children l society, the internet provides yet another medium for children to explore the topic of death independently. By increased exposure to the subject of death and conversations with a dults, coupled with increasing cognitive reasoning and thinking abilities, children eventually begin to form a more mature concept of death.

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21 Once children understand death, they can begin to understand the complex phenomena of suicide. There are two major ways in which children learn about suicide. In part because adults (i.e., parents and teachers) rarely explain suicide to children, children learn about suicide primarily on their own, from other children, or overhear adult conversations (Mishara, 2003). Adults tend to avoid the topic, as many believe that suicide is not something that children can or should have to deal with. When a suicide occurs in the family, parents usually explain that the death was an accident, even under obvious circumstances, such (Mishara, 2003). Second, children learn about suicide through the media, particularly learn through mediums such as television, movies, and the internet. For example, research conducted in Quebec (Mish ara, 1999a) found that one half of participants ages 5 7 reported seeing at least one suicide on television. Moreover, children reported that depictions of suicides on television or in movies were the primary methods of their knowledge of suicide. s (1999b) research with 65 students ages 6 12 found that even though able to n ame several methods by which one can commit suicide. For example, in response to an open ended question (i.e., how could someone commit suicide?), 58% of participants reported using a knife, 34% reported jumping, 31% reported using a firearm, and 25% repor ted poisoning. Finally, 14% indicated that they had at some point considered committing suicide, but none had attempted it. Taken together, results of this study have significant implications for professionals working with children; although

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22 children migh t not be familiar with specific terminology, they are quite aware of what it means to kill themselves and specific methods of doing so. Suicide R elated Services for Y outh in S chools Prevention Prevention is typically the primary focus in the continuum of suicide related services. Prevention can be thought of as an umbrella term that encompa sses the following activities: general suicide awareness and education, screenings, crisis and/or mental health team coordination, collaboration with community services reliance on evidence based strategies of prevention, and detailed intervention and postvention protocols aimed at preventing subsequent suicide attempts (Lieberman, Poland, & Cowan, 2006). Students spend the majority of their days at school, which is t he obvious setting for the implementation of suicide prevention programs for multiple reasons (Kalafat & Lazarus, 2002; Mazza & Reynolds, 2008). First, school education policies mandate that schools must not only educate, but protect students. The implemen tation of suicide prevention programs can be seen as one mechanism of defense for students, by ensuring their safety and the safety of others. Second, the organizational qualities of schools provide access to all students, both children and adolescents Th is gives school personnel the opportunity to raise student awareness of risk factors, foster protective factors, and identify (and intervene with) students that are determined to be at risk. Thus, schools lend themselves to many varieties of prevention and early intervention initiatives. Further, programs that are designed to reach students who are at risk for suicide can also help reach students who are struggling with other mental health issues, such as depression and

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23 anxiety. Finally, school personnel ca actual knowledge of foreseeable harm and failed to take reasonable steps to prevent such considered to be one meth od of taking reasonable measures to prevent harm to students, and at the same time these programs are a way to ensure that school personnel are protected from legal sanction in the event a completed suicide occurs. School based prevention programs can be divided into three categories: universal prevention programs, selected prevention programs, and indicated prevention programs. Universal prevention programs target entire school populations, while selected prevention programs focus efforts on a specific su bpopulation of students deemed to be at elevated risk, and indicated prevention programs target individual students who have previously attempted suicide or are experiencing clinical levels of depression (Kalafat & Lazarus, 2002; Mazza & Reynolds, 2008). Universal prevention programs involve systematic school wide activities aimed at increasing general awareness about suicidal ideation and/or behaviors, dispelling common myths, and providing information to staff and students about important risk factors and warning signs of suicide (Mazza & Reynolds, 2008). The overall goal of these programs is to ensure that school personnel are equipped to effectively identify at risk students and initiate the appropriate course of action (Kalafat & Lazarus, 2002). Kala fat and Lazarus (2002) have outlined several general components of effective universal prevention programs. First, administrative consultation is necessary to ensure that there are specific policies and procedures in place for responding to at risk student s. It is important that all school personnel are aware of the specific procedures in place to ensure

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24 that they follow the appropriate steps when dealing with potentially suicidal youth. Best practices suggest that crisis intervention policies and procedure s, including information relevant to suicide, should be documented in a district wide manual, so that practices are the same across all schools (Taylor, 2001). Then, school trainings should be provided for all faculty and staff; topics should include how t o identify students who may be at risk, and the correct procedures for referring them to the appropriate school personnel (i.e., school psychologist, guidance counselor). This training is referred to as gatekeeper training (Lieberman, Poland, & Cowan, 2006 ). Similar to gatekeeper trainings, parent training should also be conducted to inform parents of relevant warning signs or behaviors that might signal that their child is in distress. Community gatekeeper trainings should be conducted to facilitate polici es and procedures between home and schools, as well as the integration of community resources. Finally, classes for students should be conducted to familiarize students with risk factors and warning signs, as well as information regarding when and how to r eport suicide threats to adults ( Taylor, 2001). Taken in combination, the aforementioned components comprise a best practice model of a universal prevention program. Selected prevention programs, sometimes referred to as targeted prevention programs, focu s on a smaller population of students who are at higher likelihood of experiencing depression or engaging in suicidal behavior (DHHS, 2001). These students are typically identified through a school wide screening, which can be part of a universal preventio n program. Components of selected prevention programs usually consist of developing and teaching good decision making skills, helping the student to identify

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25 resources that they can utilize for help, practicing appropriate help seeking behaviors, and devel oping effective coping strategies (Mazza & Reynolds, 2008). The focus of indicated prevention programs is on an individual student who has been identified as experiencing depressive symptoms or has made a previous suicide attempt. These programs aim to re duce the current conflict or distress that the student is experiencing, and diminish any risk of the student further engaging in suicidal behavior (Mazza & Reynolds, 2008). As these programs are typically aimed at treating specific problems, they tend to d raw from individualized, empirically supported interventions for depression and/or suicidal behavior. Specific to elementary age children In order to identify at risk children, mental health professionals should consider school wide and/or targeted scree nings in early grades to identify children with high numbers of symptoms of depression and/or aggression (Greening et al., 2008). These screenings can be conducted as early as kindergarten or first grade. Children who are identified using these screenings can be provided early interventions to reduce those symptoms that are linked to subsequent suicidality. Wilcox and colleagues (2008) evaluated a universal preventive intervention aimed at socializing first grade children and using classroom management te chniques to reduce aggressive, disruptive behavior, with the ultimate purpose to delay or prevent onset of suicide ideation and attempts. Two interventions were examined: the Good Behavior Game (GBG; Barrish, 1969) and Mastery Learning (ML; Block & Burns, 1976). The based behavior management strategy that promotes good behavior by rewarding teams that do not exceed maladaptive behavior standards as set by

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26 emonstrated effectiveness in improving achievement and the underlying theory and research posit that under appropriate instructional conditions virtually all students can learn most of what the GBG was associated with a reduction of risk for suicidal ideation by ages 19 21, as children who received the GBG reported experiencing half the rates of suicidal ideation of youth in matched control classrooms. There was no statistically significant i mpact on these same indicators for youth in the ML condition. Results from this study have not been replicated. However, these preliminary findings suggest that early mastery of social demands, including appropriate behavior, in the classroom may promote l ater successful adaptation. Assessment and Intervention engagement in suicidal behavior, it becomes their legal responsibility to intervene and make certain that appropriate steps a detection of risk factors and warning signs, more direct methods of assessments exist and typically concern five major areas: assessment of depression, presence of suicidal thoughts, exploration of su icide plans, assessment of student risk and protective factors, and final determination of whether the student intends to actually commit suicide (Sommers Flanagan & Sommers Flanagan, 2008). If a student is suspected to be at risk for suicide, then typica lly the school harm (Kalafat & Lazarus, 2002; Poland & Lieberman, 2005). Methods frequently used to assess

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27 level include clinical interviews, completion of checklists, and administration of standardized questionnaires. Although specific assessment and intervention procedures differ between school districts, many share similar components. The procedures employed by the Los Angeles Unified School District (LAUSD) are aligned with best practices in assessment and intervention; the LAUSD is frequently referenced throughout the literature as an excellent model of assessment and intervention protoco ls (Poland & Lieberman, 2005). suicidal behavior. At this stage, clinical interviewing and administration of questionnaires (i.e., behavior rating scales) are cond ucted. The second step involves the intervener harm. Third, the intervener provides referrals to any appropriate community agencies. Finally, the intervener and/or other school personnel follow up with the family and provide any assistance needed to make sure the student is supported. Specific to elementary age children When assessing elementary age children who are suspected to be suicidal, the intervener should modify existin g assessment procedures to ensure the provision of developmentally appropriate services (Merrell, 2008). Most suicide assessment measures are geared towards adolescents, but children differ from adolescents in several important ways relevant to suicide (Hu nter & Smith, 2008; Mishara, 1999b; Mishara, 2003). As such, it is important to use developmentally appropriate methods and/or modify existing techniques to suit the child. Merrell (2008) outlines several important considerations that need to be kept in m ind when interviewing children. First, establishment of adequate rapport and familiarity

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28 with the child before the actual assessment commences is crucial for obtaining the maximum amount and quality of responses possible in standardized assessment situatio ns. Children need to be comfortable, especially in new and/or sensitive situations. eye contact with the child. At the same time, the child should be allowed to determine how close he or she wants to sit to the interviewer, who should be willing to sit lower to the ground to avoid intimidation of the child. Next, allowing the child to see and/or use manipulatives or drawings during the interview provides an additional way f or children to express themselves. It is also recommended that the interviewer avoid the use of abstract or symbolic questions, which could confuse the child. For example, rather than asking a younger and less cognitively sophisticated child if he or she h as been thinking about 2008, p.171). Finally, Merrell recommends that the interviewer selectively use praise or appreciative statements following self disclosures, in order to let children know their honesty is appreciated. While the majority of suicide assessment tools were developed for adolescents and adults, there are several instrument s that have been previously used with children under the age of 12 (Larzelere, Anderson, Ringle, & Jorgensen, 2004). These instruments include the following: the Suicidal Behavior Questionnaire for Children (SBQ C; Cotton & Range 1993), the Fairy Tales Tes t (Orbach et. al, 1983), the Scale for Suicidal Ideation (SSI; Beck et al., 1979), the Child Suicide Potential Scales (Pfeffer et al., 1979), the

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29 Child Adolescent Suicide Potential Index (CASPI; Pfeffer, Jiang, & Kakuma, 2000), and the Child Suicide Risk A ssessment (CSRA; Larzelere et al, 2004) The SBQ C is a downward extension of the adult version of the SBQ. It contains only four items, which are written at a third grade level. Larzelere et al. summarized that the SBQ C has good reliability, and is corr elated with other youth measures of depression and hopelessness. Of note, this measure is unique in it only assesses suicidal ideation, not predictors of suicide risk. The Fairy Tales Test, also known as the Suicidal Tendencies Test, is a four question mea toward life and death. This specific measure seems to be the most valid for children under the age of 10, as it seems to lose its effectiveness in 10 to 12 year old children, bec ause older children might not identify as strongly with the fairy tale characters as younger children (Orbach et al., 1983). The SSI is a 19 question clinical interview that was originally designed for adults, and then later validated for adolescents and p re adolescents (Allan, Kashani, Dahlmeier, Taghizadeh, & Reid, 1997). The SSI addresses suicidal ideation, like the SBQ C, but also emphasizes passive and active suicidal desires, and details regarding suicide plans. Similar to the SBQ C, this measure does not address predictors of suicide beyond suicidal ideation. Allan and colleagues (1997) examined the use of the SSI with a sample of 100 children ages 7 to 12 years who were hospitalized in a psychiatric facility. Results of their study supported the reli ability and validity of this measure of suicidal ideation within that sample. Additional research needs to examine the utility of this scale with a population of non hospitalized children.

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30 The Child Suicide Potential Scales is the most thorough assessment of suicide risk in pre adolescents (Larzelere et al., 2004). While this measure elicits information on numerous variables and predictors of suicide, it takes approximately two hours to administer as it entails a semi structured interview of the parent and the child. Therefore, this measure should not be used to screen for suicide risk, but for children that have already been identified as at risk. Despite that, a strength of the assessment is the fact that it has been found to be reliable and valid for cli nically and non clinically referred children (Pfeffer, Zuckerman, Plutchik, & Mizruchi, 1984). The CASPI is a measure based in part off the Child Suicide Potential Scales, and despite limited research on validity, is hailed as a promising screening measur e for pre adolescents and adolescents ages 6 17 by Larzelere and colleagues (2004). It is a 30 item measure that assesses three domains: anxious impulsivity and depression, suicidal ideations/acts, and family distress. The CSRA is an 18 item scale that as sesses a wide range of suicide indicators, which are grouped into three domains: worsening depression, lack of support, and death as an escape ( Larzelere et al, 2004). The CSRA has demonstrated concurrent validity for suicidal attempts, in addition to suic idal ideation. Also unique to this measure is the presence of follow child would be prompted with a (Larzelere et al, 2004, p.813). These questions allow for a more in depth assessment of harm.

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31 Postvention Postvention procedures commence after the death of a student by suicide. postvention procedures is to take necessary steps to prevent another suicide (Poland & Lie berman, 2002). While postvention procedures might differ by school district, Brock (2002) offers several general recommendations for appropriate activities. Before the crisis, anticipating the potential impact of a suicide and developing a response protoco l is perhaps the best and most effective course of action, like having a crisis team already created and trained and on standby in case of emergency. After a death by suicide has eam, and/or bring in the district wide crisis team. Before any information is shared with school personnel or students, it is necessary to verify or confirm the death was in fact a suicide, directly from the medical examiner, family, or police. The family of the victim should be contacted to not only confirm the death was in fact a suicide, but also to offer sympathy and support or assistance. After the death has been confirmed as a suicide, school personnel must decide what information to share. Informatio n about the suicide should not be released over the intercom or via a large assembly. Instead, information to students should be delivered simultaneously in classrooms, and information to parents should be delivered via a written letter. When information i s released, it is important to be truthful, including acknowledging the fact that death was a suicide, and share only relevant information. The school should arrange for grief counseling for any significantly affected students, as well as follow the victim

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32 Brock (2002) also recommends things not to do to avoid doing after the occurrence of a suicide: dismissing school early, providing bussing to the funeral, or dedicating a memorial to the student. Partaking in such activities may glorify the death. Regardless of the specific postvention activity, practitioners should keep in mind that both children and adolescents are prime for imitative behaviors. This is known as the contagion effect, when other individu als attempt to imitate the suicidal behavior of the victim (Brock, 2002). Therefore, sharing excessive or unnecessary details about a suicide might provide grieving youth with ideas or plans for similar behavior. When the media sensationalizes or glorifies death by suicide, imitative behavior among students may be exacerbated. As a result, school personnel must be mindful of which details they release. Specific to elementary age children Research has suggested that it is not until the fifth grade, or abou t 10 years of age, that children have a clear understanding of what generally do n ot understand the circumstances or events that lead to that behavior. Results of one study by Mishara (1999b) found that first and second grade students did Therefore, p ostvention for younger students needs to take into account their understanding of suicidal behavior (Brock, 2002). It cannot be assumed that children developmentally appropriate such as rewording, breaking down more abstract concepts into terms that are more understandable to them, and explaining the situation in a context in which they can understand. Also because of their age, and somewhat limited language

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33 abilities, children might not be able to effectively communicate their feelings about a completed suicide, and as a result they might express their feelings in unique ways, such as through drawings or pictures (AAS, 2008). Because secrecy about a death by suicide will only ad honestly. Although completed suicides in children are rare events, postvention procedures should still be prepared in advance in case such an event does occur, as these procedures w ill differ slightly from established protocols for older students. Role of the S chool P sychologist Provision of Mental Health Services The National Association of School Psychologists (NASP; 2003) defines mental health in children and adolescents as achievement of expected developmental NASP acknowledges the importance of mentally healthy children, citing they experience increased functioning in their home, school, and community, as well as improved quality of life. As such, NASP and effective mental health services in the school setting which include prevention and early intervention services as well as psychologists possess expertise, experience, and training in mental health issues, they have been recognized as being uniquely qualified to fill the position of school based mental health specialists in sch ools (NASP, 2003). Mental health services that school psychologists can provide include, but are not limited to, the programs, assessment, counseling, mental health, case management, and behavioral consultation services and crisis int ervention in partnership with teachers, parents, school

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34 administrators, and other members of the school community to assist in developing effective strategies to serve students in need (NASP, 2003, p.1). Crisis Interv ention Defined broadly, a crisis is an unexpected, uncontrollable event that is extremely negative and depersonalizing, that has the potential for large scale impact (Brock, 2002). Crisis events are not a normal occurrence, and they are not part of the d ay to day school experience. Examples of specific crisis events include severe illness and injury (i.e., suicide attempts, fires), violent and/or unexpected death (i.e., fatal accidents, suicide), threatened death and/or injury (i.e., domestic violence, ra pe), acts of war (i.e., terrorist attacks), natural disasters (i.e., hurricanes, floods), and man made or industrial disasters (i.e., airplane crashes, nuclear accidents). Thus, crisis response services have three main objectives: (1) primary prevention, w hich are activities aimed at preventing crisis situations from occurring and/or being prepared for crisis situations that do arise, (2) secondary prevention, which entails effectively and immediately dealing with crisis situations when they occur, and (3) tertiary prevention, which entails providing long term support to treat traumatized individuals long after the crisis event has occurred (Brock, 2002). Most schools or school districts handle crisis intervention via standardized policies and procedures, wh ich are consulted frequently in the event that a crisis situation does arise. Wise, Smead, and Huebner (1987) surveyed 193 NASP school psychologists about their training and interest regarding their involvement in the provision of crisis intervention serv ices. Specifically, participants were asked about their training in crisis

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35 intervention, their interest in the area of crisis intervention, and specific crisis related events with which they had intervened. Results indicated that 23% of participants had n o formal training in crisis intervention, while 55% reported that crisis intervention had been one of many topics covered in a seminar or course. Further, only 8% reported that they had taken a class specific to crisis intervention. Of 32 possible crises e vents, participants reported intervening in one or more crises a mean of 9.8 (range: 2 27) times over the school psychologists seem to be interested in, and faced w ith, crisis situations, they were more comprehensive approach to training in crisis intervention was needed. Allen and colleagues (2002) surveyed 276 school psycholog ists from the Directory of Nationally Certified School Psychologists regarding their training within the areas of crisis intervention. Thirty seven percent of participants reported having some type of crisis intervention training during their graduate stud ies, yet only 2% of the total n their graduate training alone. Regarding trends in graduate training with regard to crisis intervention, the researchers found that a higher percentage of recent graduates reported receiving university coursework related to crisis intervention. For examp le, 38.3% of the participants that graduated after 1993 reported receiving academic coursework related to crisis intervention, compared to 10.8% of participants who graduated prior to 1980. Similarly, 51.1% of practiti oners who graduated between 1994 and 2 000 reported experiencing

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36 school crisis events during practicum and internship, compared to 16.6% of those graduating prior to 1980. These trends seem to indicate that practitioners who graduated more recently received more graduate training within the rea lm of crisis intervention. Regarding training experiences in crisis intervention received after graduate school, the majority of respondents (80.7%) replied that they had received local training provided through their school district as well as self help t hrough reading/researching books and journal articles (63.5%). Interestingly, 26.6% of participants reported that they received crisis training at the annual NASP convention. In sum, this study indicates that although in recent years university training pr ograms have provided more coursework related to crisis intervention, many practitioners do not feel well prepared based on solely their academic training, and as a result, they seek out additional training. More recently, Nickerson and Zhe (2004) examined roles in crisis prevention and intervention. The majority of participants (93%) reported team as the most commonly used crisis prevention strategy, and viewed it as the most effective as well. The most frequently reported crisis events experienced by participants were student on student assaults, serious illness or death of students, unexpected student deaths, and suicide attempts. Notably, only 33% of participants reported being involved in suicide prevention programs at their school; the only less common prevention strategy was the use of metal detectors. This study suggests that school psychologists should be prepared to assume a variety o f crisis intervention roles, ranging from prevention of suicide (including initiation of universal prevention programs at their schools) to participation on crisis teams.

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37 In summary, the studies cited above underscore that school psychologists are often en gaged in a variety of crisis related situations. Practitioners seem to understand the importance of being knowledgeable and trained to deal with situations when they arise, but not all have received sufficient training in graduate school on crisis interven tion. Thus, many school psychologists would likely benefit greatly from additional formal training via graduate coursework or comprehensive in service trainings. Suicide Related Services in Schools Activities related to suicide prevention and intervention are among the most frequent crisis situations that school psychologists encounter (Nickerson & Zhe, 2004). ved the third highest effectiveness rating, indicating that while many were not actually involved in implementing those programs, they felt that suicide prevention programs were quite effective. reparation for crisis intervention in general, there is a paucity of literature regarding roles in suicide related surprising, as the majority of crisis related services i nvolve suicide (Debski et al., 2007). In addition, no published studies have examined the provision of suicide related services at different school levels, such as elementary, middle, or high schools. Thus, no research eparedness dealing specifically with elementary school age children. Further, no published studies have specifically examined the

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38 provision of postvention services. The small number of existing studies to be discussed next have instead focused on the provi sion of prevention and intervention services. Debski and colleagues (2007) surveyed 162 school psychologists regarding their professional roles, training, preparedness, and knowledge regarding youth suicide. Only 40% of participants reported receiving gra duate level coursework in prevention, and less than 25% in postvention services. However 93% of participants reported being involved in at least one suicide prevention or postvention activity on the job. Additionally, 77% of participants reported having at least one potentially suicidal student referred to them for assistance in the two year s underscoring the need for school psychologists to receive formal training specific to suicide related services. Anderson and Miller (2008) examined school psychologi level of involvement with school based suicide prevention programs. The researchers also gathered information regarding the different types of prevention programs with which school psychologists were currently involved. In regard s to their training in suicide prevention, 69.3% participants reported that their main source of training was from professional conferences, compared to 50% of participants reported receiving such training as part of their graduate studies. Further, 59.2% of participants indicated that that they would like more training in that area. Approximately 35% of participants reported suicide prevention as part of their roles, spec ifically mentioning involvement in the following programs: in service trainings (28.2%), s tudent self report screening (18.8%) curriculum programs for students (11.8%), and comprehensive programs (4.4%). Alarmingly, nearly 50% of participants reported tha t no suicide prevention

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39 programs were currently in place at their schools. Such findings suggest a considerable gap between best practice and actual practice with respect to systematic prevention of suicide. While there is a gap in the extant literature r egarding provision of suicide related services to elementary age students, one study conducted in a large school district in Florida provided preliminary data. Results found that elementary school psychologists (N=88) reported receiving an average of 2.5 r eferrals within the past two years fo r suicidal children (Cunningham, Sundman, Thalji, Snodgrass, & Suldo, 2009). The average number of children referred for a suicide assessment may underestimate the actual number of children in need, as the range of refe rrals reported by individual psychologists was between 0 and 10. These findings offer preliminary support for the need to provide suicide related services to children, including those in elementary schools. However, this study is limited by the use of a ge ographically restricted sample. It is currently unclear how often school psychologists working in elementary schools across the country encounter suicidal children. Of note, while NASP advocates for school based practitioners to provide mental health ser vices, other school based personnel can and are involved in the delivery of school based mental health services. Foster et al. (2005) surveyed a nationally representative sample of school based personnel in elementary, middle, and high schools. One purpose of their study was to identify which school based personnel were involved in the provision of school based mental health services. In total, 1, 147 schools in 1064 districts across the country responded to the survey. Results indicated that the most commo n types of school mental h ealth providers employed by responding schools were

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40 school counselors (77%), school nurses (69%), school psychologists (68%), and social workers (44%). These findings are important, as the two most frequently identified school bas ed mental health providers were not school psychologists. Therefore, it is feasible that referrals for potentially suicidal youth to school psychologists might underestimate the scope of the problem due to the fact that other school based per sonnel (e.g., school counselors ) may also receive the referrals and subsequently engage in the appropriate activities. This hypothesis is furthered by the fact that it is common for school psychologists to serve multiple schools, and therefore they are less likely to re ceive referrals that occur on d ays in which they are not physically present at a particular school. Training in Suicide Related Services for School Psychologists Psychology (2000), s chool psychology training programs must ensure that their students demonstrate competence within several professional practice domains, one of which is knowledge and sk ills within the area of mental health, including integration of these skills into practical applications via practicum or internship. Specific to crisis intervention, the of crisis intervention and collaborate with school personnel, parents, and the community in the aftermath of crises (e.g., suicide, death, natural disasters, murder, bombs or bomb The Amer ican Psychological Association (APA) also has rigorous training standards for graduate programs. Due to the enormity of the APA and the many divisions

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41 encompassed by it, all training programs must adhere to several commonalities and guidelines to ensure ac creditation yet APA acknowledges the individual differences between professional psychological programs. According to the Guidelines and Principles for Accreditation of Programs in Professional Psychology (APA, 2008), professional psychology programs must provide knowledge and training in: the scientific, methodological, and theoretical foundations of practice in the substantive area(s) of professional psychology in which the program has its training (p.10). In sum, school psychologists that graduate from a NASP approved and APA accredited approved training program should have received coursework and/or practical experience to refine their skills within the domain of mental health. NASP approved programs require specific coursework tied to crisis intervent ion. While APA does not specifically call for training in crisis intervention, coursework and applied experiences in mental health should provide training within this area. Of note, multiple school psychology training programs are not NASP approved and/or APA accredited It is unknown what proportion of those non accredited programs elects to offer training in crisis intervention even though they are not mandated to provide it. graduate studies and specific mention of suicide as a crisis, there is not a formal training requirement specific to suicide as part of graduate education. This is perhaps why the provision of suicide related services comes through conferences, workshops, and/or in service presentations, in addition to graduate training. These findings were echoed by Debeski and colleagues (2007), who found that while the almost all (99%) of the ir

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42 participants had received some training in suicide assessments, only 40% had received such training as part of their graduate coursework. The majority of participants received most of their training in suicide risk assessment from professional developme nt workshops and self study. Further, both studies found that few school psychologists received formal training in postvention procedures. In sum, there seems to be insufficient graduate level training for school psychologists on suicide related professio nal activities. It is more common to receive some type of training within the realm of crisis intervention, but not specific to suicide relate services. Given the frequency that school psychologists have cited suicide as a crisis they encounter, the gaps i n formal preparation to guide appropriate responses is surprising. While this might be an area touched upon in graduate coursework or training, it seems that most school psychologists must seek out additional trainings via conferences (i.e., NASP) or distr ict in services or workshops. Further, no published studies to date developmental level of student served. Also, no studies were found that examined the availability of training (e.g., graduate coursework, in services, workshops) focused solely on the unique needs of elementary school age children. Because completed suicides are relatively rare among this age group, some professionals could assume it is not necessary to be fluent in suicide prevention and intervention if they intend to focus their professional services on this age group. However, recent preliminary data regarding the frequency with which elementary school students are referred to school psychologists as p otentially suicidal suggests this would be an erroneous conclusion. Thus, additional

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43 research is needed to further explore the professional preparation, experience, and perceptions of school psychologists who work primarily with children. Conclusions Alt hough completed suicides among children under the age of 10 remain a rare occurrence, suicide is the sixth leading cause of death among children ages 5 14 years (CDC, 2008). While the manifestation of suicidal ideation and/or attempts is more common among adolescents, children are capable of and do experience suicidal ideations as well as demonstrate suicidal behaviors. Further, often times children are not referred or brought to the attention of the school psychologist, as their threats are considered imma ture and unfounded. Specific risk and protective factors exist that are unique to children (Greening et al., 2008). As such, it is important that school psychologists are prepared to work effectively with these suicidal children Age, developmental level, cognitive ability, and experiences with death and/or suicide have all been identified as factors influencing a or warning signs may differ from older children or adolescents. School psychologists working with young children should be aware of these differences and effectively modify their practices to suit the child. A gap currently exists in the literature in regards to the specific examination of school psycholo related services. preparedness in dealing with elementary school age children. Working with such a

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44 distinct population calls for specific procedures and modifications, and as such has implications for specialized training opportunities. The current study aims to provide data that clarifies the need for suicide related services for children in elementary school, via identifying the frequency with which practitioners from across the country encounter suicidal children at various developmental levels. In addition, the current study aims to determine school ide related services, and thus provide implications for training.

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45 Chapter Three Methods This chapter provides a discussion of the database that was analyzed in this study, including the methods used to select the participants, and a discussion of the demographic characteristics of the participants. The instrument and procedures used for data collection, as well as procedures are then discussed, followed by an overview of procedures used to answer the research questions. Participants To answer the res earch questions included in this study, an archival dataset was analyzed. The dataset used in the current study was part of a larger research project investigating the current role of school psychologists in the provision of school based mental health (SBM H) services (Friedrich, 2008) On May 12, 2009 the principal investigator (PI) of the larger study received written communication from the USF Division of Research Integrity and Compliance that study number 107624 G (title: School based Mental Health Servi ces: A National Survey of School Psychologists' Practices and Perceptions) meets federal criteria for exemption from IRB oversight primarily because the study involves only adult participants Approval was also obtained from the NASP Research Committee on March 26, 2009 to utilize the NASP membership database to draw the sample of participants The author of this proposal had an active role in assisting the PI collect the data including selecting the three items included in the larger study that related t o suicide.

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46 Participant Selection Participants in the larger study were school psychologists who were affiliated with their national professional organization, the National Association of School Psychologists (NASP). A total of 600 participants were select ed from the NASP membership database using a simple random probability sampling method. As summarized more thoroughly by Friedrich (2008), t he inclusionary criteria were set to include only NASP Regular members who are identified as school psychologists an d who are currently practicing in a school setting Lewis, Truscott, and Volker (2008) conducted a national study to determine the ratio of NASP and non NASP member school psychologists in schools. A total of 124 pract itioners were contacted by cold calli ng schools and asking to speak to the school psychologist. The majority of school psychologists that were reached 57.3%, indentified as NASP members. This finding supports the contention that most school psychologists in the United States are NASP members Further, F agan (2002 ) estimates that there are approximately 30,000 35,000 school psychologists in the United States. According to the NASP membership database, in 2008 2009 there were 25,245 NASP members. That mate of all school psychologists in the United States thus supporting the estimate that 60 70% of school psychologists in the United States are NASP members (Merrell, Ervin, & Gimpel, 2006) Taken together, this research supports the use of NASP members f or a representative sample of school psychologists in the United States. The overall survey response rate in the larger study was 38 % yielding a final sample of 226 participants between the ages of 25 and 68 ( M = 42.60 SD = 12.40 ). After

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47 data screening, a u seable sample of 220 participants was yielded and subsequently utilized in all analyses. D emographic characteristics of the sample are presented in Table 1. Also included in Table 1 are comparison demographic characteristics of NASP members, using 2004 20 05 membership data ( Curtis, 2007; Curtis et al., 2008). As seen in the table, the membership composition of the current sample was similar to the national NASP sample in terms of gender and ethnicity. Table 1 Comparison of Demographic Characteristics of School Psy chologists in Archival Database (N=22 0 ) and a National Sample of NASP Members (N=1,748) Current Study NASP Members Variable n % % Gender Male Female 44 176 20% 80% 26% 74% Ethnicity American Indian/Alaskan Native Asian American/Pacific Isl ander Black/African American Caucasian Hispanic Other 4 6 7 198 5 0 2% 3 % 3 % 90% 2% 0% .8% .9% 1.9% 92.6% 3.0% .8% P rofessional characteristics of the current sample can be seen in Table 2. When possible, comparisons were made to the professional c haracteristics of the NASP sample ; personal communication, April 7, 2010 ) research. Of note, N/A indicates that no data exists at the national level (i.e., for a NASP sample) on that specific

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48 demographic item primarily due to diffe rences in which the items were operationalized in the current study Table 2 Professional Characteristics of School Psycholog ists in Archival Database (N=220 ) Current Study NASP Members Variable n % % Highest Degree Earned Bachelors Masters Specialist D octorate Other Type of School Served Private Public Parochial All Parochial and Public Number of Buildings Served 1 5 6 10 11 15 15+ School Psychologist to Student Ratio 1: <500 1:500 999 1:1000 1499 1:1500 2000 1: > 2000 Percent of Time at Each School Lev el Preschool 0% >0% < 50% 100% Elementary 0% >0% < 50% 100% Middle/Jr. High 0% >0% < 50% 100% High 0% >0% < 50% 100% 1 49 119 49 2 6 207 2 1 3 19 1 19 5 3 31 67 64 27 28 128 82 8 2 44 49 101 26 88 93 27 13 115 74 20 11 < 1% 22% 53% 22% 1% 3% 95% 1% <1% 1% 87.61% 8.72% 2.30% 1.38% 14.29% 30.88% 29.49% 12.44% 12.90% 58% 36% 4% 1% 20% 22% 46% 12% 40% 42% 12% 6% 52% 33% 9% 5% 0.1% 32.6 % 34 .9% 32 .4% N/A 5.2% 83.1% 2.1% N/A N/A N/A N/A N/A N/A M =1482:1 N/A N/A N/A N/A N/A M =2.9 hrs/wk N/A N/A N/A N/A M =19.7 hrs/wk N/A N/A N/A N/A M =8.1 hrs/wk N/A N/A N/A N/A M =7.3 hrs/wk N/A N/A N/A N/A

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49 Other 0% >0% < 50% 100% 205 14 0 1 93% 6% 0% <1% M =1.4 hrs/wk N/ A N/A N/A N/A I nstrument The SBMH survey was developed by the principal investigator of the larger study to examine the delivery of school based mental health services by school psychologists across the United States. As described by Friedrich (2008), th e survey consisted of 149 items divided into eight sections: demographic information, referral concerns, mental health services provided, barriers to mental health service provision, enablers to mental health service provision, and training in school based mental health. Questions were both open and closed response format. Embedded within the larger SBMH survey were questions added by the author of this document to collect data pertinent to the aim s of the current study. Specifically, three multi part ques tions regarding the frequency with which elementary school psychologists are referred potentially suicidal children in their school(s), the frequency with which these school psychologists experience the occurrence of a completed suicide, and whether the pe rceived level of practitioner preparedness for professional roles relevant to suicide differs as a function of school level served. Those three items pertaining specifically to suicide were adapted from a previous survey (i.e., Debski et al., 2007), and us ed successfully with 122 school psychologists in a local school district as part of an earlier research study (Cunningham et al., 2009) Questions regarding suicide were included in two sections of the SBMH survey: referral concerns and training opportunit ies. Specific demographic and content items of interest are included in Appendix A.

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50 Procedure This section briefly summarizes the procedures used to create the archival dataset to be examined in the current study. A description of procedures was ascert ained through written documents describing the specific procedures involved in the larger study that yielded the dataset (Friedrich, 2008). The survey was sent out in two separate mailings, three weeks apart. Participants were mailed the survey, a cover le tter (see Appendix B), and a postage paid, pre addressed return envelope with an assigned code. To maintain confidentiality, each respondent was assigned a code number that was included on the pre addressed return envelope for purposes of tracking which pa rticipants had already responded and thus did not need to receive a second mailed survey. Response to the survey was considered as consent to participate. As incentive to participate, five people who completed and returned the survey were randomly selected to receive a $50 Visa gift card. As surveys were returned, they were entered into an SPSS database. Once all surveys were entered, data integrity checks were conducted on 10% of surveys. Overview of Proposed Data Analyses The following analyses were con ducted to answer the research questions presented in the current study. Research Question 1 : What is the frequency with which school psychologists who work at different school levels receive referrals for potentially suicidal youth? To address this res earch question responses to item s 15a, 15b, and 15c, which ask In the past two years, about how many students have been referred to you as potentially were examined. P ercentages were ca lculated for the sample of practitioners who provide d a response

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51 (rather than circle N/A) Data was excluded from participants who report ed on demographic question nine that they have not served a given school level in the past year, yet still provided a r esponse for items 15a, 15b, or 15c (i.e., the sub item that corresponds to a school level that they have not served in the past year). Descriptive statistics were provided; specifically, the range and mean frequency of referrals were calculated for each sc hool level served. The mean response obtained on item 15a (i.e., referrals for students in elementary schools ) was of particular interest. Research Question 2 : Does the frequency of referrals for potentially suicidal youth differ as a function of school l evel served ( i.e., elementary, middle, high)? To address this research question, the mean frequency referrals for potentially suicidal youth for each school level were calculated, and analyzed again as a function of school level served to determine if the frequency of referrals differed reliably depending upon school level served. Differences in mean scores between items 15a, 15b, and 15c were compared via a series of repeated measures t tests using data from the subs ample of participants who served at lea st two school levels (i.e., elementary and middle schools, high and middle schools, and elementary and high schools). Research Question 3 : What is the frequency with which school psychologists who work in different school levels experience the occurrence of a completed suicide? To address this research question responses to items 16a, 16b, and 16c, which ask In the past two years, about how many completed student suicides have occurred in your were ex amined. P ercentages were calculated for the sample of practitioners who provide d a response (rather than circle

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52 N/A) Data was excluded from participants who report ed on demographic question nine that they have not served a given school level in the past year, yet still provided a response for items 16a, 16 b or 16c (i.e., the sub item that corresponds to a school level that they have not served in the past year). Descriptive statistics were provided; specifically, the range and mean frequency of completed suicides were calculated for each school level served. The mean response obtained on item 16a (i.e., completed suicides for students in elementary schools) was of particular interest. Research Question 4 : Does the frequency of occurrences of completed sui cides differ as a function of school level served ( i.e., elementary, middle, high)? To address this research question, the mean frequency of occurrence of completed suicides for each school level were calculated, and analyzed again as a function of scho ol level served to determine if the frequency of completed suicides differed reliably depending upon school level served. Differences in mean scores between items 16a, 16b, and 16c were compared via a series of repeated measures t tests using data from th e substample of participants who served at least two school levels (i.e., elementary and middle schools, high and middle schools, and elementary and high schools). Research Question 5: Does the perceived level of elementary school ess for professional roles relevant to suicide differ as a function of the proportion of time they spend servi ng that population with respect to: a. Prevention? b. Intervention/assessment? c. In school counseling or support?

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53 d. Postvention? To address this research question participants were sorted into subsamples based on the proportions of time (i.e., 1 24%, 25 49%, 50 74%, 75 99%, 100%) they reported serving elementary school children via item 9 Frequency data was provided for items 26a, 26b, 26c, and 26d first for data provided for the group of participants who reported spending any time serving elementary schools then the data for the five subsamples. Specifically, the frequency/percentage of the participant subsample indicating each response fo r each separate professional role was calculated. For the purposes of analyses, preparedness levels were represented by the following va lues: 0 =Not at all Prepared, 1 = A Little Prepared, 2 =Moderately Prepared, 3 = Well Prepared, and 4 =Extremely Prepared. Nex t, within each subsample of participants that spend s a particular amount of time serving elementary school children the mean response for each professional role was calculated, and descriptive statistics (means, standard deviations, modes) were reported b y subgroup. To determine if preparedness differs depending upon proportion of time differences in mean scores between groups were compared via a series of ANOVAs (i.e., one ANOVA for each professional role category). In the event a significant univariate effect was detected, follow up Tukey tests and group means would be examined to identify differences between pairs of groups (e.g., 1 24% vs. 100%) on perceived competence for each professional activity that yielded a significant univariate effect. Rese arch Question 6 : Does the perceived level of practitioner preparedness for professional roles relevant to suicide differ as a function of school level served ( i.e ., elementary, middle, high) with respect to: a. Prevention?

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54 b. Intervention/assessment? c. In school counseling or support? d. Postvention? To address this research question data was predominantly served (i.e., environment in which they report their time on demographic question #9) Frequ ency data was provided for items 26a, 26b, 26c, and 26d first for data provided by the complete sample, then the data for the three subsamples who predominantly serve a specific school level (i.e., elementary, middle, or high school students). Specifically the frequency/ percentage of the participant sample or subsample indicating each response for each separate professional role was calculated For the purposes of analyses, preparedness levels were represented by the following values: 0 =Not at all Prepared 1 = A Little Prepared, 2 =Moderately Prepared, 3 = Well Prepared, and 4 =Extremely Prepared. Next, w ithin each subsample of participants who predominantly serve a given school level the mean response for each professional role was calculated, and descriptiv e statistics (means, standard deviations, modes) were reported by school level subgroup To d etermine if preparedness differed depending upon school level predominantly served, differences in mean scores between groups were compared via a series of ANOVAs (i.e., one ANOVA for each professional role category). In the event a significant univariate effect was detected, follow up Tukey tests and group means were examined to identify differences between pairs of school level groups on perceived competence for e ach professional activity that yielded a significant univariate effect.

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55 Chapter Four Results This chapter presents the results of the statistical analyses conducted to answer the research questions within the current study. For the first and third re search questions, frequencies and percentages of referrals for potentially suicidal students, and for completed suicides, were calculated and presented for the three different school levels of interest (i.e., elementary, middle/junior high, and high). Desc riptive statistics are also presented, specifically the means, standard deviations, and ranges. Regarding the second and fourth research questions, results of repeated measures t tests that were conducted to analyze differences between mean scores for scho ol psychologists who provided responses (regarding referrals for suicidal students or frequencies of completed suicides) for at least two school levels served (e.g., elementary and middle schools) are presented To answer the final two research questions, ANOVAs and follow up Tukey tests were preparedness for professional roles relevant to suicide differs based upon the proportion of time spent serving elementary school s, and/or differs as a function of school level primarily served (i.e., elementary, middle/junior high, high school). Data Screening In total, 226 surveys were returned out of a possible 600 yielding a 38% return rate. The PI of the larger study reviewe d the data entered for every tenth participant starting from the fourth survey to check for errors. Additional data were checked (i.e.,

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56 data entered for participants immediately preceding and following every tenth protocol) in the event a data entry error was detected. In sum, approximately 13% of the data were reviewed for accuracy at completion of this process. During the data screening process, it was observed that five participants indicated that they served in an administrative position (e.g., directo r of autism services, coordinator of student services) and one participant reported serving in the role of mental health consultant; these six participants were excluded from data analysis because they were not school based practitioners. Thus, the final dataset yielded a useable total sample of 220 participants. Data Analyses Surveys were initially entered into an SPSS database as they were returned, and data entry checks were conducted within the same database. After the data entry checks were complet e and a final sample was created, the data was transferred into SAS Version 9.2 and statistical analyses were conducted using this software. Research Question 1: What is the frequency with which school psychologists who work in different school levels r eceive referrals for potentially suicidal youth? To answer this research question, frequencies and percentages were calculated for responses to items 15a, 15b, and 15c for participants who provided a numerical the 8, 10, and 14 participants that reported that they had not served a given school level in the past year (i.e., demographic item nine) yet still provided a response for items 15a, 15b, or 15c, respectively, w ere excluded from analyses conducted for that specific school level.

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57 Frequency of referrals for potentially suicidal children at the elementary school level. Table 3 illustrates the frequency of referrals at the elementary school level. There were 173 sch ool psychologists who served elementary schools in this particular subsample of interest. The sum total of referrals received at this school level was 283. Of note, it was assum ed that each referral was a discrete event ( such that two respondents did not h ave work on the same case). Frequencies ranged from 0 to 10, with the majority of participants who served elementary schools (57%) indicating they received at least one referral in the past two years for a potentially suicidal elementary school student. T able 3 Frequencies of Referrals at the Elementary School Level (N=173) Number of Referrals Frequency Number Reported Percent of Sample 0 75 43.35% 1 33 19.08% 2 22 12.72% 3 14 8.09% 4 10 5.78% 5 10 5.78% 6 3 1.73% 8 2 1.16% 10 4 2.31% Frequency of referrals for potentially suicidal adolescents at the middle/junior high school level Frequencies of referrals at the middle/junior high school level are summarized in Table 4. The particular subsample had 130 participants. The total sum of r eferrals received at this school level was 383. Frequencies of referrals at this school level ranged from 0 to 25. Eighty four participants serving middle schools (64.62%) indicated that they had received at least one referral in the past two years for a p otentially suicidal middle school student.

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58 Table 4 Frequencies of Referrals at the Middle/Junior High School Level (N=130) Number of Referrals Frequency Number Reported Percent of Sample 0 46 35.38% 1 15 11.54% 2 26 20.00% 3 12 9.23% 4 3 2.31% 5 11 8.46% 6 2 1.54% 7 1 0.77% 8 3 2.31% 10 2 1.54% 12 3 2.31% 13 1 0.77% 15 1 0.77% 20 2 1.54% 21 1 0.77% 25 1 0.77% Frequency of referrals for potentially suicidal adolescents at the high school level Table 5 depicts the frequencies of ref errals for suicidal adolescents at the high school level. There were 101 participants in this particular subsample. The total sum of referrals at this school level was 475. Seventy two participants serving high schools (71.29%) indicated that they had rece ived at least one referral in the past two years for a potentially suicidal high school student While the majority of participants in this subsample reported receiving multiple referrals, a single participant reported receiving 80 referrals within the pas t two years. A statistical examination for univariate outliers five standard deviations from the mean response. Thus, the outlier was removed from subsequent an alyses within this research question regarding referrals at the high school

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59 level, resulting in a sample of 100 for further analyses. With this subsample of 100 participants, the maxi mum referral frequency decreased from 80 to 38. Table 5 Frequencies of Referrals at the High School Level (N=101) Number of Referrals Frequency Number Reported Percent of Sample 0 29 28.71% 1 13 12.87% 2 18 17.82% 3 7 6.93% 4 8 7.92% 5 4 3.96% 6 3 2.97% 8 3 2.97% 10 7 6.93% 12 2 1.98% 15 1 0.99% 20 3 2.97% 24 1 0 .99% 38 1 0.99% 80 1 0.99% An interesting commonality emerged across subsamples when examining the frequencies of referrals. Within each group (i.e., elementary school, middle/junior high school, high school), more participants reported receiving at least one referral than not receiving any at all. For example, within the elementary school sample, 43.35% of participants reported that they had received no referrals in the past two years, while 56.65% of participants indicated they had received a mi nimum of one referral. To further examine differences of referrals between school levels served, descriptive statistics were employed. Table 6 includes the mean number of students referred in the prior two years as potentially suicidal at each of the thr ee school levels.

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60 Table 6 Means, Standard Deviations, and Ranges of Referrals for Potentially Suicidal Youth Received in the Past Two Years by School Level School Level N M SD Range Elementary School 173 1.64 2.20 0 10 Middle School Midd le School High School 130 2.95 4.51 0 25 High School 100 3.95 5.99 0 38 The mean number of referrals at the elementary school level was 1.64 ( SD = 2.20), and ranged from 0 to 10. School psychologists who served middle/junior high schools reported receiving an average of 2.95 ( SD =4.51) referrals in the past two years, with the number of referrals ranging from 0 to 25. School psychologists who served high schools reported receiving an average of 3.95 ( SD = 5.99) referrals in the pas t two years, with the number of referrals ranging from 0 to 38. school level means could not be performed due to the violation of the assumption of independence (specifically some participants had scores in more than one category, precluding an independent grouping variable), these results appear clinically significant. Specifically, school psychologists serving middle and high schools receive approximately twice the frequenc y of referrals for potentially suicidal students as compared to school psychologists who work with elementary school students. Although the frequency with which school psychologists in elementary schools receive referrals is lower than the frequency of oc currences in both middle/junior high and high schools, these results demonstrate that a national sample of school psychologists who serve elementary schools do in fact receive referrals (at least occasionally) for potentially suicidal children.

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61 Research Q uestion 2: Does the frequency of referrals for potentially suicidal youth differ as a function of school level served (i.e., elementary, middle, high)? As aforementioned, typical one way between groups ANOVA could not be used to determine the probability that the differences in means by school level occurred due to chance because of violations of the assumptions for ANOVA tests. Specifically, the assumption of independence was violated because some participants had scores in more than one category, preclu ding an independent grouping variable. Thus, an alternate strategy (i.e., repeated measures t tests) was employed to determine the statistical significance of differences in school level means (e.g., if the mean level of referrals received for students in elementary and middle schools differed significantly amongst practitioners who served both school levels). To conduct this series of three analyses (elementary vs. middle, elementary vs. high, middle vs. high), three subsamples were created using only par ticipants that indicated on demographic item nine that they served the following settings: elementary and middle schools, high and middle schools, and elementary and high schools. Similar to research question one, participants that reported that they had n ot served a given school level in the past year (i.e., demographic item nine) yet still provided a response for items 15a, 15b, or 15c (i.e., referrals for potentially suicidal students) were excluded from analyses. Additionally, the participant who provid ed a response for item 15c but was identified as an extreme outlier was also excluded from inclusion in the subsamples pertinent to high school. Following the formation of subsamples, three paired sample t tests were conducted to determine if means between pairs of school levels differ ed reliably.

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62 Frequency of referrals for potentially suicidal students in elementary schools vs. middle/junior high schools Results of the paired sample t test using the data from the subsample of 104 participants who provi ded responses to both items 15a and item 15b revealed a significant difference between mean levels of referrals received by these school psychologists who work in both elementary and middle /junior high schools, t (103) = 4.06; p < .01. Specifically, acr oss a two year period, these school psychologists received an average of 1.23 ( SD = 2.10) referrals for potentially suicidal students in their elementary schools, as compared to 2.55 ( SD = 4.32) among their middle school students. Frequency of referrals for potentially suicidal students in middle/junior high schools vs. high schools Results of the paired sample t test using data from the subsample of 74 participants who provided responses to both items 15b and 15c did not reveal a significant difference between mean levels of referrals received by psychologists who work in both middle/junior high schools and high schools, t (73) = 0.09; p =.93. In other words, within a two year period, these school psychologists received a statistically similar number of referrals for potentially suicidal students in their middle schools as in their high schools; specifically, an average of 2.84 ( SD =4.86) and 2.80 ( SD =4.12) referrals for potentially suicidal students in their middle and high schools, respectively. Freque ncy of referrals for potentially suicidal students in elementary schools vs. high schools Results of the paired sample t test using data from the subsample of 75 participants who provided responses to both items 15a and 15c revealed a significant differen ce between mean levels of referrals received by psychologists who work in both elementary and high schools, t (74) = 3.35; p <.01. Specifically, within a two year period, these school psychologists received an average of 1.12 ( SD =2.01) referrals for potent ially

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63 suicidal students in their elementary schools, compared to an average of 3.25 ( SD =5.81) among their high school students. In sum, school psychologists who serve elementary schools receive fewer referrals for potentially suicidal students than they receive at their middle or high schools. The number of referrals received at the secondary level is similar regardless of school level served (i.e., middle/junior high school or high school). Research Question 3: What is the frequency with which school psy chologists who work in different school levels experience the occurrence of a completed suicide? To answer this research question, frequencies and percentages were calculated for responses to items 16a, 16b, and 16c for participants who provided a numer ical response, not served a given school level in the past year (i.e., demographic item nine) yet still provided a response for items 16a, 16b, or 16c were excluded f rom analyses conducted for that specific school level. Frequency of completed suicides at the elementary school level. Frequencies of completed suicides at the elementary school level are summarized in Table 7. The sum total of completed suicides is 8. T he majority of participants (95.95%) indicated that they had not experienced a completed suicide in the elementary schools they served during the past two years. Table 7 Frequencies of Completed Suicides at the Elementary School Level (N=173) Completed Su icides Frequency Number Reported Percent of Sample 0 166 95.95% 1 6 3.47% 2 1 0.58%

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64 Frequency of completed suicides at the middle/junior high school level Table 8 depicts the number of completed suicides experienced by middle/junior high school psychologists within the past two years. The sum total of completed suicides at this school level was 9. Similar to the elementary school subsample, the majority of participants (95.38%) did not experience a completed suicide within the past two years. A lso, this subsample of participants experienced a similar frequency of completed suicides as reported by school psychologists who served students at the elementary school level (9 vs. 8, respectively). Table 8 Frequencies of Completed Suicides at the Middl e/Junior High School Level (N=130) Completed Suicides Frequency Number Reported Percent of Sample 0 124 95.38% 1 4 3.08% 2 1 0.77% 3 1 0.77% Frequency of completed suicides at the high school level Table 9 illustrates the frequencies of complet ed suicides at the high school level. The sum total of completed suicides at this school level was 29. Approximately 13% of high school psychologists reported experiencing at least one completed suicide among students at the high schools that they served w ithin the past two years. Table 9 Frequencies of Completed Suicides at the High School Level (N=101) Completed Suicides Frequency Number Reported Percent of Sample 0 88 87.13% 1 2 8.91% 2 9 1.98% 3 1 0.99% 6 1 0.99%

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65 Of note, the participant who reported six completed suicides had occurred within his/her high schools was removed from subsequent analyses because this response was identified as an extreme outlier (i.e., > 5 standard deviations from the mean) during data screening for this research question. This was not the same participant who was removed from the examination of mean referrals at the high school level. To further examine differences in completed suicides between school levels served, descriptive statistics were employed. Table 10 includes the means, standard deviations, and ranges of completed suicides at the three school levels of interest. Table 10 Means, Standard Deviations, and Ranges of Completed Suicide Experiences in the Past Two Years by School Level School Level N M SD Range Elementary School 173 .05 .24 0 2 Middle School Middle School High School 130 .07 .36 0 3 High School 100 .16 .49 0 3 f these differences in school level means could not be performed due to the violation of the assumption of independence. Nonetheless, these results appear to be clinically significant. School psychologists serving elementary and middle schools seem to exp erience similar numbers of completed suicides, and such occurrences seem to be quite rare, eight and nine total, among 173 and 130 practitioners, respectively. School psychologists serving high schools seem to experience two times as many completed suicide s. While the frequency of occurrences of completed suicides at the elementary and middle school level is low, these numbers indicate that a national sample of school

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66 psychologists who serve elementary and middle schools do in fact experience completed suic ides, albeit rarely. Research Question 4: Does the frequency of occurrences of completed suicides differ as a function of school level served (i.e., elementary, middle, high)? To address this research question, three new datasets were created using only p articipants that indicated on demographic item nine that they serve at least two settings: elementary school and middle school, high school and middle school, and elementary and high school. Similar to research question two participants who reported that they had not served a given school level in the past year (i.e., demographic item nine) yet still provided a response for items 16a, 16b, or 16c (i.e., completed suicides) were excluded from analyses. Additionally, the one participant that provided a resp onse for item 16c and was later identified as extreme outlier during analyses for research question three was also excluded from analyses of this research question that pertained to high schools. Three separate paired sample t tests were conducted to deter mine if group means between pairs of groups (i.e., school level served) differ ed reliably. Frequency of completed suicides in elementary schools vs. middle/junior high schools Results of the paired sample t test using the data from the subsample of 104 p articipants who provided responses to both item 16a and item 16b failed to reveal a significant difference between mean levels of completed suicides experienced by these school psychologists who work in both elementary and middle /junior high schools, t (1 03) = .38; p =.71. Specifically, across a two year period, these 104 school psychologists experienced an average of .07 ( SD = .29) completed suicides in their elementary schools, as compared to .08 ( SD = .39) among their middle school students,

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67 which is a statistically similar rate. Frequency of completed suicides in middle/junior high schools vs. high schools. Results of the paired sample t test using the data from the subsample of 73 participants who provided responses to both item 16b and item 16c reve aled a significant difference between mean levels of completed suicides experienced by these school psychologists who work in both middle /junior high schools and high schools, t (72) = 2.04, p < 05. Specifically, across a two year period, these school psy chologists experienced an average of .04 ( SD = .26) completed suicides in their middle/junior high schools, which is significantly less than the mean number experienced at their high school s ( M =.10, SD = .41). Frequency of completed suicides in elementary schools vs. high schools. Results of the paired sample t test using the data from the subsample of 74 participants who provided responses to both item 16a and item 16c failed to reveal a significant difference between mean levels of completed suicides exp erienced by these school psychologists who work in both elementary schools and high schools, t (73) = 1.16; p =.25. More specifically, across a two year period, school psychologists experienced an average of .07 ( SD = .25) completed suicides in their elem entary schools, as compared to .12 ( SD = .44) among their high school students, which is a statistically similar rate when examined within this reduced sample size. While a visual examination of means from research question three may suggest significant di fferences between school levels are evident, the current analysis failed to produce a s tatistically s ignificant difference between means. This may be due to the fact that when participants serving only high schools were removed from the dataset utilized in the repeated measures analysis, the mean number of

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68 completed suicides at the high school level lowered from .16 to .12 This reduction in mean occurrences made it more difficult to statistically detect a significant difference between groups. Research Que stion 5: preparedness for professional roles relevant to suicide differ as a function of the proportion of time they spend serving that population with respect to: a. Prevention? b. Interventio n/assessment? c. In school counseling or support? d. Postvention? To answer this research question, the subsample of participants who self reported on item nine that they served elementary schools were divided into subgroups based upon the percent of t ime they indicated serving elementary schools. After removing the 44 participants from the sample who indicated spending no time serving an elementary school, five groups were created: approximately one quarter of time in elementary schools (1% 24%), appro ximately one half (25% 49%), approximately three quarters (50% 74%), almost full time (75% 99%) and completely full time (100%). Table 11 includes additional information regarding these group assignments.

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69 Table 11 Elementary School Psychologist Subgroups (N=176) Percent of Time Category N Percent of Sample 1% 24% Approximately One Quarter 11 6.25% Middle School 25% 49% High School Approximately One Half 38 21.59% 50% 74% Approximately Three Quarters 55 31.25% 75% 99% Almost Full Time 46 26.14% 100% Completely Full Time 26 14.77% Mean responses regarding perceived level of preparedness for each separate professional role (i.e., prevention, assessment, counseling/support, postvention) were calculated for the total subsample of pa rticipants serving elementary school students, as well as for each of the five subgroups. Table 12 includes the means and standard deviations, which are presented in parentheses, for the elementary school sample as well as each of the five subgroups. Of no te, higher scores indicate higher levels of school Table 12 Mean Levels of Preparedness for Professional Roles by Proportion of Time Spent Serving Elementary Schools Professional Role Sample (N=176) Approximately One Quarter ( n =11) Approximately One Half ( n =38) Approximately Three Quarters ( n =55) Almost Full Time ( n =46) Completely Full Time ( n =26) Prevention 2.30 (.94) 2.36 (.81) 2.08 (.91) 2.01 (1.04) 2.04 (.79) 1.85 (1.08) Assessment 2.28 (.94) 2.27 (.79) 2.39 (1.00) 2.22 (1.05) 2.28 (.78) 2.23 (.99) Counseling 1.85 (1.02) 2.18 (.75) 1.79 (1.00) 1.81 (1.16) 1.84 (.90) 1.88 (1.07) Postvention 1.76 (1.02) 2.36 (.67) 1.60 (1.08) 1.75 (1.04) 1.74 (.95) 1.77 (1.02) *p < .0 5

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70 upon proportion of time spent serving an elementary school, differences in mean scores between groups were compared via four one way ANOVAs, between subjects design. N one of these analyses indicated significant results for any of the professional roles. That is, the percent of time spent serving elementary schools did not seem to have a significant es specifically relevant to suicide prevention, assessment, counseling, or postvention. Table 13 includes a summary of each of the ANOVA results. Of note, follow up tests to compare means between pairs of groups were not conducted due to the failure to det ect an overall effect of group. Table 13 ANOVA Summary Table for Perceived Preparedness for Professional Roles by Percent of Time Spent Serving Elementary Schools Source N df SS MS F p Prevention 175 4 2.21 .55 .62 .65 Error 170 Assessment Error Counseling/Support Error Postvention Error 176 175 176 4 171 4 170 4 171 .77 1.44 4.95 .19 .36 1.24 .21 .34 1.19 .93 .85 .32 p < .05

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71 Research Question 6: Does the perceived level of practitioner preparedness for professional roles relevant to suicide differ as a function of school level primarily served (i.e., elementary, middle, high) with respect to: a. Prevention? b. Intervention/assessment? c. In school counseling or support? d. Postvention? To answer this research question, a subsamp le was created comprised of only those participants who indicated on demographic item nine that they predominately served (i.e., spent 50% or more of their time serving) elementary schools, middle/junior high schools, or high schools. This dataset included three new subgroups: predominantly elementary school psychologists ( N =118), predominantly middle/junior high school psychologists ( N =34), and predominantly high school psychologists ( N =31). Of note, 19 of those participants split their time equally betwee n preschools and elementary schools ( n = 4), elementary and middle schools ( n = 7), elementary and high schools ( n = 2), or middle and high schools ( n = 6). Rather than deleting these participants from the dataset and unnecessarily reducing power, those 19 participants were included in the groups that corresponded to the most advanced age level predominantly served (for instance, the 6 participants who spent 50% of their time in middle schools and 50% of their time in high exposure to suicidal youth and postvention activities increases linearly as a function of age level of students served.

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72 As a basis for comparison, mean responses regarding perceived level of preparedness for each separate professional role (i.e., prevention, assessment, counseling/support, postvention) were calculated for the whole sample ( N = 220). Then, these desc riptive statistics were calculated for the three subgroups of interest. Table 14 summarizes ANOVA summary statistics for significant differences on preparedness to fill professional roles by school level predominantly served. Table 14 ANOVA Summary Table for Perceived Preparedness for Professional Roles by School Level Predominantly Served Source df SS MS F p Prevention 2 8.91 4.46 5.24 .0062 Error 179 Assessment Error Counseling/Support Error Postvention Error 2 180 2 179 2 180 7.49 12.15 12.47 3 .75 6.07 6.23 4.72 5.91 6.03 .01 .0033 .0029 *p < .05 T able 1 5 presents the means and standard deviations for the total sample, as well by subgroup. To depending upon school le vel served, four one way ANOVAs, between subjects design were conducted. In the event that a significant univariate effect was detected, follow up Tukey tests were conducted and group means were examined to identify differences

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73 between pairs of school leve l groups on perceived competence for each professional activity that yielded a significant univariate effect. Table 15 Mean Levels of Perceived Preparedness for Professional Roles by School Level Predominantly Served Professional Role Total Sample ( N = 220) Elementary School Subgroup ( n =118) Middle School Subgroup ( n =34) High School Subgroup ( n =31) Prevention 2.10 (.95) 1.98 a (.96) 2.18 a,b (.88) 2.58 b (.81) Assessment 2.31 (.94) 2.22 a (.93) 2.50 a,b (.83) 2.74 b (.77) Counseling 1.95 (1.04) 1.83 a ( 1.07) 2.12 a,b (.88) 2.51 b (1.93) Postvention 1.81 (1.04) 1.72 a (1.03) 1.74 a (1.05) 2.42 b (.89) Note. Significant differences between group means are indicated by different letters. Means having the same subscript are not significantly different. *p < .05 As shown in Table 15 significant differences were found between school psychologists who predominantly served elementary schools and high schools on all four professional roles relevant to suicide. Specifically, the mean level of school psych higher for school psychologists who predominantly served high schools as compared to those professionals who primarily served elementary schools. School psychologists wh o predominately served middle schools were not distinguished from their peers who served either elementary or high schools on three of four professional roles. Within the fourth area, perception of preparedness to fulfill postvention roles, the mean percep tion of school psychologists predominantly serving middle schools was similar to the perceptions of the school psychologists who predominantly serve elementary schools;

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74 both groups perceived themselves to be less prepared to provide postvention services th an school psychologists who predominantly serve high schools.

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75 Chapter Five Discussion The primary purpose of the current study was to encounters with suicidal children and adolescents in their practice. The study aimed to provide concrete figures regarding the frequency of both referrals for and completed suicides among students in different school levels (i.e., elementary school, middle/junior high school, high school). The final purpose of the study was to determine whet her practitioner perceived preparedness to engage in professional roles relevant to youth suicide (i.e., prevention, assessment, counseling/support, postvention) differed as a function of school level predominantly served. This chapter summarizes the resul ts of the current study and discusses the findings in the context of the extant literature. The chapter is organized by the topic investigated within the current research study. After the discussion of results and significant findings, implications of the results for school psychologists are summarized limitations of the current study are reviewed, and directions for future research are discussed. Discussion of Results Frequency of Referrals for Suicidal Students The purpose of this first area of resear ch was to gather data regarding the frequency of referrals for potentially suicidal youth within in a two year time period by school level served. Results indicated that school psychologists serving high schools received the most referrals, with an average of approximately four referrals within a two

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76 year time period. Middle/junior high school psychologists reported receiving about three referrals within the same time period which was one student less than those referred at the high school level. School ps ychologists who reported serving elementary schools reported receiving approximately one to two referrals for potentially suicidal children over a two year time span. Taken together, the results regarding the frequency of referrals for potentially suicid al youth are significant. Previous published research has not specifically examined the frequency of referrals for potentially suicidal youth by school level served, and as such, results from this study augment the current literature base substantially. Re sults demonstrate that the majority of practitioners serving all school levels (i.e., elementary school, middle/junior high school, high school) encounter at least one potentially suicidal youth within a two year period in their professional practice, rega rdless if the practitioner works with children or adolescents. Significant differences were not found between mean referrals for practitioners serving middle/junior high school and high school. Specifically, school psychologists serving middle and high sch ools receive approximately twice the frequency of referrals for potentially suicidal students as compared to school psychologists who work with elementary school students. Although the frequency with which school psychologists in elementary schools receiv e referrals is lower than the frequency of occurrences in both middle/junior high and high schools, results demonstrate that a national sample of school psychologists who serve elementary schools do occasionally receive referrals for potentially suicidal c hildren. The mean number of referrals at the elementary school level was the least of the three school levels, with an average of between one and two students during a two year

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77 time period, although some practitioners received as many as ten referrals dur ing the same time frame. This particular finding is somewhat similar to previous research conducted in a n urban Florida school district that found that practitioners at the same school level reported receiving an average of 2.5 referrals for suicidal child ren, with the same 0 to 10 range, within a two year time period (Cunningham et al., 2009). While these ranges are identical, it is important to note that there was a difference in mean number of referrals within elementary schools of approximately one stud ent every two years, on average. This difference could be accounted for by the fact that traditional practitioners within the smaller sample of local practitioners served an average of 1.69 school buildings (range: 1 3) with the majority of school psychol ogists (81.6%) reporting a school psychologist to student ratio of between 1:<500 1:1000 1499 The national sample of practitioners in the current study served an average of 3.24 school buildings ranging from 1 34 buildings with (60.4%) of psychologist s reporting a school psychologist to student ratio of between 1:500 and 1:1499 Thus, school psychologists in the local Florida sample served fewer students and worked in less buildings suggesting the possibility that practitioners who are more present in a specific school or schools (i.e., spend more time there) are more likely to receive referrals for suicidal youth This can be due to the fact that teachers are more familiar with them, and therefore more likely to refer a student, or that they are more proactive in their school in providing information on risk factors and warning signs. Alternatively, perhaps school psychologists who are more integrated in a few schools field referrals that would have otherwise been directed to the school guidance counse lor. Another hypothesis is that practitioners who serve more schools, and therefore spend less time in a given school might only receive referrals for

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78 youth that demonstrate blatant, as opposed to more subtle, warning signs. Other plausible reasons for th e higher rate of referrals in the Florida sample entail the fact that the local sample served a predominantly urban area; youth in city environments may experience more risk factors (e.g., poverty, crime/violence, family stressors) than youth nationwide Of particular interest, this study provides concrete evidence supporting the need for school psychologists employed in elementary school settings to be trained in how to provide suicide related services to children. As the majority of practitioners employe d by public schools practice in elementary schools (Curtis, Hunley, Walker, & Baker, 1999), the results of the current study support the need to inform professional practices relevant to this specific population of school psychologists. While the frequency of referrals is significantly less than those received at the middle/junior high or high school levels, these children are being referred nonetheless and there is clearly a need to be prepared to provide services to these children. Further, because adults may consider suicidal threats by children to be immature and unfounded, they may not formally refer children who make such threats to the appropriate professional for assistance. As such, the number of referrals actually received by school psychologists w orking in elementary schools might under represent the actual number of children experiencing suicidality. The practical implications of these results are also important, as findings indicate that school psychologists serving all school levels receive re ferrals for potentially suicidal students, and would need to engage in, at the very least, assessments of risk to self harm. As such, all practitioners need to be familiar with assessment protocols and policies. T his study provides evidence for school psyc hology training programs that trainees should receive education in suicide related services, particularly information specific to

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79 developmental levels of students (i.e., children, adolescents). Professional development (e.g., district in services or confer ence trainings specific to the provision of suicide related services) are another mechanism via which school psychologists can seek out training within this specific area of service delivery. Frequency of Completed Suicides by Students A second aim of t his research was to gather concrete figures regarding the frequency of completed suicides at different school levels within in a two year time period. Results indicate that school psychologists serving elementary schools and middle/junior high schools expe rience similar numbers of completed suicides: a total of eight and nine deaths reported by 173 and 130 practitioners, respectively. Completed suicides at the high school level were almost three times more frequent, with a total frequency of 29 completed su icides within a two year time period reported by 101 school psychologists across the country. This finding is consistent with literature reviewed in chapter two: adolescents aged 15 19 (i.e., high school age) have a higher rate of completed suicides than t heir younger peers (Heron et al., 2008). These findings are significant for several reasons. First, completed suicides, while rare, apparently do occur on occasion at the elementary and middle/junior high school levels. Therefore, school psychologists ser ving these school levels would be well suited to ensure they have adequate training in postvention procedures and activities. School psychologists at the elementary school level should be sure that postvention services are developmentally appropriate, as M of death and suicide is quite different than their older peers. Completed suicides are more common at the high school level. As such, practitioners at this level should be

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8 0 particularly sure that detai led postvention procedures are in place. Indeed, these practitioners should ensure that they are well trained in all professional roles relevant to suicide, as it is likely that before a completed suicide occurs, the student can be identified as in need of support services in order to prevent a tragic outcome. Of note, although statistically differences in mean numbers of completed suicides were observed among the subsample of participants who reported serving both middle/junior high schools and high scho ols, mean differences in number of completed suicides were not statistically different among school psychologists who served both elementary and high schools. This result should be interpreted with caution for several reasons. A visual examination of means among the entire sample suggested that school psychologists serving high schools seem to experience two times as many completed the means yielded from the reduced sample size that was employed in the repeated measures analyses. Specifically the school psychologists that were excluded from this analysis reported more high schoo l student deaths by suicide than reported by participa nts who served both elementary and high schools (mean of .16 for the total sample compared to .12 for the reduced sample). It is plausible that the high school psychologists omitted from the repeated measures analysis experience more completed suicides bec ause they serve multiple high schools (rather than dividing their time between elementary and high schools). School psychologists who were excluded from the reduced samples used in research questions two and four were most likely to be those practitioners who served one school, who are the most likely to be fully integrated

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81 into a school and therefore perhaps most likely to seek out or field referrals for suicidal youth. Perceived Preparedness for Professional Roles Relevant to Youth Suicide by Proportion of Time Spent in Elementary School The perceived preparedness to engage in professional roles relevant to suicide perceived by school psychologists who predominantly served elementary schools did not significantly differ significantly as a function of th e proportion of time they spent there. However, examinations of non significant trends suggested that school psychologists who spent the least amount of time (i.e., 1 24% of their time) in an elementary school, perceived themselves to be the most prepared to engage in suicide related activities across all professional roles (i.e., prevention, assessment, counseling, postvention). It is hypothesized that this could be due to the fact that since these practitioners spend only approximately one quarter of thei r time serving one or more elementary schools, the rest of their time could be spent serving a middle/junior high or high school where they might receive more hands on increased experience engaging in these roles. Of note, full time elementary school psy chologists perceived themselves to be suicide. Out of the professional roles, full time elementary school psychologists perceived themselves to be least prepared to engage in prevention and postvention activities. This finding makes sense in the context of the literature reviewed in chapter two, in which there was a paucity of evidence based prevention activities aimed specifically at children. Similarly, as few school psych ologists serving the elementary school level actually experience a completed suicide, it is reasonable to draw the

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82 conclusion that these psychologists might not perceive themselves to be prepared to engage in postvention activities because they have not ha d the opportunity to enact the skills needed to effectively provide postvention services. Perceived Preparedness for Professional Roles Relevant to Youth Suicide by School Level Served Within the total sample, an examination of respondents average perce ived preparedness to fill professional roles relevant to suicide indicate that school psychologists feel related activities. On the whole, the sample felt most prepared to conduct assessments of risk to self harm, followed by prevention of suicide risk, providing in school counseling or support for students identified as potentially suicidal, and finally relatively least prepared to engage in postvention activities. When further examined by school lev el subgroup, the same trend is apparent: of all suicide related activities, practitioners rated themselves the lowest on ability to provide postvention activities. These findings support the need for increased training in postvention procedures, as this na tional sample of school psychologists, with the exception of practitioners predominantly serving high schools, predominantly served high schools perceived themselves to be study, this population of school psychologists has more experience with applying knowledge and skills related to postvention services when compa red to elementary and middle/junior high school psychologists. On the other hand, this difference could reflect that school psychologists who anticipate working with adolescents seek out additional

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83 education pertinent to postvention and thus rate themselve s higher in this area even without having had a chance to yet demonstrate this knowledge via applied work. School psychologists who predominantly served elementary schools perceived themselves to be the least prepared to provide suicide related services when compared to practitioners serving the other school levels, particularly high schools. The implications for this particular finding are quite significant, as this finding demonstrates that school psychologists who predominantly serve elementary schools do not feel maximally prepared in their abilities to effectively provide suicide related services to children, as the average ratings from school psychologists who predominantly serve elementary schools suggest room for growth. As data from the current st udy illustrates, most practitioners serving elementary school students encounter at least one suicidal youth in their practice every couple of years, and a few practitioners have experienced a completed suicide within their elementary school students. To e nsure that such practitioners are able to provide effective services in a preventative fa shion and as called for (i.e., when a suicidal student is encountered), specific training in providing suicide related services to children may be warranted. While d ifferences in means were not statistically significant, a visual examination of means suggest that school psychologists who predominantly served middle/junior high schools perceived themselves to be more prepared (relative to their colleagues who predomina ntly serve elementary schools) to engage in suicide related activities, but not as prepared as their colleagues who predominantly serve high schools. Similarly, predominantly middle/junior high school psychologists perceived themselves to be the most prepa red to conduct assessments of potentially suicidal youth, and least prepared to

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84 engage in postvention activities. Again, this finding is supported by data gathered in the current study that school psychologists who predominantly serve middle/junior high sc hools regularly encounter potentially suicidal youth in their practice, and have minimal experiences with completed suicides. Specifically, school psychologists at this school level have increased opportunities to conduct assessments of risk to self harm, as they receive an average of about three referrals within a two year period. As the total number of completed suicides within a two year period was nine, they likely have limited experiences providing postvention services as they have limited exposure to deaths by suicide. The correspondence between professional activities an d perceptions of preparedness to provide these services suggest that school psychologists confidence may be enhanced (or weakened) as a function of opportunity to engage in the releva nt professional activities. School psychologists who predominantly served high schools perceived themselves to be the most prepared to engage in all suicide related activities, with their school psychologists at the high school level encounter more potentially suicidal youth as well as completed suicides. As such, it is reasonable to speculate that since these psychologists are engaging in suicide related activities more often than their elementary school and middle/junior high school colleagues, they feel more confident to do so as they have increased experience in applying knowled ge and skills relevant to suicide related services. Similar to their colleagues serving predominantly elementary and middle/junior high schools, high school psychologists also perceived themselves to be the

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85 least prepared to fill postvention roles. While c ompleted suicides are more prevalent at the high school level, it is more common to receive referrals for potentially suicidal youth. Thus, school psychologists who predominantly serve this level would be more familiar, and possibly more comfortable, condu cting assessments of risk to self harm rather than engaging in postvention activities. preparedness in providing suicide related services to potentially suicidal youth by school lev el served, the results from the current study serve as baseline data regarding school related perce ived preparedness to engage in professional roles relevant to suicide, but did not examine such perceptions by school level served. Of note, Debski and colleagues only inquired about assessment and postvention services. In regard to assessment most of the assessment activities. In regards to the provision of postventi on While examined using a slightly different metric (i.e., three point metric, versus five point metric used in the current study) results from the current study corroborate Debski and colleagues findings, mainly in the respect that the majority of practitioners feel at least somewhat prepared urrent

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86 ly to engage in professional activities relevant to suicide, and more prepared to engage in assessment activit ies than postvention activities. While focusing solely on school based prevention services, Anderson and Miller (2008) found that 59.2% of participants within their study indicated that they felt Responses to a different research question found that 59.3% of participants also reported that they wou ld like additional training in that area. These results also corroborate the findings of the current study, in that the majority of practitioners felt activities relevant to the provision of prevention services. As a whole, practitioners in the current study did not perceive themselves to be related services. This finding reinforces the importance of ensuring practitioners receive specific training in providing suicide related services. Previous research has found that school psychologists have reported receiving some training within the realm of crisis intervention, but few reported receiving training specific to suicide (Allen et al., 2002 ; Wise et al., 1987). This is surprising, as suicide is the most frequently cited crisis that school psychologists encounter (Nickerson & Zhe, 2004). Furthermore, no research could be located that examined training in suicide related services specific to c hildren. As such, it is important that school psychology training programs provide coursework and/or training in not only crisis intervention, but suicide in particular. More specifically, it is important to ensure the inclusion of developmentally appropri ate suicide related services to children.

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87 ability to engage in particular skills is needed in order to initiate such activities (Bandura, 1997). For example, a meta analysi s of 114 studies examining the relationship between self efficacy and work related performance found a moderate, positive correlation efficacy beliefs and actual work related performance (Stajkovic & Luthans, 1998). In other words, employees who felt more confident in their abilities to engage in certain work related tasks were more likely to actually engage in those activities. Ideally, increases in confidence (i.e., perceptions of preparedness) would be induced via a professional development rather than only an outcome of needs encountered (and thus services delivered) in a school. A recent examination of the outcomes of a professional development workshop geared toward improving the preparation of military psychologists to assess and treat suicidal patients found that result of training (Oordt, Jobes, Fonseca, & Schmidt, 2009). Oordt and colleagues further found that the training which increase efficacy also increased application of training related behaviors (i.e., self reported changes in suicide care practices and clinical policy). Specifically, immediately after training, 97% of participants indicated they agreed or str ongly agreed to change at least one aspect of their work related to suicidal patients; at 6 month follow up, 83% of participants had actually treating suicidal beha vior significantly increased following the training, and maintained at 6 month follow up.

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88 In sum, research supports the i mportance of increasing employee s confidence in order to increase the likelihood of actually engaging in the relevant activities. Fu rthermore, research also supports that content specific training (i.e., professional activities, but also increased the application of those behavior and/or activities. As there professional role relevant to suicide, it seems as though school psychologists that serve all school levels could benefit from training specific to the provision of suicid e related services. Implications of the Results for School Psychologists Taken together, the findings from this study underscore the need for psychologists that serve all school levels to provide competent suicide related services to youth, as the majori ty of practitioners across all three school levels encounter potentially suicidal youth in their practice. Practitioners must not only have the knowledge and skills necessary to effectively engage in these roles, but confidence in their abilities as well. The current findings support the need for increased training in professional roles relevant to suicide at both the graduate level as well as through professional development efforts, mselves as related services. It is important to note that most While there is definitely room for improvement, mean ratings of perceived preparedness suggest that the vast majority of school psychologists feel at least a little prepared to

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89 pr ovide suicide related services, which underscores the fac t that school psychologists, as a whole, seem to have existing skills and knowledge relevant to the provision of suicide related services. Results of the current study also provide evidence for school psychology training programs that practitioners should receive training in suicide related services specific to developmental levels of students (i.e., children, adolescents). At a more systemic level, practitioners must advocate for professional development specific to suicide. Annual NASP conventions, state level conferences, and/or district level in services are natural avenues through which practitioners can seek out additional training and knowledge to ensure they have the necessary skills and knowledge, but also the confidence in their abilities to effec tively provide these services. Additionally, school psychology training programs should try to ensure that information relevant to the provision of suicide related services is included in specialist level coursework not just in doctoral coursework. The ma jority of practitioners within the United States hold a specialist degree (Curtis et al., 2008), a fact that was confirmed by findings in the current study, which underscores the need for this training for all graduate students, regardless of the degree th ey seek. Finally, it is important to note that many graduate traini ng programs typically train their students to work with low incidence populations, such as with students who are deaf or hard of hearing, have significant developmental delays, and have tra umatic brain injuries. As such, providing training at the graduate level to prepare school psychologists to provide developmentally appropriate suicide related services to children may be viewed as training school psychologists to be optimally prepared to work with another low incidence population.

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90 An alternate approach to broad training involves preparing some school psychologists to be specialists with low incidence populations. Thus, it might be more cost effective for districts to train a small team o f practitioners to be specialists within the domain (s) of suicide prevention, assessment/intervention, and/or postvention. While it is important that all practitioners have at least a foundational knowledge of suicide and the provision of suicide related s ervices, it might be more practical to have a few expertly trained practitioners who could be called on to consult or handle at risk cases at least within large districts that can accommodate specialists. It will continue to be the case that practitioner s in rural areas must have a working knowledge of all aspects of service delivery pertinent to youth suicide. Delimitations of the Current Study A delimitation is defined as purposefully including a limitation within a research study to limit the scope of the study. Within the current study, participants only included school psychologists who are currently practicing in a school setting, as opposed to those who practice in an alternative setting (e.g., hospital, university). Limiting the participants only to current school based practitioners provides a more accurate depiction of voices of those practitioners who are in more atypical settings. Limitations of the Current Study Due to the use of an existing dataset, the author of the current study had little control over data collection procedures, nor the majority of the content included in the survey. However, documentation provided by the primary researcher in charge of

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91 designing the study and collecting the data suggested that precautions were taken to address potential threats to validity (Friedrich, 2008). Even so, a few limitations exist that may potentially limit the validity of the findings. First, a potential thr eat to external validity relates to population validity. The sample in the current study was comprised solely of Regular NASP members. Therefore, findings might not be applicable to the small proportion of school based practitioners who are not members of NASP. Limitations are also inherent to the use of mail survey methodology (Dillman, 2007). First, coverage error can occur when the list from which the sample is drawn does not include all elements of the population. As mentioned earlier, the sample of t he current study was compared to overall NASP membership characteristics, and was found to be similar on the most salient demographic items (i.e., gender, ethnicity, highest degree earned). Furthermore, surveys were returned from 41/51 states, suggesting a truly national and representative sample. Second, low response rates may illustrate differences between those respondents who completed the survey versus those who did not. The response rate of the current study was 38%, which is lower than other research studies conducted on similar topics, which had a response rate of 50% (i.e., Debski el al., 2007). Therefore, it is possible that the response s of the current sample do not necessarily represent the experiences of the overall desired population. Third, me asurement error can occur when respondents misunderstand or incorrectly answer questions. To reduce the likelih ood of this occurring, the PI of the larger study piloted the survey for readability and clarity; school psychologists in the pilot did not repor t concerns with understanding (Friedrich, 2008). Fourth, the desire to provide socially desirable responses to questions

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92 poses a threat to internal validity. The intent of the survey, as outlined in the cover letter and title of survey, conveys the rationa le of the study. If a school psychologist does not provide SBMH services at all, they may be inclined to respond falsely, thus limiting the validity of the responses. This factor also might explain the low response rate. Finally, the survey asks participan ts to recall information from memory. As a result, recall bias might occur, in which participants provide inaccurate information. However, no comments were left on the survey that suggested that this was problematic for any of the items analyzed in the cur rent study. Two limitation s exist specific to item directions. First the two items asking participants to record the amount of referrals or completed suicides was worded in such a way that participants might have provided an estimate or approximate respo nse instead of the actual number. For example, the directions for the item querying the amount of In the past two years, about how many items ask participants to recall information from memory, specifically a two year time period. It is possible that recall bias might occur, in that participants provide inaccurate information. However, as events such as referrals for potentially suicidal y outh and completed suicides are salient, it can be argued that these events might not be affected by recall bias. Similarly, these specific items were previously used in two studies that have yielded meaningful results (i.e., Cunningham et al., 2009; Debsk i et al., 2007). Notably, it is likely that most practitioners do not keep extensive documentation of their school based psychological service activities However, despite the threat of recall bias, statistically

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93 significant and logical results were yielde d, as well as a full distribution of self reported frequencies (i.e., 6, 7, 24) as opposed to rounded numbers (e.g., 10, 20, etc.) Also of note the survey item intended to gather information about referrals for suicidal youth asked respondents to reflec t on the number of students referred to them as I t is possible that there could be some variability in how uld have been interpreted narrowly by some respondents, or more broadly by others (e.g., to include any student with depression) It is thus possible that participants either over or under reported the frequency of referrals they received for student in ne ed of assessment of risk to self harm in their respective schools. Impact of Memory on Recall Due to the use of survey methodology, and thus the heavy reliance on the of memory on recall was examined. There are several fac ability to accurately recall information for surveys, which are briefly outlined below. While a bit outdated, Bradburn, Rips, and Shevell (1987) provide a helpful and r elevant summary of the impact of memory and inference on recall in regards to survey research. They indicate that when asked to recall specific quantitative information from memory, respondents often have trouble complying with the demands of the task. On items for which respondents are asked to recount specific numbers or amounts (e.g., how many times have you going to the doctor in the past two years?) respondents often do not take the time to look up or check responses, and instead provide an estimate. It is possible that respondents could make two common errors: errors of omission (forgetting an event

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94 or events) or commission (counting events that occurred outside the specified time period). It can often take a few seconds respondents to recall an answ er, longer if the activity is common (e.g., going for a drink with a friend). Similarly, recalling information can become more difficult for respondents when their memory is full of similar types of common events. This might lead to the respondent confusin g details of the specific event in question, which in turn can lead to a decline in accurate responses, specifically when too many questions are asked within the time that the respondent is willing to devote to filling out the survey. While much of the re search on recall and memory indicates that recalling quantitative information on surveys is not always dependable, there is some research to the contrary. Dippo (a s cited in Ayhan & Isiksal, 2004) reported that events that are rson either because of their importance, their uniqueness or vividness are remembered better because more attention is paid to the event when it entail the person to d evote more of their time and/or energy to the specific event, therefore making it easier to remember and thus retrieve from memory. Directions for Future Research As this study is the first examination of the frequency of referrals for potentially suicid al youth and completed suicides by school level served, as well as practitioners perceived preparedness to engage in professional roles relevant to suicide by school level served, additional studies are needed to extend and replicate the current findings. Future

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95 suicide might be enhanced by elaborating on the information requested. Specifically, use of open ended questions instead of forced choice response might yield useful information, such as graduate school or conference training received specific to suicide, as well as availability and use of district materials relevant to suicide. It would also be beneficial to assess practitioners actual knowledge related to sui cide. This could be done by having practitioners answer quizzes or tests of knowledge (i.e., Debski et al., 2007) to gauge their content knowledge within this domain. Then, their actual knowledge could be compared to their perceived preparedness to engage in professional roles relevant to suicide, to determine if higher levels of knowledge (i.e., higher quiz scores) correlate to higher levels of perceived preparedness. Another direction for future research should specifically focus on investigating elemen information that would confirm the frequency of referrals, completed suicides, and perceived prepared to engage in suicide related services, more information specific to p olicies procedures at the elementary school level, and specific activities or modification of existing practices should be further examined. Specifically, questions inquiring about what modifications exist, if any, between policies and procedures at differ ent school levels could yield useful information that could inform training, policy, and procedures within this area. Conclusions experience with referrals for potentially sui cidal youth and completed suicides, specifically examined by school level served by a given school psychologist.

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96 perceived preparedness to fill professional roles relevant t o suicide differs as a result of school level served. Results indicated that across all school levels (i.e., elementary, middle/junior high, high), the majority of practitioner received referrals for at least one potentially suicidal youth in the past two years Completed suicides were experienced more often by school psychologists serving high schools, but were present at the elementary school and middle/junior high school levels to a lesser degree. Among school psychologists who served elementary schools at all, perceived preparedness to engage in professional roles relevant to suicide did not significantly differ as a function of the proportion of time they spent in an elementary school setting. Finally, school psychologists who predominantly served high schools rated themselves significantly more prepared to engage in suicide related roles than their colleagues serving elementary school. School psychologists who predominately served middle schools were similar to their colleagues who served either element ary or high schools on three of four professional roles; regarding the fourth role (i.e., postvention), middle/junior high school psychologists rated themselves similarly to the perceptions of the school psychologists who predominantly serve elementary sch ools. Results of the current study indicate that the majority of school psychologists professional roles relevant to suicide. While these results are encouraging it is also apparent that there remains a need for training specific to the provision of suicide related services as well as the consideration of developmental of students This fact must be considered by graduate training programs when preparing their students for pr actice,

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97 regardless of the developmental level of the student with whom they intend to work. Furthermore, opportunities to engage in professional development must be available for school psychologists to enhance the knowledge and skills necessary for effect ive provision of suicide related services in schools, such that all school psychologists can perceive themselves to be extremely prepared to provide such services.

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98 References Allen, M., Jerome, A., White, A., Marston, S., Lamb, S., Pope, D., & Rawlin s, C. (2002). The preparation of school psychologists for crisis intervention. Psychology in the Schools, 39 427 438. Allan,W., Kashani, J., Dahlmeier, J.,Taghizadeh, P., & Reid, J. (1997). Psychometric properties and clinical utility of the Scale for Su icide Ideation with inpatient children. Journal of Abnormal Child Psychology 25 465 473. American Association of Suicidology. (1998). Suicide postvention guidelines: Suggestions for dealing with the aftermath of suicide in the schools. Washington, DC: Au thor. American Association of Suicidology. (2007). Some facts about suicide and depression Retrieved November 29, 2008 from http:// www.suicidology.org. American Association of Suicidology. (2008). Youth suicide fact sheet Retrieved November 29, 2008 from http:// www.suicidology.org. American Psychological Association. (2008). Guidelines and Principles for Accreditation of Programs in Professional Psychology Retrieved March 2009 from the American Psychological Association website: http://www.apa.org /ed/gp2000.html Anderson, K. & Miller, D. (2008 February). School based suicide prevention and the role of the school psychologist. Presented at the National Association of School Psychologists Annual Convention, New Orleans, LA.

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99 Ash, P. (2006). Children and adolescents. In R. Simon & R. Hales (Eds.), Textbook of suicide assessment and management (pp.35 56). American Psychiatric Publishing, Inc. Ayhan, H.O., & Isiksal, S. (2004). Memory recall errors in retrospective surveys: A reverse record check study Quality and Quantity, 38, 475 493. Bandura, A. (1997). Self efficacy: The exercise of control. New York: Freeman. Barrish, H., Saunders, M., & Wolf, M. (1969) Good Behavior Game: Effects of individual contingencies for group consequences on disruptive b ehavior in a classroom. Journal of Applied Behavior Analysis 2 119 124. Beck A., Kovacs M., & Weissman A. (1979). Assessment of suicidal intention: the Scale for Suicidal Ideation. Journal of Consulting and Clinical Psychology, 47 343 352. Block, J., & Burns, R. (1976). Mastery learning. In L. Shulman (Ed.), Review of Research in Education vol. 4 (pp. 3 49). F.E. Peacock: Itasca, IL. Bradburn, N. M., Rips, L. J., & Shevell, S. K. (1987). Answering autobiographical questions: The impact of memory and in ference on surveys. Science 236, 157 161. Bridge, J.A., Greenhouse, J.B., Weldon, A.H. (2008). Suicide trends among youths aged 10 to 19 years in the United States 1996 2005. Journal of the American Medical Association 300 1025 1026. Brock, S.E. (2002) Crisis theory: A foundation for the comprehensive crisis prevention and intervention team. In S. E. Brock, P. J. Lazarus, & S. R. Jimerson (Eds.), Best

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100 practices in school crisis prevention and intervention (pp. 5 17). Bethesda, MD: National Association of School Psychologists. Brock, S. E., Sandoval, J., & Hart, S. (2006). Suicidal ideation and behaviors. In G. G. Bear & K. M. Minke (Eds.), intervention (pp. 225 238). Bethesda, MD: NASP Publications. Cent er for Disease Control and Prevention. (2006). Youth risk behavior surveillance United States, 2005. Morbidity and Mortality Weekly Review, CDC Surveillance Summaries, 55, 1 107. Center for Disease Control. (2008). Deaths: Preliminary data for 2006. Nati onal Vital Statistics Report, 56 1 52. Centre for Suicide Prevention. (2000). Children and suicide. Alert #39. Cotton C., & Range L. (1993). Suicidality, hopelessness, and attitudes toward life and death in children. Death Studies, 17 185 191. Cox, M., Garrett, E., & Graham, J.A. (2005). Death in disney films: implications for Omega Journal of Death and Dying 50 267 280. Cunningham, J., Sundman, A., Thalji, A., Snodgrass, H., & Suldo, S. M. (2009 February). Preventio n, assessment, and intervention of suicidality in elementary age children. Presented at the National Association of School Psychologists Annual Convention, Boston, MA. Curtis, M. J, Hunley, S. A., Walker, K. J., & Baker, A. C. (1999). Demographic character istics and professional practices in school psychology. School Psychology Review, 28 (1), 104 116.

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101 Curtis, M. J. (2007, July). School psychology in the United States 2004 2005. Presentation made to the Delegate Assembly of the National Association of School Psychologists. Curtis, M. J., Lopez, A. D., Castillo, J. M., Batsche, G. M., Minch, D., & Smith, J. C. (2008). The status of school psychology: Demographic characteristics, employment conditions, professional practices, and continuing professional devel opment. Communiqu, 36, 27 29. Debski, J., Spadafore, C. D., Jacob, S., Poole, D., & Hixson, M. (2007). Suicide intervention: Training, roles, and knowledge of school psychologists. Psychology in the Schools, 44 157 170. Dillman, D. A. (2007). Mail and internet surveys: The tailored design method (2nd ed.) New York, New York: Wiley Fagan, T. K. (2002). Trends in the history of school psychology in the United States. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology IV (pp. 209 221). Bethesda, MD: National Association of School Psychologists. Foster, S., Rollefson, M., Doksum, T., Noonan, D., Robinson, G., & Teich, J. (2005). School mental health services in the United States, 2002 2003 DHHS Pub no. (SMA) 05 4068. Rockville, MD: Cen ter for Mental Health Services, Substance Abuse and Mental Health Administration. Friedrich, A. (2008). School based mental health services: A national survey of school dissertation proposal University of South Florida, Tampa, FL.

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102 Greening, L., Stoppelbe in, L., Fite, P., Dhossche, D., Erath, S., Brown, et al. (2008). Pathways to suicidal behaviors in childhood. Suicide and Life Threatening Behavior. 38 35 45. Heron, M.P., Hoyert, D.L., Xu, J., Scott, C., & Tejada Vera, B. (2008). Deaths: Preliminary data for 2006 National Vital Statistics Reports, 56 National Center for Health Statistics: Hyattsville, MD. ge, cognitive ability, death experience, and maternal communicative competence. Omega, Journal of Death and Dying, 57 142 162. Kalafat, J., & Lazarus, P.J. (2002). Suicide prevention in schools. In S.E. Brock, P.J. Lazarus, & S.R. Jimerson (Eds.), Best pr actices in school crises prevention and intervention. Bethesda, MD: National Association of School Psychologists. Larzelere, R.E., Anderson, J.J., Ringle, J.L., & Jorgensen, D.D. (2004). The child risk suicide assessment: A screening measure of suicide in pre adolescents. Death Studies 28 809 827. Lewis, M. F., Truscott, S. D., & Volker, M. A. (2008). Demographics and professional practices of school psychologists: A comparison of NASP and non NASP school psychologists by telephone survey. Psychology in the Schools 45, 467 482. Lieberman, R., Poland, S., & Cowan, K. (2006). Suicide prevention and intervention: Best practices for principals National Association of Secondary School Principals: Principal Leadership 7 11 15. Mazza, J. J., & Reynolds, W. M. (2008). School wide approaches to prevention of and intervention for depression and suicidal behaviors. In B. Doll & J. A. Cummings

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103 (Eds.), Transforming school mental health services: Population based approaches to promoting the competency and wellness of children (pp. 213 241). Bethesda, MD: NASP Publications. Merrell, K. W., Ervin, R. A., & Gimpel, G. A. (2006). School psychology for the 21 st century pp. 3 5 The Guilford Press: New York. Merrell, K. W. (2008). Behavioral, social, and emotional assess ment of children and adolescents (3 rd ed.) pp.133 176 Mahwah, NJ: Lawrence Erlbaum Associates. Milling, L., Campbell, N. B., Davenport, C. W., & Carpenter, G. (1991). Suicidal behavior among psychiatric inpatient children: An estimate of prevalence. Chi ld Psychiatry and Human Development, 22 71 77. Mishara, B. L. (1999a). Childhood conceptions of death and suicide: Empirical investigations and implications for suicide prevention. In D DeLeo, A Schmidtke, & RFW Diekstra (Eds.), Suicide prevention: A hol istic approach (pp.111 120). Dordrecht: Kluwer Academic Publishers Mishara, B. L. (1999b). Conceptions of death and suicide in children ages 6 12 and their implications for suicide prevention. Suicide and Life Threatening Behavior, 29, 105 118. Mishara, B. Crisis, 24 128 130. National Adolescent Health Information Center. (2006). Fact sheet on suicide: Adolescents & young adults San Francisco, CA: Author, University of California, San Francisco.

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104 National Association of School Psychologists. (2000). NASP standards for training and field placement programs in school psychology. Retrieved March 2009 from the National Association of School Psychologists website: http://www.naspweb.org/stan dards/FinalStandards.pdf National Association of School Psychologists. (2003). NASP p osition state ment on mental health s ervices in the schools. Retrieved March 2009 from the National Association of School Psychologists website: http://www.nasponline.org/a bout_NASP/pospaper_mhs.aspx National Association of School Psychologists. (2008). The importance of school mental health services. R etrieved April 2009 from the National Association of School Psychologists website: http://www.nasponline.org/about_nasp/pos itionpapers/MentalHealthServices.pdf Nickerson, A.B., & Zhe, E. J. (2004). Crisis prevention and intervention: A survey of school psychologists. Psychology in the Schools, 41 477 488. Oordt, M. S., Jobes, D. A., Fonseca, V. P., & Schmidt, S. M. (2009). Tr aining mental health professionals to assess and manage suicidal behavior: Can provider confidence and practice behaviors be altered? Suicide and Life Threatening Behavior, 39 21 32. Orbach, I., Feshbach, S., Carlson, G., Glaubman, G., & Gross,Y. (1983). Attraction and repulsion by life and death in suicidal and in normal children. Journal of Consulting and Clinical Psychology 51 661 670.

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105 Pfeffer C., Conte H., Plutchik R., & Jerrett I. (1979). Suicidal behavior in latency age children: an empirical study Journal of the American Academy of Child Psychiatry 18 679 692. Pfeffer C., Conte H., Plutchik R., & Jerrett I. (1980). Suicidal behavior in latency age children: an outpatient population. Journal of the American Academy of Child Psychiatry, 19 703 71 0. Pfeffer, C. R., Jiang, H., & Kakuma,T. (2000). Child Adolescent Suicidal Potential Index (CASPI): A screen for risk for early onset suicidal behavior. Psychological Assessment 12 304 318. Pfeffer, C., Zuckerman, S., Plutchik, R., & Mizruchi M. (1984). Suicidal behavior in normal school children: A comparison with child psychiatric inpatients. Journal of the American Academy of Child Psychiatry, 23 416 423. Poland, S., & Lieberman, R. (200 2 ). Best practices in suicide intervention. In A. Thomas & J. Gr imes (Eds.), Best Practices in School Psychology IV. (pp.1151 1165). Bethesda, MD: National Association of School Psychologists. Sommers Flanagan, J., & Sommers Flanagan, R. (2008). Clinical interviewing (4 th ed.). Suicide assessment. (pp. 245 277). Hobo ken, NJ: John Wiley & Sons. Stajkovic, A. D., & Luthans, F. (1998). Self efficacy and work related performance: A meta analysis. Psychological Bulletin, 124 240 261. Taylor, K. R. (2001) Student suicide: Could you be held liable? Principal Leadership 2 74 78.

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106 US Department of Health and Human Services (2001). National strategy for suicide prevention: Goals and objectives for action Rockville, MD: Office of the Surgeon General, US Dept, of Health and Human Services, Public Health Service. Wilcox, H. C., Kellam, S. G., Brown, C. H., Poducka, J. M., Ialongo, N.S., Wang, W., & Anthony, J. C. (2008). The impact of two universal randomized first and second grade classroom interventions on young adult suicide ideation and attempts. Drug & Alcohol Depen dence, 95 63 70. Willis, C. A. (2002). The grieving process in children: Strategies for understanding, Early Childhood Education Journal, 29 221 226. Wise, P.S., Smead, V. S., & Huebner, E. S. (1987). Crisis intervention: Involvement and training needs of school psychology personnel. The Journal of School Psychology, 25 185 187.

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107 Appendices

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108 Appendix A: Content Items of Interest (Modified to fit in Current Document ) I. DEMOGRAP HIC INFORMATION 1. Gender (please circle) A Female B Male 2. Age _____________ 3. Ethnicity (circle one) A American Indian/Alaskan Native D Caucasian B Asian American/Pacific Islan der E. Hispanic C. Black/African American F Other, please specify: _________________________ 4. Years practicing psychology in school setting (include present year) _____________ 5. State in which employed (e.g., IL, F L, NY) _____________ 6. Highest degree earned (e.g., bachelors, masters, specialist, doctorate) _____________ 7. How many different school buildings do you serve in your current position? _____________ 8. What type of school(s) do you serve in you r current position? (circle one) A Private B Public C Parochial 9. What percent of your time is assigned to serving students at each school level? (e.g., 25%, 50%; total should equal 100%) _________Presc hool __________Elementary School __________Middle/Jr. High School __________High School __________Other, please specify:_________________________ 10. In your current position, what is the school psychologist: student ratio? (circle one) A 1: <500 B 1: 500 999 C 1: 1000 1499 D. 1: 1500 2000 E 1 : >2000 15. In the past two years, about how many students have been referred to you as potentially suicidal in your: A. Elementary school(s)? Number =_ _____ or N/A (I have not worked in elementary schools) B. Middle school(s)? Number =______ or N/A (I have not worked in middle schools) C High school(s)? Number =______ or N/A (I have not worked in hig h schools) 16. In the past two years, about how many completed student suicides have occurred in your: A Elementary school? Number =______ or N/A (I have not worked in elementary schools) B. Middle school? Number =______ or N/A (I have not worked in middle schools) C. High school? Number =______ or N/A (I have not worked in high schools)

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109 Appendix A: Continued 26. How well prepared do you perceive yourself to be in each of the following areas? 0= Not at all prepared, 1= A Little Prepared, 2=Moderately Prepared, 3=Well Prepared, 4=Extremely Prepared Not at All Prepared A Little Prepared Moderately Prepared Well Prepared Extremely Prepared A Prevention of suicide risk? 0 1 2 3 4 B Conducting ass essment of suicide risk for individual students? 0 1 2 3 4 C Providing in school counseling/support for students identified as potentially suicidal? 0 1 2 3 4 D Providing postvention (i.e., assisting after a completed student suicide)? 0 1 2 3 4

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110 Appendix B: Cover Letter March, 2009 Dear NASP Member, increased involvement by school psychologists in the provision of mental health assessment and intervention serv ices We are asking for your assistance in expanding based mental health services by completing the enclosed survey. Our goals in conducting the study are to better understand (a) the types of problems for which students a re referred for mental health help, (b) factors that facilitate and prohibit school psychologists from providing mental health assessment and intervention services, and (c) the specific knowledge and skill areas in which additional training would be helpfu l in order to enable school psychologists to provide mental health interventions. Findings from this study may ultimately aide in shape the mental health training provi ded in school psychology programs and in district professional development programs. You are being asked to be part of this study because you are a practicing school psychologist whose primary employment is in a school setting. We would like you to be a participant in this study, regardless of the amount of time you currently spend providing mental health services Your decision to participate in this study is completely voluntary and you are free to withdrawal at any time without penalty. Participati on in the study involves completing the enclosed questionnaire and returning it in the enclosed envelope within three weeks The survey will only take 12 15 minutes to complete and we have provided you with a postage paid envelope to use in returning the survey. A returned survey will be considered consent to participate in the study. As a small token of our appreciation, five people who return completed questionnaires will be randomly selected to receive a $50.00 Visa gift card. In order for us to provid e these awards, a code number has been included on the return envelope. Please note that data will be reported only in aggregate form and findings may be published; importantly, the responses of individuals will be treated in the strictest confidence. Wh en a questionnaire is returned, it will immediately be separated from the envelope, so that the individual respondent cannot be identified. Thank you in advance for your time and assistance with this research project. If you have any questions or concer ns about the project, please feel free to contact us at the numbers and emails listed below. We also invite you to contact us if you would like to obtain the results of the study.

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111 Appendix B: (Continued) Thank you so much for your participation. S incerely, Allison A. Friedrich, M.A. Shannon Suldo, Ph.D. Principal Investigator Chairperson of Dissertation Research Doctoral Candidate, Assistant Professor School Psychology Program School Psychology Program University of South Florida University of South Florida afriedri@usf.edu ; (813) 927 4586 suldo@coedu.usf.edu ; (813) 974 2223