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:t1t  YOUTH SUICIDE 
National Program Inspection 
\tlVICES. 
CI.r 
iJa 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF ANALYSIS AND INSPECTIONS

November 1986
 . -
Office of the Inspector General

The mission of the Office of the Inspector General 
(OIG) is to

promote the efficiency, effectiveness and integri 
ty of programs

in the Uni ted States Department of Health and Humn Services

(HHS). It does this by developi g methods to detect and prevent
fraud, waste and abuse. 
Created by statute in 1976, the 
Inspector General keeps both the Secretary and the Congress fUlly 
and currently informed about programs or management problems and 
recommends corrective action. The OIG performs its mission by 
conducting audi ts, investigations and inspections wi
approximately 1, 
200 staff strategically located around the
country. 
Office of Analysis and Inspections

This report is produced by the Office of Analysis and Inspections 
(OAI), one of the three major offices within the OIG. 
The other 
two are the Office of Audit and the Office of Investigations.
OAI conducts inspections which are, typically, short-term studies

designed to determine program effectiveness, efficiency and

vulnerabili ty to fraud or abuse.

Thi s Report 
Youth Suicide, 
Enti tIed " " this inspection was conducted to 
collect information to supplement the work of the HBS Task Force
on Youth Suicide. 
The report was prepared by the Regional Inspector General, Off 
ice 
IX. 
of Analysis and Inspections, Region  Participating in this
project were the following people: 
Kaye D. Kidwell, National Project Director, Region IX,
Seattle, WA 
Kathy Admire, Senior Analyst, Region IX, Seattle, WA
Ta zi tans, 
Headquarters, Washington, DC 
Alana Landey, Headquarters, Washington
, DC 
Lucille Cop, Region II, New York Ci ty, NY
William Counihan, Region 
II, New York City, NY
Phil Onofrio, Region V, Chicago, IL 
Neil Merino, Region IX, San Francisco, CA  YOUTH SUICIDE

\ i

KUSSEROW
RICHARD  P. 
INSPECTOR GENERA  NOVEMBER 19 
 8 6

CONTROL iP-09-86-00032
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TABLE OF CONTENTS

Page 
INTRODUCTION 
MAJOR FINDINGS 
RECOMMNDATIONS 
SUICIDAL YOUTH:  AN OVERVIEW

GENERA COMMNITY INVOLVEMENT AN PUBLIC AWARENESS: 
COMMUNITY RESPONSE 
PUBLIC AWARENESS

THE COMMNITY SERVICE SYSTEM: 
TABLE 1: CLIENTS SERVED BY COMMNITY RESPONDENTS 
HHS GRATEES 
MENTAL HEALTH SERVICE S 
CRISIS INTERVENTION/HOTLINES 

SCHOOLS 
JUVENILE JUSTICE FACILITIES 
ICE 
POL 
MEDICAL EXAINERS 
SURVIVOR' S GROUPS 
TABLE 2: ESTIMATE OF SUICIDAL IDEATION AMONG 
RESPONDENTS' YOUTH CLIENTS 
TABLE 3: RESPONDENTS' ESTIMATE OF YOUTH CLIENTS

AT SE  OUS RISK OF SUICIDE

IDENTIFICATION OF YOUTH AT RISK OF SUICIDE:

DETECTION AN ACTION

TRAINING 
( i  FACTORS CONTRIBUTING TO SUCCESSFUL TREATMENT AN PREVENTION 
I j 
WHY AREN' T KIDS BEING SERVED: 
BARRIERS TO SERVING YOUTH AT RISK OF SUICIDE 
GAPS IN SERVING YOUTH AT RISK OF SUICIDE 
TABLE 4: YOUTH SUICIDE COMPLETERS AMONG 
RESPONDENTS' CLIENTS 
FEDERA ROLE 
STATE AN LOCAL ROLE 
COMMNITY RESPONSE TO YOUTH SUICIDE:  A SUMMRY 
APPENDIX A:  STUDY METHODOLOGY 
APPENDIX B:  COMMUNITIES CONTACTED DURING INSPECTION 
APPENDIX C:  QUESTIONS ASKED BY YOUTH ABOUT SUICIDE  ! -
INTRODUCTION

Public attention is focusing on the tragedy of suicide among the
s youth. 
nation  According to data from the National Center for 
year-olds 
Health Statistics, the suicide rate among l5- to 24-
(i. e., 
increased 129% from 1960 to 1983  from 5. 2 to 11. 9 suicides 
During 1983, 28, 
pleirv e10s0., 000 youth).  295 Americans took their own
Of these, 5, 050 were 5 to 24 years old. This averages 14
a day. 
Every 100 minutes, another young person kills himself. 
The actual number of deaths may be two times higher than the 
reported incidence because (a) there is no common definition of 
suicide among medical examiners/coroners, (b) the social stigma 
attached to suicide encourages underreporting and (c) some 
accidents. 
suicides are masked, such as car 
In recogni tion of the effect youth suicide has on society as a 
whole, President Reagan, pursuant to Senate Joint Resolution 53,
proclaimed June 1985 as Youth Suicide Prevention Month. 
As part
, J

of the federal government' s response to the call for action on 
this problem, the Department of Health and Human Services (DHHS) 
June, 
cosponsored a National Conference on Youth Suicide during 
Suicide. 
and established a high-level HHS Task Force on Youth 
The Task Force includes senior officials from the National 
Institute of Mental Health, National Institute of Drug Abuse, 
National Institute of Alcohol Abuse and Alcoholism, Centers for 
Disease Control, and the Office of Human Development Services 
(OHDS) Administration for Children, Youth and Families.

s .-andate 
The Task Force  is to "assess and consolidate 
tiate 
information which currently exists and to recommend or ini 
acti vi ties which will a ttack-- ' head on ' --the youth suicide
dilemma " and to generate research on the factors which place 
young people at risk of suicide. It sponsored three national

conferences on (1) Risk Factors, (2) Prevention and Intervention

1986. 
and (3) Strategies for the Future between May and November 
The Task Force will culminate its work with a series of reports

and final recommendations which will be presented to the

Secretary in January 1987. 
Inspector General 
The Off ice of  (OIG) was asked to conduct a
quali tati ve national program inspection of youth suicide which 
Force. 
would supplement the work undertaken by the Task  The 
focus of the inspection was to (a) assess the extent to which 
HHS-funded programs are involved in efforts to prevent youth
suicide, 
(b) review how selected communi ties are responding to
the problems associated wi th youth suicide and (c) identify 
barriers and gaps which hinder delivery of services to suicidal 
families. 
youth and/or their 
reports. 
The results of the inspection are reflected in two  The 
enclosed report, enti  Youth Suicide , reflects findings based 
tIed 
on 348 interviews, including many of the nationally known and
recogni zed experts in the field of suicide research and 
prevention. Of this total, 170 in-person interviews were  ties in 9 states. 
conducted through visits to 10 communi  In a 
telephone survey of randomly selected communi ty services agencies 
(most of whom were funded by DHHS), OIG staff interviewed 178
persons. In all,  ties. 
we talked to persons in 183 communi 
Under separate cover is a companion  Inventory 
report, entitled 
of State Initiatives in Addressing Youth Suicide  It reflects 
findings based on telephone interviews with 283 officials from 
5 program areas in each of the 50 states, including 
(c) maternal and child health,
(a) education, (b) mental health, 
(d) drug and alcohol abuse, and 
(e) children s services. 
! 1
 MAJOR FINDINGS 
1. Youth at risk of suicide come from various walks of life and 
personal experiences. They come from dysfunctional families 
families. 
as well as loving, supportive  Health, educational 
trends, 
and social service agencies describe increasing 
however, in (a) the number of very young (aged 10 and under)
attempters, 
(b) suicide ideation among youth of all ages, 
(c) multiple forms of self-destructive behavior and (d) a

sense of futility among youth.

destructive 
2. Suicide is viewed as the ultimate form of self-
behavior. It is a symptom and should not be dealt wi th in 
isolation from other self-destructive behaviors or from 
social, health and educational problems facing young people. 
3. Communi ty response to youth suicide ranges from fear, denial 
prevention. 
and resistance to widespread support for suicide 
4. Public education is helpful to demystify and prevent
suicides. 
Anyone who lives or works with youth should learn 
help. 
to recognize the signs of risk and where to go for 
News and entertainment media need to avoid sensationalizing 
suicide.
or glamorizing youth 
) i 
5. Educational, heal 
th and social service providers rely 
risk. 
primarily on subjective approaches to detect youth at 
Once detected, however, suicidal youth generally are screened 
out and referred to mental health providers. At issue are
both legal lfabili ty 
and lack of staff expertise among non-
mental health providers. As agencies become more 
knowledgeable and sophisticated in detecting suicidal youth, 
potential exists for more agencies to screen out suicidal 
youth from participation in their programs. 
6. Among HHS grantees, runaway programs have the greatest focus 
on youth suicide. Most community and migrant health centers 
and family planning programs are involved minimally. Many 
grantees expressed a need for more training and information
on youth suicide. 
7. Many youth who kill themselves never enter the service system 
and those who do often drop out prior to completing
trea tment. 
This is due, in part, to the stigma associated 
suicide. 
wi th mental health problems and 
8. More than half the study respondents ci 
risk.t ed family problems as 
contributing factors to suicidal  Family support is key
to 
(a) getting youth into treatment, 
(b) assuring they do not 
drop out of treatment and (c) effecting a successful outcome. 
9. Lack of financial resources or private insurance limits 
treatment. 
access to mental health 
iii  10. The most significant gaps in the service system include

(a) too few inpatient psychiatric adolescent beds, 
particularly for public pay patients who, if admitted, are 
discharged prematurely, (b) limited subacute and alternative 
living arrangements, including residential treatment, day 
care, 
treatment, group homes and foster  (c) limited out
patient treatment in communi ty mental health centers where 
supply, and 
demand is greater than  (d) scarce crisis 
intervention programs and hotlines wi th a special focus for 
you th . 
ty based. 
11. Suicide prevention must be communi  School programs
are key and should be developed in coordination wi th existing 
communi ty resources, including mental health and crisis
intervention programs. 
Networking is crucial to keeping 
cracks. 
youth from falling through the 
RECOMMENDATIONS 
I J 
Recognizing the public s need for accurate information, the

Department of Health and Human Services should assume a

leadership role in educating the public to the seriousness of

youth suicide. Public education should not focus solely on

problems, such as 
youth suicide, but should address related 
self-
the extent o  destructive behavior among the nation
youth and removing the stigma associated with mental heal
treatment. 
11. 
The Department should assure that grantees serving youth

receive adequate training and technical assistance on issues

related to suicide and other self-destructive behaviors and

their prevention.

The Department should continue to fund research on youth

r "
 suicide, including evaluation of the effectiveness of

prevention models and education programs.

The Department should identify a coordinator for youth
suicide-related ini 
tiati ves.  SUICIDAL YOUTH:  AN OVERVI EW

Youth suicide is considered to be a serious problem by most of

study. 
the service providers sampled in this  Many cautioned 
against viewing suicide in isolation from other types of self
destructi ve 
behavior and other social and health problems facing 
young people. Suicide is a symptom, not a disease or illness 
like alcoholism or schizophrenia. They emphasized that the 
reported incidence of completed suicides underestimates the 
magni tude of the problem. As a mental health provider noted, 
The numbers are not that significant, but the devastation caused 
II A number of 
by a completion outweighs all other problems. 
problems, including substance abuse, physical and sexual abuse 
and teen pregnancies, are viewed to be more significant than 
youth suicide among discrete service populations. 
A few trends surfaced among respondents ' descriptions of youth at 
1 '	
risk of suicide. The most frequently mentioned were (a) an 
increase in younger attempters (ages 5 to 10), (b) an increase in 
ideation and open discussion among all youth, (c) an increase in
ill),
seriously disturbed youth (including chronically mentally 
(d) an increase in multiple forms of self-destructive behavior
and (e) 
an increasing sense of futility among youth which leads 
moment. 
them to live only for the  As one community mental health
provider sumarized, 
II They ' re sicker and younger when they first
come to us. 
suicide, 
In describing the characteristics of youth at risk of 
nts ci 
half the respond  ted family problems, conflicts or 
factor. 
dysfunction as a contributing  More than a third 
mentioned that the suicidal youth they see are the victims of

physical and/or sexual abuse, and 17% said family and/or youth

factors. 
abuse of alcohol or drugs were key  Other 
difficulties, 
characteristics of youth at risk included learning 
depression, isolation, loneliness, low self esteem, poor self

image, poor impulse controls, poor coping skills, inabili ty to

communicate, perceived futility in the present, lack of hope for

the future, need for instant gratification, and unrealistic

perceptions of death.

On the other hand, some high achievers and perfectionists are 
suicide. 
also considered to be at risk of  These youth impose 
rigidly high expectations on themselves or perceive pressures 
socially. 
from their parents and peers to succeed academically or 
Their sense of self worth is contingent upon achievement, and 
failure. 
they cannot accept what they perceive or define as 
one crisis worker explained, "I associate suicide with 
indomitable spirit. A young person says, ' If I can' t succeed my 
way, I'll die my way.  The touchstone of suicide is not intent 
to die, but to use suicide as the solution to life s problems. 
The goal is not death. The method is death to end the pain
they  re in.  Two specific target groups of youth were singled out by many 
respondents as being particularly vulnerablcer itsoe ssu.i cide--refugees
from  war-torn countries and youth in farm  Refugees have 
suffered loss of families killed in their homelands, may feel 
guil ty for surviving when others died, and have never completed
the grieving process. 
The farm crisis reportedly has resulted in 
adult suicides which, in turn, have trickled down to youth who 
families' 
are becoming increasingly despondent about their 
losses. 
I r

rr; 
)"i  GENERA COMMUNITY INVOLVEMENT AND PUBLIC AWARENESS 
COMMUNITY RESPONSE

Study respondents were asked to characterize their communi ties 
suicide. Al 
response to the problem of youth  though three basic 
necessary. In 
themes surfaced, a caveat is  some categories of 
service agencies, there was a parallel between the respondent' 
assessment of his communi tyr i' ss kco.n cern and his own agency 
involvement with youth at  This was most apparent among 
community health centers, many of whom do not come in contact
with suicidal youth. 
The three emerging themes were: 
Approximately 21% of those who answered the question said 
youth suicide is not an issue in their communi ties, primarily 
because none has occurred. As a social worker in a youth 
out of sight, out of mind. It 
agency said, " only hits home 
wihte.n  it' s someone you know.  Most people don' t personalize
else. 
When it occurs, it happens to someone 
Another 19% said denial, fear and resistance characterize 
s " 
f 
 their communities. In some cases, there  utter denial that 
young people take their own lives.  Some are driven by fear 
and conclude that "if you don t recognize it, it will go 
j I
 away.  In some cases the resistance is exacerbating the 
problem among surviving youth. A runaway shelter
administrator noted, " 
There have been several suicides among
high school students with no discussion allowed in the 
o media coverage for the communi ty at large.

schools and 

Kids aren t allowed to mourn, and the result is negative.

Approximately 
37% said their communi ties are very concerned 
r !

about the problem, are eager to learn and respond, and have 
cooperated in marshalling support. As an example, in one 
small midwestern farm communi ty, there was a six-week general 
school. 
education night course for adults held at the local 
Parents and other adults learned what signs to look for, what 
to do when they detected a suicidal person, and what to do 
families. 
about the stresses in their  Others pointed out
It'  ignored. 
s an issue that cannot be  Nobody finds a
child' 
s death acceptable--we must do something. 
te varied. In 
Other responses were qui  some areas, other youth
issues-- are 
primarily teen pregnancy and substance abuse--
percei ved to be of such import that the problem of suicide 
diminishes in comparison. In some communi ties, cyclical patterns 
were described: first, outrage and hysteria occur immediately 
after a suicide; then, individuals and agencies scurry to 
intervene and educate; and finally, concern "dries out" until 
another death occurs. Some mental health professionals 
particularly distinguish between communi ty response to youth 
suicide and the mental health problems among children which, if 
unrecognized and untended, will create future personal and  societal problems. 
They believe their communi ties are very
uninformed about mental heal 
th problems of youth. 
PUBLIC AWARENESS

The consensus among study respondents was that public awareness

suicides. 
is necessary to demystify and prevent  Generally,
public education has a posi ti ve effect 
when people (a) understand 
that suicide can happen to someone they know and (b) are taught 
what to do and where to go for help whern itshkey.  detect a friend, 
peer, colleague or loved one who is at  In other words,
education leads to better decision making. A few respondents 
expressed fear, however, that public awareness can have a mixed 
impact and may increase the incidence among youth. "It may bring 
suicide on more quickly among persons who eventually would 
destroy themselves, " said a family planning practitioner. 
communi ty health practi tioner cautioned, "You need to educate the 
too. It' 
public to save lives, but you ll lose some,  s a 
dilemma. " 
J ! 
A major concern among many respondents is the role of both the 
news and entertainment media. The power of the media is 
negative. 
phenomenal, whether it is positive or  Respondents 
believe children and adolescents to be particularly vulnerable to 
media influence and point to problems when the media 
sensationalize, glamorize or romanticize a death. Movies, TV and 
1 !  music particularly give kids erroneous messages about death and
dying. 
To the contrary, as one school official noted, "Kids need 
to realize there s no Easter Sunday for mortals.  A hotline
director 
sumari zed the belief expressed by many respondents 
t underesti'ate the influence of the media. 
Don  Kids get the 
idea they can have everything--every sexual, travel, cosmetic and 
drug experience. It distorts the way they perceive life and
themselves . " 
Some respondents expressed gratitude that their local media are
suicides. 
1 :  responsi ve and responsible in their coverage of  Some 
others, however, were appalled and angry over media insensi ti vi ty 
and irresponsibility. In one school when two completions and one 
serious attempt occurred, the local news media sensationalized 
t. 
each story "bigger and bigger. They tried to talk to kids when 
we said they couldn  When we wouldn t allow them on campus, 
they followed kids home and queried them when their parents 
weren  t present. We had a memorial service in the school gym for 
attend. It 
one student whose family asked the press not to  out.  was 
like war, trying to keep reporters and cameramen  One snuck 
in with a camera under his coat. 
In sumary, many study respondents call for responsible public 
education in order to reduce the social taboos which hinder (a) a 
person from expressing suicidal feelings and (b) family, friends, 
teachers and service providers from receiving the message. In 
s "  k. to tell" 
particular, it helps young people learn that it' 
when a friend is in danger. A& a school psychologist teaches
students, " It' 
s better to lose a friendship than a friend.  THE COMMUNITY SERVICE SYSTEM

The description of the service system which follows is based on

discussions with 305 providers who served over 1. 
6 million youth.

They represent social, mental health, health, educational,

juvenile justice and other service areas which touch on the lives

of young people. Table 1 reflects the number of youth served by

the study respondents who were able to provide data on their

clientele. 
TABLE 1 
CLIENTS SERVED BY COMNITY RESPONDENTS 
Total Number  Percent 
Provider/Program  Clients  Total  Number  You t h 
(N = 261)  Served  You t h  Served  Served 
r .

UNDUPLICATED COUNTS: 
Communi ty Mental Heal th Centers  261  012  173  36. 
r;! 
(N = 62) 
Other  Mental Heal th  Providers  661  672  56. 
(N = 33) 
Communi ty /Migran t  Heal th Centers  383  209  180  956  47.
j"1 
(N = 33) 
Child/Teen Health Clinics  (N = 4)  15, 950  950  100. 
Family Planning (N = 18)  414  087  210  446  50. 
Runaway  & Homeless  Programs  111  870  93 , 924  84. 
(N = 71) 
Multi-Service Youth Agencies  240  970  99. 
(N = 8) 
Schools (N = 12)  860  740  860  740  100. 
Juvenile Justice (N = 4)  140  140  100.
61  61 
TOTALS  163, 909  591  971  73. 
DUPLICATED COUNTS:

Crisis Programs/Hotlines (N = 16)  631  607  293  580  46.
 HHS GRANTEES

Three categories of HHS-funded grantees were surveyed during the 
study to assess the extent to which they are involved in efforts 
to prevent youth suicide. These grantees were (a) runaway and 
homeless youth programs funded by the Office of Human Development
Services 
(OHDS), (b) family planning agencies funded by the 
Public Health Service (PHS) and (c) community health centers and 
migrant health centers, also funded by PHS. 
Runaway and Homeless Youth Programs  Most of the runaway and 
homeless programs sampled both on-site and by telephone focused 
on young people ages 18 and under. A few, particularly large 
programs, also served parents and other adults through their 
crisis intervention, emergency shelter and counseling programs. 
The runaway and homeless programs provided a broad range of 
services, including emergency shelter, individual, family and 
group counseling, legal representation for youth in custody 
hearings, case advocacy, medical and dental care, drop-
services (primarily food and clothing for street people), 
recreation programs, hotlines and communi ty education. 
Most runaway and homeless program respondents in the sample 
believed that the youth they serve are at risk of suicide. On 
average, they report that about 39% of their clients have 
considered suicide and 12% are at serious risk of killing 
themsel ves . (See Tables 2 and 3 on pages 13 and 14. ) A few 
dissenters pointed out, however, that runaways, homeless youth 
instinct. 
and street kids have a strong survival 
Several shelters admitted to screening out youth at risk of 
suicide, primarily because of the liability they would incur if a 
care. 
client completed suicide while in their  Those who do 
accept youth at risk take great precautions to not leave the 
day. 
youth alone, but rather to supervise them 24 hours a  Such 
suicide watches" require an intense one-on-one monitoring 
staff. 
capabili ty among the shelter 
Family Planning  Most of the family planning grantees sampled by 
telephone in this study had little or no involvement in youth 
exceptions 
suicide issues. The  (19% of the sample) were 
primarily comprehensive health centers, multi-service agencies or 
local health departments that incorporated a family planning 
program. 
One of these had a separate suicide counseling program 
referred. 
to which youth at risk were  Another agency had a 
psychiatrist and a mental hreiaslkth.  counselor on staff to help 
detect and treat those at  Other suicide-related services
included: 
(a) school and community outreach, including 
presentations on subjects such as depression, grief management,
self-esteem and decision making, (b) peer advocate training, 
year-olds, and 
(c) sex abuse therapy for two- to six- (d) basic
counseling. 
Otherwise, the grantees noted that they would refer 
providers. 
any client they believe to be at risk to mental health 
inabili ty to 
Several family planning respondents decried their  identify or assess risk of suicide, especially given their lack

of training and limited staff and funding which prescribe their 
service priori ties. Overall, they estimated that less than 5% of 
their young clients have considered suicide and less than 1% are 
a t serious risk (see Tables 2 and 3). 
Community Health Centers (CHCs) and Migrant Health Centers 
These health clinics (sampled by telephone) serve low income 
people in underserved rural or inner city areas. A third said 
they had special pediatric staff to serve children and youth.
More than a third provide mental health services, although they 
are available only to adults in some instances. An addi tional 8% 
wi th no mental health services indicated the availability of 
educational and/or social services. A few work wi th the schools 
ties. 
in their communi 
The tone of these interviews was significantly different from 
respondents. 
other types of study  Seventy percent said they had 
virtually no involvement wi th the issue of youth suicide.
1 :
 typical comment was, "  re a medical facili ty, and people come 
to us for medical problems only. 
Approximately 25% of the clinics had occasionally been involved

suicide. 
with the issue of youth  Three clinics are actively 
involved in screening kids for risk factors, including suicide. 
clinics: "
Noted a staff member at one of these  A. lot of kids at 
s a real tie. 
risk of suicide also need medical care. There 
Overall, the community and migrant health centers estimated that 
over a third of the youth they serve have had some suicidal 
ideation and tha  8% are seriously at risk. (See Tables 2
and 3. 
MENTAL HEALTH SERVICES

The availabilittiye sof.  mental health services varies significantly

among communi  Ideally, communi ties offer a broad range of
services, varying in intensi 
ty, which collectively comprise a
continuum of care. I' Such a system theoretically enables clients 
to move from one component of the service system to another as
their treatment needs change. 
In the course of this study, we 
contacted over 100 mental health providers--a wide array in 
tional 
communi ties selected for on-site field work plus an addi 
sample of communi ty mental health centers and National Health 
telephone. 
Service Corps psychiatrists by  Nearly all the 
providers indicated at least some involvement wi th youth at risk
of suicide. 
They represented the following components of the 
mental health service system: 
Mental Health Centers 
Communi ty  (CMHCs)  These agencies, funded 
primarily from public sources and sliding fees, are often located 
in low income and underserved areas. Some are staffed to provide 
outpa tient counseling, while others offer a comprehensive range
of services ,  including hotlines , emergency/crisis intervention, 
treatment. 
day treatment, communi ty education and residential  Over a third of the sample had specialized staff to work wi 

18. 
children and youth, primarily up to the age of  Most
categorize youth over 18 as adults. 
Sixty peirscseunte so.f  the sample said they work wi th schools on mental 
heal th  Some participate on crisis teams that respond to 
school suicides. Many work with other communi ty sectors,
providing speakers, sponsoring workshops and conferences,
promoting networking and developing coali tions around suicide
issues. 
Sixty percent frequently or routinely treat suicidal youth.
Another 30 % occasionally do. Ten percent indicated they rarely 
ever treat youth at risk of suicide. On average, CMHCs estimate
that 38% of the youth they serve evidence some suicidal ideation 
and that more than half are at serious risk of suicide (see
Tables 2 and 3). 
Other Outpatient Mental Health Clinics . A few other outpatient

mental health clinics , primarily attached to major medical or

psychiatric facilities, were visited during on-si te fieldwork.

All reported involvement wi th suicidal youth.

Therapists in private Practice  Several private therapists were 
contacted during on-site fieldwork. Most have been involved in 
counseling suicidal youth and reflect concerns similar to 
therapists employed in CMHCs and other outpatient mental health
clinics. 
The biggest difference is that their caseloads consist
primarily of private pay clients. 
Day Treatment pr5grams  At a more intense level, a few

communi ties 	offer adolescent day treatment programs , which are

sometimes used as an alternative to hospitalization. They
provide a highly structured, therapeutic environment during the

day, but participants reside elsewhere--often wi th their

homes. 
families, in foster care or group  Many clients have been
discharged from psychiatric hospi tals. 
These youth attend school on site and participate in recreational

and other structured social acti vi ties. 
I .	 training.  Some receive vocational
There is a strong emphasis on counseling and therapy,
as well as on strengthening problem solving and practical daily 
living skills. Where feasible, the rest of the family is 
involved in the treatment plan. Participants commonly stay in 
years. 
day treatment for months or even  The threat of suicide is
reported to be " 
an ever present risk" among youth in these 
programs. 
ties 
Group Homes and Residential Treatment Facili  Some 
communi ties a	 lso have group homes and residential treatment

facili ties 
which provide an even higher level of structure and 
intensity. Of those visited, some focused on drug and alcohol

treatment while others were primarily psychiatric facili ties. 
Participants reside on site with varying degrees of supervision
 and independence. Indicated 
one program director: "If a kid 
can  t make it here, then he has to be hospi tal i z ed. We re the 
last stop before inpatient treatment or the first step back into 
SUbstantively, the 
society upon discharge from the hospital. 
programs visited were similar to the day treatment programs,
offer ing on-site 
educational, vocational, recreational and 
therapeutic components with a strong focus on problem solving and 
practical skill development. Stays ranged from a few months to a 
few years. Residential facilities are actively and routinely 
invol ved wi th yout  considered to be at risk of suicide. 
Inpatient psychiatric Hospitals  At the most intense level are 
the acute, inpatietnite sps.y chiatric facili ties. OIG staff visi ted a
dozen such facili 
Eight had special units for adolescents. 
Youth who are acutely at risk of suicide are admi tted to 
inpatient facilities most frequently for a few days of crisis 
stabilization, but sometimes for more extended periods. 
addi tion to intense psychotherapy and crisis management, these
facili ties 
emphasize educational, recreational, coping and
practical skills. 
Emergency Services  Communi ties vary dramatically in their 
ties, 
approach to suicidal emergencies. In most larger communi 
there was some focal point for trying to stabilize a crisis
si tuation 
and/or determine whether voluntary or involuntary 
commi tment to a hospi tal is warranted. Sometimes this function
1'1 
was performed by hospi 
sttaalf efm.e rgency room staff or by communi 
mental health center  Other communi ties have specialized
mobile crisis uni 
ts which are available 24 hours a day and can go
to the person in~crisis to conduct an evaluation. 
f .
 One city
visi ted 
had a specialized mobile crisis team that focuses 
specifically on children and youth. 
CRISIS INTERVENTION/HOTLINES

The crisis intervention programs contacted ranged from hotlines 
serving solely latch-key grade school children to comprehensive 
ages. 
purpose organizations 
crisis care for all  The latter multi-
treatment,
included such services as phone hotlines, therapeutic 
r .
 drop-in group counseling, day care referral, communi ty outreach, 
training, 
chemical dependency detoxification, suicide prevention 
grief counseling and survivors ' support, research, and 
psychological autopsies. Their focus also ranged from specific 
target groups such as teenagers to all ages, from suicide-
specific to general crises. Some hotlines are manned 24 hours a 
day, others for the few hours children are home alone after
school.  f ic local 
Some serve speci  communi ties, others are
national in scope. 
Despi te their range of siztei,e sst.r ucture, 
services and targets, they had some commonali  Most rely on 
volunteers to staff their crisis phone lines and require these 
volunteers to complete intensive training after which the 
selected volunteers formally commi t to contribute specific 
time. 
amounts of  Those wi th suicidal focus or expertise are 
sought after in their communi ties as resources to train adults  ( 

and youth on suicide prevention. Some also provide intervention

teams to assist school officials when suicides occur among the

student body. 
On average, they estimate that 34% of the youth 
they serve evidence suicidal ideation and 9% are at serious risk

of suicide. 
(See Tables 2 and 3. 
Some hotlines advocate reflective listening with a guarantee of

anonymi ty to help the caller work through a crisis and reach his

own decision. Others aggressively trace calls when they believe

the caller to be at or near suicide and call the police or other 
intervene. 
emergency response units to  The latter is impossible, 
lines. 
however, through the national 
Beyond basic funding, a great challenge facing most crisis 
programs is maintaining the reservoir of experienced, trained
vol unteers. Other major concerns include: 
outreach-- services, 
getting kids to call, to use the crisis 
(i. e., 
determining lethali ty  the seriousness of suicidal 
r i

intent) in youth, since most assessment tools are geared to

adul ts ,
getting kids to treatment. "
Once we intervene, the system 
the caller do sn' t follow through, " noted a

falls apart 

di rector. 
In one communi ty, local hospitals were converting excess beds to 
I I

adolescent care and marketing them as suicide prevention
services. 
They use a crisis line approach, but then won t talk 
to callers unless they re interested in hospi tali za tion. 
SCHOOLS 
o '. 
public and private Schools  Public and private school

respondents in the study varied from officials of the second

largest school district in the nation serving 585,

kindergarten through 12th grade to an al  000 students

terna te grammar and high 
school program serving 65 depressed youth and juvenile 
delinquents ages 5 to 21, whom the public schools could no longer 
serve. 
The most comprehensive intervention and prevention efforts were 
in place in districts and schools where visible and frequently 
mul tiple suicides among the student body had sparked peer,
response. 
parental, school and community concern and  Among the
school ini tiati ves,  for: 
OIG staff saw models 
risk, 
screening elementary school children to determine 
crisis intervention teams in the schools who respond to

emergencies, 
student curricula for in-class prevention awareness,

afterschool hotlines, 
peer counseling,

in-service training, wri 
tten manuals and resource guides for 
faculty and staff,
 ( ' 
"
and youth on suicide prevention. Some also provide intervention 
teams to assist school officials when suicides occur among the
student body. 
On average, they estimate that 34% of the youth 
they serve evidence suicidal ideation and 9% are at serious risk
of suicide. (See Tables 2 and 3. 
Some hotlines advocate reflective listening with a guarantee of

anonymi ty to help the caller work through a crisis and reach his

own decision. Others aggressively trace calls when they believe

the caller to be at or near suicide and call the police or other 
emergency response units to intervene. The latter is impossible, 
lines. 
however, through the national 
Beyond basic funding, a great challenge facing most crisis 
programs is maintaining the reservoir of experienced, trained
volunteers. 
Other major concerns include: 
outreach--getting kids to call, to use the crisis services, 
(i. e., 
determining lethali ty  the seriousness of suicidal 
r i

intent) in youth, since most assessment tools are geared to 
adul ts, 
treatment. "
getting kids to  Once we intervene, the system 
falls apart 
 the caller do sn I t follow through, " noted a

di rector. 
In one communi ty, local hospi tals were converting excess beds to

r r

adolescent care and marketing them as suicide prevention

services.  I t 
talk 
They use a crisis line approach, but then won 
I re  tion. 
to callers unless they  interested in hospi tali za 
SCHOOLS 
public and private Schools  Public and private school 
respondents in the study varied from officials of the second 
largest school district in the nation serving 585, 000 students in 
kindergarten through 12th grade to an alternate grammar and high 
school program serving 65 depressed youth and juvenile 
delinquents ages 5 to 21, whom the public schools could no longer 
serve. 
The most comprehensive intervention and prevention efforts were

in place in districts and schools where visible and frequently

mul tiple suicides among the student body had sparked peer, 
parental, school and communi ty concern and response. Among the

school ini tiati ves,  for: 
OIG staff saw models 
risk, 
screening elementary school children to determine 
crisis intervention teams in the schools who respond to

emergencies, 
student curricula for in-class prevention awareness,

afterschool hotlines, 
peer counseling,

in-service training, wri 
tten manuals and resource guides for

facul ty and staff,
 " -
periodic or ongoing workshops, seminars and conferences, and

crisis. 
protocols for action in the event of a suicide 
suicide,
Admi ttedly, some districts are cautiously addressing 
gi ven the myriad demands upon schools, limi ted funding for
special ini tiati ves, liabili ty 
concerns, and communi ty and/or 
services. 
parental pressures to focus only on academic 
An interview was conducted with the archi 
peer Programs  tects of 
a peer program which has been adopted by over 150 schools in 
several states. The program is based on the premise that 
natural helpers" (those to whom students are likely to turn in a 
school. 
crisis) exist in every peer group in a  The concept is to 
identify those kids and give them intensive training so they can 
do an even better job of what they would be doing anyway-
identifying and supporting peers wi th problems. Selection of 
these " natural helpers" is accomplished through an "anonymous 
survey of all students. The program stresses that the role of a 
natural helper" is to identify and support a peer with a 
problem, not to be a counselor. Even with intensive training, 
natural
one of the biggest challenges has been to persuade the "
helpers 
" to " share the secret" with an adult when they suspect or 
attempt. 
are told of a pending suicide 
Many schools, therapists and other service providers were

enthusiastic about the role peers can play in the identification

suicide. 
of youth at risk of  Some schools have resisted 
liability. 
implementing peer programs because of a concern with 
JUVENILE JUSTICE FACILITIES 
A few juvenile justice facili ties were visited during the on-si
fieldwork. All 
expressed considerable concern and involvement 
wi th the potential for suicide among the youth detained in their 
care and stressed that they place a strong etmipehsas.i s on minimizing 
suicide in their facili 
the opportuni ty for  They estimate 
r .

that 68% of their population have some suicidal ideation and more

suicide. 
than a third are at serious risk of  (See Tables 2
and 3.  One facility reported that because they are not
considered to be a treatment facili 
ty, they are precluded from 
conducting a psychological evaluation until a child has been in

residence for at least two weeks.

POLICE 
ties
Since suicide is not considered to be a crime in the communi 
visi ted 
by OIG staff, the police generally were not actively 
involved in suicide issues. A few basic exceptions existed. 
half of the cities, police investigate suicide attempts, looking 
especially for indications of p1h8ys.i cial, sexual or substance 
abuse of attempters under age  In a third of theI  coiftfiicese, st.he
police investigate deaths for the medical examiners 

one communi ty, a youth counselor was assigned to the police

department to intervene in crises, including working wi 
 , !
suicide. 
attempters or youth at risk of  Finally, one officer 
note  that the police investigate persons who aid attempters 
crime.  ties, 
since assisting a suicide is a  In some communi 
mobile crisis teams are dispatched through the police department

and in others police trace calls and run interception when they

receive direct calls from suicidal youth or are asked by crisis

intervene. 
hotlines to trace and  Commonly, when the police 
encounter suicidal youth, they refer them to mental health 
agencies for evaluation. 
MEDICAL EXAMINERS

The role and philosophy of medical examiners visi 
ted varies
greatly. 
Two had no protocol or official cri teria for 
determining suicide, noting that deaths are deemed to be

exists. 
In one city, 
accidents unless hard evidence of suicide 
the medical examiners' staff did no on-site (scene of death) 
investigations, relying on the police or morticians to transport
the bodies for examination. 
Only one medical examiner had an
1 :
 extensive suicide protocol used by investigative staff to define 
not only the cause and manner of death but also what led up to
the death. 
Basically, these investigators do a psychological
autopsy. 
The other examiners ' offices noted that they do routine 
i. e., 
autopsies to determine the type of death-- accident, natural
cause, homocide, suicide. 
In two communi ties, the issue of age is key in suicide

determinations. In 
one state, deaths of children aged ten and 
under cannot be considered suicides. In a large urban county in

another state, t e medical examiner said, "  re cautious about

determining suicide, 
" and said he would not consider any death of 
a youngster aged 14 or under as a suicide. He explained that the

age cri terion differed 
from county to county depending on each 
medical examiner' s policies. Yet in another large urban area, 
year-
the youngest documented suicide was a seven- old boy who left 
himself. 
a note of intent and shot  Some medical examiners 
admi tted feeling, and sometimes succumbing to, pressure from

families to determine deaths as accidents or natural causes

stigma. 
because of the associated 
SURVIVOR' S GROUPS 
The need for grief counseling is being recognized in many 
communi ties. Whether it is provided through special survivor 
organizations, churches, mental health centers or crisis 
intervention programs, these grief counseling groups help family 
pain, 
members, friends, colleagues and classmates to survive the 
anger, guilt and other emotions associated wi th a suicide. Most 
counsel wi th loving support toward a goal of preventing family or 
anguish. 
friends from also taking their own lives in their  TABLE 2 
ESTIMATE OF SUICIDAL IDEATION AMONG RESPONDENTS' YOUTH CLIENTS

Number Who
 Percent Who

Provider / Program  Total Number
 Considered
 Considered

(N = 179)
 Youth Served
 Suicide
 Suicide

UNDUPLICATED COUNTS: 
Community Mental Health Centers
 971
 819
 38. 
(N = 41)

Other Mental Heal th Providers  13, 421
 655
 49. 
I :
 (N = 27)

Community/Migrant Health Centers
 203
 311
 35. 
(N = 19)

I :	
Child/Teen Health Clinics (N = 
 500
 500
 20. 
f I
 Family Planning (N =  122  175
 462

Runaway & Homeless Programs  655
 489
 38. 
(N = 58) 
Mu1 ti-Service Youth Agencies  11 , 370
 173
 27. 
(N = 4) 
Schools (N = 6)  146  920
 , 109

Juvenile Justice (N = 
 090
 514
 67. 
TOTALS  532  305
 108  032  20. 
DUPLICATED COUNTS:

Crisis Programs/Hotlines (N = 13)
 548
 081  34.  TABLE 3 
RESPONDENTS' ESTIMATE OF YOUTH CLIENTS AT SERIOUS RISK OF SUICIDE

Number  Percent 
Provider/Program  Total Number
 You t h  You t h 
(N = 183)
 Youth Served
 At Ri s k  At Risk 
UNDUPLICATED COUNTS: 
Community Mental Health Centers  183  666  22. 
(N = 46) 
I.. 
Other Mental Health Providers  527  268  34. 
(N = 26) 
Community/Migrant Health Centers  86, 527  , 710 
(N = 20) 
Child/Teen Health Clinics (N =  500  255 
Family Planning (N = 8)  122  195  222 
Runaway & Homeless Programs  , 779  318  12. 
(N = 54) 
Multi-Service Youth Agencies  570  368  30. 
(N = 4) 
Schools (N = 9)  150  635  920 
Juvenile Justice (N =  090  917  35. 
I ! 
TOTALS  543, 006  644 
DUPLICATED COUNTS: 
Crisis Programs/Hot lines (N = 11)  039  191  IDENTIFICATION OF YOUTH AT RISK OF SUICIDE

DETECTION AND ACTION

School officials and service providers were asked to describe how

they detect youth at risk of suicide among their service

population. 
Mental health providers (both inpatient and out
patient) all had some type of screening approach to identify

suicide risk. These approaches varied from (a) reliance on their

clinical expertise and training to identify warning signs

(including body language) to (b) patient self-reporting at intake
to 
(c) routine mental health status examinations and structured 
(d) formal clinical assessments. Mental health 
interviews to 
professionals note that by the time a client is referred to them, 
someone in the social, health or educational service system or a 
problem. 
family member or friend has identified a mental health 
Thus, the practi tioners often are alert to any warnings or signs 
of suicidal risk. Some youth are particularly difficult to
identify. 
For example, one inpatient psychiatric practitioner
said, " 
The ones who scare us are those who can t verbalize, but 
give clues through drawings or gestures. 
Among non-mental health respondents, approximately half rely on 
risk.
subjective or informal approaches to detecting youth at 
('I 
This ranges from observation of behavior and open-ended

discussions to " how do you feel about yourself" questions during
the intake process. 
Approximately ten percent apply what they 
describe as a full suicide assessment. OIG staff did not 
evaluate these t9-ls. A few programs, including runaway 
shel ters, currently are testing screening tools developed by

OHDS-funded grantees. In addi tion to detection, such tools are 
designed to help workers begin to structure intervention
approaches. 
A few respondents admitted to doing nothing to detect youth at 
risk of suicide. Most prominent among those " no detection 
centers, 
respondents were 45% of the community and migrant health 
19% of the schools and 22% of the crisis programs/hotlines. 
r !

Agencies were asked if an HHS-developed screening tool would be 
them. 
helpful to  Of the 271 who responded to the question, 41% 
said it would be helpful and thetoy owolu.l d actually use it, and 16% 
said they would not use such a  Most of the latter 
respondents are satisfied wi th the tools they currently are using
or testing. 
The exceptions are the schools who face special 
constraints. Most schools are not allowed to do such assessments 
without parental permission. Others are precluded by time and 
resource limitations. For example, in some districts, school 
counselors and psychologists must focus on special education 
students since their funding is derived primarilAy cftr.o m 
P . L. 94-142, the Education for the Handicapped  The 
remaining 43% qualif ied their answers, noting that they might 
modify their current approaches by adopting portions of any new 
tools developed by HHS or others.  Actions taken subsequent to detection also vary widely. Most 
hospitals, 
non-mental health providers refer at-risk youth to 
CMHCs or private therapists for further evaluation, intervention 
and treatment. It should be noted that some school districts are 
tioners 
precluded by law from referring students to private practi 
or anyone not tax-supported. Hotlines specifically mentioned the 
need to talk a caller through the immediate crisis before making
referrals. 
Some hotlines trace calls or try in some way to 
identify the caller and seek police or paramedic intervention 
situation. 
when a caller is in a highly lethal  Some 
organizations, including schools, family planning and runaway 
shel ters have in-house staff who counsel clients. Approximately 
20% of the runaway and homeless programs have a triage protocol. 
Acutely suicidal youth are screened out and taken to inpatient 
psychiatric facilities or to outpatient facilities, depending on 
availabili ty. Two factors provide the primary impetus to screen
out acutely suicidal youth: 
(a) a recognition that mental health 
professionals may be better able to intervene and save the
client'  (b) the threat of legal/financial liabili ty if
s life and 
client. 
the youth dies while still a program  Less acute youth 
are monitored closely (via 24-hour suicide watches) and
counseled. 
Many agencies " contract" with the youth who remain 
under their care. In essence, the youth is asked to agree to a
no suicide pact, 
" to promise he will not commi t suicide for a 
specific period of time. 
TRAINING 
In approximately 15% of the service agencies, staff and 
issues. 
volunteers have not received any training on suicide 
approxima tely ha!f the agencies, staff receive some kind of in-
service training that touches on suicide--these range from an
hour  s presentation to week-long intensive sessions on detection 
and intervention. Another 13% have sent their staff to suicide 
workshops, and 17% said their staff had received mental health 
hired. 
and/or suicide-specific training prior to being 
FACTORS CONTRIBUTING TO SUCCESSFUL TREATMENT AND PREVENTION

Study respondents were asked to describe what works for them in 
suicide. 
addressing the problems of youth at risk of  The 
that, 
consensus was that youth at risk need professional help and 
plan. 
if possible, the family should be involved in the treatment 
As a medical practitioner emphasized, " We can 't treat suicide. 
We have to treat what caused the child to consider this as an 
option. 
This ties into the next most common response--to
provide a supportive environment. 
Families are an integral part
of a support system.  possible,
Where parental involvement is not 
other players (e. 
g., teachers, counselors, peers, friends) in the 
important. 
support system become even more  Also emphasized was 
the need to develop caring, trusting, honest relationships,
preferably one-on-one. 
This is especially important in
developing posi ti ve therapeutic relationships. 
Kids need to be 
problems. 
able to talk about their feelings and their  This can  ( !

occur more easily when someone listens and cares in a 
nonthreatening, nonjudgmental way. 
Other frequent suggestions were to (a) teach youth better daily

living skills--how to cope wi th problems, make wiser decisions,

(b) contract during the immediacy of crisis by establishing a no-

suicide pact, (c) provide peer advocacy through the schools,

(d) provide strong case management once a child is in the system 
to assure he doesn t drop through the cracks, (e) assure 
continuity of care and (f) sanitize the environment by removing
the lethal i 
tems--e.g., guns and pills--which can be used easily 
upon impulse. As one researcher pointed out, "Often whether kids 
is. 
die or not depends on how well stocked their medicine cabinet 
Completers die because the means are readily available.  WHY AREN' T KIDS BEING SERVED? 
BARIERS TO SERVING YOUTH AT RISK OF SUICIDE 
Several major barriers to serving youth at risk of suicide were

identified consistently by all types of respondents:

Accessing the service system  Significant numbers aolfl y.o uth who

kill themselves never enter the service system at 
Some 
typical comments:

There is a certain segment of suicidal youth who do not give
any signs, but who are incredibly lethal. We can impact
those who are ambivalent, but not those who are beyond 
ambivalence. " (CMHC therapist) 
The ones in therapy aren t killing themselves. It' s those 
beyond our reach we must worry about.  (psychiatrist) 
A county medical examiner s study of 25 youth suicides (age 19
services. 
and under) found that 72% had not received any  Indeed,
the overwhelming majority of service agencies interviewed by OIG 
staff were unaware of any completed suicides wi thin the past year
among their clients. (See Table 4 on page 25.  Mental health
professionals are not in a posi tion to ini 
tially screen youth who
might be suicidal. They are dependent on parents, school 
personnel, pediatricians, clergy and other " front-line" workers 
to detect that something is amiss and that professional help is
needed. 
I :	 Over half the mental health providers indicated that one 
of their biggest~challenges is getting kids into treatment. 
This is not a problem unique to mental health providers. Youth
have a general reputation for reluctance to enter any tradi tional
service system. 
Many of the health clinics ' staff indicated 
their difficulties in getting youth, especially adolescents, in 
treatment. "
thei r doora for medical  Kids won t come in and
they  re very hostile when they do, " noted a physician at an 
adolescent health clinic. "Unless they need a sports physical,

they  re acutely ill by the time we see them, n said a communi ty 
heal th center physician.

There is, however, a particular stigma associated wi th mental 
health services. Young people fear being labeled " crazy " and are 
terrified that their peers will find out they are in therapy.
Respondents stressed that young people should be told what to 
expect before they enter the mental health service system. 
Furthermore, suicide is still a taboo subject for many people.
Convincing minorities to enter the treatment system is seen as a 
particularly difficult challenge.

Parents are often seen as contributing to the problem. Over a 
third of the mental health providers and a fourth of the runaway

programs saw parental resistance and denial as a major barrier to
 Subacute programs and al terna ti ve li 
ving arrangements
Another major gap in the mental health service system is
the need for an array of subacute facili 
ties, other
therapeutic programs and al 
terna ti ve living
arrangements, such as residential treatment facili ties

day treatment programs, group homes and foster c
 are.
Respondents stress the need for follow-UD of care.
Noted one hospital-
We can bring
based psychiatrist, 
them in from the ledge, but without continuity of care, 
they' 
ll be right back out there in a different
presentation 
, but just as suicidal. 
Many hospi tali zed 
youth cannot be discharged
successfully from a psychiatric facili 
ty wi thout an 
intermediate stop in an after-care program. A range of
therapeutic options with varying levels of service
intensi ty and supervision are needed. 
These programs
also serve a key role as alternatives to inpatient

treatment. 
Because so many hospitalized youth cannot 
realistically return home to a stable family 
environment, alternative living arrangements are
cri tical. 
There is also a need for respi 
te care for 
parents and foster families. These latter programs are
ties. 
nonexistent or rare in most communi 
Outpatient therapy  Al though available in most 
communi ties, communi ty mental heal th centers are plagued
ting lists.
wi th chronic staff shortages and long wai 
Frequently they can accept only the most severe cases. 
Noted one health clinic physician, "Even following a
' s a six 
crisis, ~there to eight week waiting period for 
CMHC counseling. " A CMHC clinician said, "We are 
forced, due to lack of resources, to wai t until a 
patient is imminently suicidal before we can intervene
and treat. 
" Some CMHCs do not have specialized staff to 
work with youth, and several identified the need for 
more family therapy. Al though the services of pri 
va te 
therapists are available in many communi 
ties, fees are
often prohibi ti vely  families. 
high for many 
Emergency mobile crisis response teams 
Communi ties
wi thout 
this type of service stress the need for crisis 
teams, available on a 24-hour basis, that can go to a
youth in a suicidal crisis for stabilization and
evaluation. 
Even where available, it sometimes takes 
too long for the crisis unit to respond. 
Hotlines 
Although many communities have at least one 
hotline, sometimes it is difficult to get through--a cri tical 
problem for a person in imminent danger. A hotline director
admitted, " 
If teens are put on hold more than sixty seconds,
bthieliyn greu allo hsto.t liWnee nse.v er hear from them again. " There are few
Those wi thout special outreach to youth
find that few adolescents use their services.  , '
Men tal health continuum of care

Inpatient psychiatric beds and special uni 
ts for
adolescents 
The most frequently mentioned gap in the
service system is the lack of inpatient psychiatric beds

for youth (reported by more than half of the communi 

mental health centers, more than a quarter of the

runaway programs, communi ty health centers and other

therapists, and numerous other respondents as well). 
In many communi ttise.s,  there are no speciali zed adolescent
psychiatric uni 
Youth are placed in adult 
psychiatric wards or general purpose hospi tal beds, 
nei ther of which is regarded as a satisfactory
al ternati ve. 
Even in communi ties that have adolescent
psychiatric uni 
ts, access is extremely limi ted for other 
than private pay patients. One runaway shelter reported 
that they had experienced three serious suicide attempts 
from three different youth in a two-month period. 
each case, there was no inpatient bed available, and 
they eventually had to send these youth back home to 
await placement. Noted an official at a juvenile
justice institution, " 
If parents can afford it or have 
insurance, we can sometimes transfer a severely 
disturbed kid to a psychiatric hospital, but otherwise
it' 
s the juvenile prison.
I !

Staff at many of the inpatient psychiatric facili ties 
agree that demand outweighs supply: 
re turned away unless they re dripping blood.

We can only accept the most extreme cases.

By the time we can treat them, we can' t reach 
them. " 
In some cases, the only way for a child without

insurance to be admi tted as an inpatient is for the 
parents to negate custody and declare the youth a ward

of the court.

Inpatient staff report tremendous pressure to discharge

possible. 
public pay patients as soon as  Over a third 
said they cannot keep public pay patients long enough. 
allowed to keep them two weeks when they need to 
re 
stay three to six months, " noted a psychiatrist. After
care facilities such as residential and day treatment 
programs complain that youth are frequently discharged 
tions. 
to them in highly unstable condi  Noted one
director, " 
The hospital stays are briefer and briefer, 
so there s more recycling all the time. We get them 
back here when they re not even close to being
stabilized. "  , ) 
Others require large co-payments and have annual or lifetime

pay. 
limits on what they will  Health main'tenance organizations
were ?ingled out by several respondents as providing inadequate 
mental health coverage for their membeFs. 
Legal barriers 
Commi tment laws  Laws regarding the voluntary and
invol untary commi tment of youth to inpatient facilities vary
among jurisdictions. It is difficult in most, however, 
acute 
commi t an  y suicidal youth wi thout his consent. 
Concern over liability  Fear of liability keeps many service 
youth. 
providers from serving potentially suicidal  One state 
is rewri ting regulations for its drug and alcohol inpatient 
treatment facilities, requiring that youth at risk of suicide 
be screened out of treatment. There were reports of
increased insurance costs associated wi 
th crisis 
intervention. One telephone hotline reported a 900% increase 
in insurance rates during this past year. 
parental consent  In many jurisdictions, youth cannot

recei ve services wi thout the signature of a parent or
guardian. 
Other Barriers.

Transporta tion  This is particularly a problem in rural

areas and communi ties wi thout adequate public transportation.

I :
 Staff fear a  burnout  Suicidal youth are a difficult, 
serve. 
highly stressful group to  The threat of suicide 
raises anxiety at every level. Providers express fear that 
even if I can detect a potential suicide, I can t keep it 
shelter, "
from happening.  Noted staff from a runaway  Our 
fear of dealing with high risk kids blocks us from 
effectively serving them. 
Cul tural/societal attitudes toward self-destructive behavior 
Several respondents expressed concern over the promotion of
self-destructi ve 
behavior at rock concerts, through music
videos and in movies. 
Said a therapist, "  m fighting a 
whole culture that' s condoning self-destructive behavior 
through MTV, rock concerts, Rambo fantasies and a general 
punk lifestyle. 
GAPS IN SERVING YOUTH AT RISK OF SUICIDE

general is 
Many respondents stressed that the service system in 
stretched to capaci ty and that most communi ties need more.

poor. 
The need for 
services for youth, particularly the 
addi tional staff and funding was one of the most frequently 
provider. 
mentioned issues, regardless of the type of  Other 
major gaps include:  youth. 
the treatment of high risk  Many parents feel threatened
and are extremely defensive to the possibility that they might be
part  f the problem. 
It is also a challenge to convince them of
the seriousness of a suicidal threat and to enlist their

cooperation. 
Noted one school official, "A fourth grader told a 
counselor how he was going to commi t suicide. When we told his 
parents--an attorney and a health profeasional--their reaction
was, 'he doesn't 
even know what that means. 
Parents often react negatively to the mental health stigma or are 
s welfare. 
apathetic toward their children  Noted a therapist,
We have had parents whose kids have attempted suicide refuse
trea tment, 
because they didn 't want their kids to be labeled 
crazy. " A psychiatrist who heads a clinic specifically for
suicidal youth said that " 
of the 40% who refuse treatment,
usually it' 
s the whole family, not just the kid, who isn
interested. " 
n equally big problem is that many youth who enter treatment 
don  t stay long enough. A clinic which speciali zes in depressed 
and suicidal youth found that 80% of their patients do not 
complete the necessary treatment. Young people are notorious for 
not keeping appointments. Many won t come voluntarily, so
wi thout strong family support the likelihood of dropping out of 
therapy is considerable, especially after the immediate crisis 
has been stabilized. 
The dilemma of getting and keeping youth in treatment was

sumarized by a therapist, " 
Unfortunately, many kids at risk of 
suicide never ge  identified or by the time we get to them it' 
too late. But an even greater tragedy is that many who are 
identified refuse treatment or drop out before we ve had a chance 
1'1  to do much good. 
Respondents also express frustration that once treated, youth are 
forced to return to the same unhealthy environment that 
r :  place. 
contributed to the crisis in the first  Noted one
psychiatrist, " 
It is very frustrating to discharge them back to 
the same hopeless environment--no job, a screwed-up family and a 
r "
 bleak future. So many have so few options. 
Lack of resources  Men tal heal th therapy is expens i ve. 
Outpatient therapy commonly ranges from $50 to $100 an hour, and 
inpatient treatment without private insurance coverage is 
families. For families 
prohibi tive for all but the wealthiest of 
with limited resources and no insurance, there are few treatment 
options available. For outpatient services, these families will 
most likely be steered to community mesnctaall eh.e alth agencies, which 
charge for services on a sliding fee  For some families, 
even a sliding fee is prohibitive. 
Available insurance is often inadequate. Many policies place 
ta tions 
1 imi  on men tal health services. For example, some do not 
doctors. 
cover the services of clinicians who are not medical  , "

Services in rural areas

Rural communi ties face a special

challenge because the nearest mental health services are

often miles away. 
Noted one communi ty health clinician
places like this, you 
re lucky to have even one mental health
professional in the whole communi 
ty. "

School programs 
One of the most common themes was the need

for school programs which include a focus on faculty, staff
parents and students. 
Components need to include staff

training, a student curriculum and a well-
defined protocol
outlining steps to take in the event of a suicide 

emergency.
There were reports of resistance from some school board

members and administrators, partly out of a fear that any

effort would encourage suicide, or a denial that this is a

problem in their atudent populations.

Communi ty education and awareness 
There is a need for

extensive training and education on youth suicide throughout

communi ties. Anyone who comes into regular contact wi

youth, the so-called " gate-keepers, 
" should be made aware of 
the potential for suicide among young people, know the

help. 
warning signa to look for, and where to go for  This
includes parents, school personnel, hospital emergency room 
staffs, pediatricians and primary care physicians, child
protecti ve services 
staff, foster parents, clergy, coaches,
the whole array of youth service agencies, and the 
police, as
well as youth themselves. The 
importance of developing peer
programs was frequently stressed. 
There is also a need for better training of mental heal 

professionals, to work with both youth and suicidal persons

number of mental health professionals said

of any age. 

they wished they had better diagnostic 
predict the potential lethali ty of  tools, particularly to

, I  suicidal risk. A few
stressed that standardized diagnostic tests don 
t work well

on youth. 
Networking 
Respondents said that service agencies need to 
join together in cooperatively preventing youth suicide,
rather than working in isolation. Many mentioned turf

problems, which are exacerbated by the fact that so many

dollars. 
agencies are competing for the same limited 
Some
typical comments:

Too many people claim ownership of different parts of

the same kid. " (CMHC therapist)

Each service agency is very isolated from the others. 
They don t know what' s happening in the other parts of 
' lives. It' 
their clients  s very important to mesh
service systems.  (psychiatrist affiliated wi th a

uni versi ty) 
Because suicide is a symptom of children wi 
th serious,
often multiple problems, networking is very important.  Suicide can be the ultimate effect of falling through

the cracks and being treated by a compartmentalized

service system. " (therapist)

Services to pre-teens and older youth  Many respondents 
stressed the need to focus more on older youth, particularly 
, as well as pre-teens. 
those 17 and older Several mental 
heal th providers said that they have had patients as young as
fi ve or six 
who evidenced obvious suicidal symptoms. 
Respondents also stressed the need for early intervention. 
Identifying and treating young children at risk prevents 
problems from escalating into even more serious dimensions as 
these children move into adolescence. 
I!;
 FEDERAL ROLE

More than half the respondents said they would like to see HHS

suicide. 
involved in educating the public about youth  They 
support the federal government assuming a leadership role in 
recognizing the seriousness of the problem and serving as a 
catalyst to encourage communi ties to develop their own

ini tiati ves. 
Most stressed that the thrust of a public education 
campaign should not focus solely on youth suicide, but should

address related problems such as removing the stigma associated

wi th seeking mental health treatment and the extent of all self-

destructive behavior among today ' s youth. Of the HHS-funded 
grantees contacted in this study, over a third of the runaway

programs and over a quarter of the family planning programs and

communi ty /migrant health centers said they would like more 
issue. 
training and information on this 
There is a particular interest in having the Department develop

) i	 and disseminate materials on youth suicide or support a
clearinghouse for materials developed elsewhere. There was great
II as they 
concern that communi ties not  reinvent the wheel 
 develop
their own initiatives. A significant number of materials, 

including curricula, have been developed, but there is no central

reposi tory where interested parties can go to see what is

available.

Other suggestions which surfaced frequently:

research. 
HHS should support youth suicide  Evaluating what 
works in prev nting suicides is especially needed. 
HHS should establish national policies in support of youth 
and the family. Many respondents echoed the theme that lI our 
children are our future. 
There is a great deal of concern 
families. 
I i	 about the disintegration of American 
HHS should provide demonstration funding for suicide 
prevention programs as well as stabilized funding for mental 
general. 
heal th and youth services in 
STATE AND LOCAL ROLE

Respondents believe that youth suicide issues need to be 
addressed primarily at the community level through grass roots
involvement. 
There is a need for a collaborative, community-
based approach to this problem. Respondents especially stressed 
the need for public education, communi ty awareness and the
the schools. 
invol vement of  They also called for private sector 
involvement, particularly for businesses to educate their own 
employees about mental health and youth suicide issues and to 
support financially local service agencies.  ) ,

COMMUNITY RESPONSE TO YOUTH SUICIDE:  A SUMMRY 
Nobody really knows what prevents youth suicide. There is 
clearly a need for more research in this area. We have attempted

to sumari ze, however, what the study respondents collectively

suicide. 
see as key elements to addressing the problem of youth 
No community had all of these elements in place, but many are

goals. 
striving toward these as  This, then, is what a model 
service system and communi ty approach would include: 
A full continuum of mental health services, including

Inpatient psychiatric facili ties, preferably wi
special uni ts for adolescents. 
A range of subacute programs for youth wi th varying 
levels of service intensity and supervision, including
residential treatment facili 
ties, day treatment programs 
homes. 
and therapeutic group  These are needed as
after-care
" programs for youth discharged from
inpa tient facil i ties, as well as for al terna ti ves to 
talization. 
hospi 
Outpa tient counseling, preferably by therapists who

specialize in treating youth and who involve the entire

family in treatment.

A mobile emergency crisis response team which can go to

ou;h, responding quickly in the event of a suicidal

crlS1S. 
Improved access to mental health services for those wi th 
I ,
 no insurance and limi ted 
private resources. 
Special training on youth suicide for mental health

professionals. 
Programs in the schools, including

Training for teachers, nurses, counselors,

administrators and other school personnel in the

identification of youth at risk of suicide and other

self-destructi ve behaviors.

Training parents similarly, plus emphasi zing the need to

rid the home of guns, medicines and other potentially

lethal weapons, and stressing the importance of seeking

professional help for high risk children.

A curriculum for students, which focuses not only on 
suicide issues, but also other self-destructive behavior 
and youth problems, with a strong emphasis on developing 
ti ve mental 
good coping and decision making skills, posi 
skills. 
health attitudes and "life management"  Development of peer advocacy programs, wi th emphasis on 
peer identification, referral and support of youth wi 
problems, rather than peer counseling. 
A well-defined step-by-step protocol to use in the event

of a suicide or an attempt, to avoid contagion among

students. 
A clearly defined referral system to use when at-risk

youth are identified.

An evaluation component to determine which ini tiatives 
suicide. 
are helping to prevent 
Utilizing existing community resources, such as crisis

intervention centers, communi ty mental health centers

and private therapists, in the development of school-

initiatives. 
based strategies and 
collabora ti ve 
A communi tv-wide  approach to addressing youth 
suicide, including 
Group homes, foster homes and other al terna ti ve living 
arrangements for youth who cannot live at home. 
Training programs for agencies and individuals who work 
personnel,
wi th youth, including emergency room 
pediatricians," primary care 
physicians, child protective 
service workers, foster parents, youth agencies, 
coaches, clergy, juvenile justice programs and police. 
A responslble media which has adopted voluntary 
suicides. 
guidelines in the coverage of youth 
Improved networking and cooperation among agencies and
indi viduals 
who serve youth. 
Greater attention to suicide among older youth and

pre-teens.  APPENDIX A

STUDY METHODOLOGY

During this study, OIG staff interviewed a total of 631 
people,
as defined by the following categories: 
STUDY RESPONDENTS

Communi ty Mental Health Centers

Other Mental Health Providers 
Communi ty and Migrant Health Centers
Children I 
s and Teen Health Clinics 
Family Planning Programs 
Runaway and Homeless Youth Programs 
Mul ti-Service Youth Agencies 
Crisis Intervention Programs and Hotlines
Schools
Juvenile Justice 
1 :  Survi vor/Grief Counseling Groups

Local Governmen

Police 
Medical Examiner I s Offices 
Experts, Researchers, Academicians 
State Programs (a minimum in each state of education
283
mental health, children I s 
services, substance
I I

abuse, and maternal and child health programs)

TOTAL  631 
Interviews were field in person and by telephone. Of the total,
170 in-
person interviews were conducted through staff visi 
states.  ts to 
ten communi ties in nine 
On-si te fieldwork was conducted 
in February and March 1986 in: 
Phoenix, Arizona 
Chicago, Illinois

Los Angeles, California 
Central New Jersey

San Francisco, California  New York City, New York

Denver, Colorado 
Fairfax County, Virginia

J r  Jacksonville, Florida  Seattle, Washington 
Selection of these sites was based on the following cri teria: 
geographic spread 
a mix of large and small populous states 
a mix of cities and larger urban areas
states wi 
th a high rate and/or high incidence of suicide 
presence of innovative state, local government and private
sector efforts 
a mix of communi ties wi th recognized suicide prevention

programs and communi ties wi thout such recognized efforts.
 Community contacts included: 
Schools (K-12)
P6lice 
Juvenile justice programs

Heal th and mental health providers (both inpatient and

outpatient) 
Child welfare agencies

Medical examiners/coroners 
Hotlines/crisis intervention centers

Drug and alcohol programs

Youth shelters/runaway and homeless youth programs

Survi vor groups 
Youth/peer groups

State and local governments

Res earcher s / academi c i ans/ experts 
Also during February and March, OIG staff interviewed by 
telephone 178 persons representing community service agencies
funded by HHS, ei ther directly or indirectly. These respondents
I !
 (a) direct
were selected at random from nationwide lists of 
grantees and (b) service 
providers funded under block grants to
states. 
Four categories of respondents were selected from OHDS 
lists: 
and PHS grantee 
family planning programs 
runaway and homeless youth programs 
migrant health centers 
communi ty and 
National Health Service Corps psychiatric si tes 
Sites belonging t  the fifth category--community mental health 
(June 
centers--were selected from the National Directory of CMHCs 
1985) prepared by the National Council of Communi ty Mental Health 
Centers, because mental health programs are funded through HHS 
block grants to the states, and comprehensive lists of state
grantees were unavailable. 
A total of IS3 local communi ties were represented in interviews 
telephone. 
conducted on-site and by  (See Appendix B, which lists 
the specific communi ties represented in the on-si te fieldwork and 
I ' 
random telephone surveys. 
During April, 283 state respondents were interviewed by telephone

in an effort to inventory state initiatives which address youth

suicide issues. The findings from this inventory are published

under separate cover. The following five agencies were contacted

in each state. Generically, these core state agencies were

defined as: 
educa tion/public instruction

mental health

drug and alcohol abuse

maternal and child health

children  s services (foster care, child  abuse and neglect,
and children 
s protective services)  In some states, knowledgeable representatives from governor 
s and

lieutenant governor s offices, legislatures and planning agencies

were contacted. 
In sumary, OIG staff contacted representatives of state and

local, public and private sectors in all 50 states, Puerto Rico

and the Virgin Islands. 
f'1  MONTANA  NORTH DAKOTA
 VIRGINIA 
Billings  Bismarck  Arlington
Fairfax 
Grand Forks 
Falls Church 
NEBRASKA 
Lincoln  OHIO  McLean 
Omaha  Cleveland  New Canton 
Columbus  Res ton 
Toledo  Richmond 
NEVADA 
Las Vegas
 Youngstown  Springfield 
Reno 
OKLAHOMA  VIRGIN  ISLAN S 
NEW HAPSHIRE
 Alva  St.  Thomas 
Manches ter
 Ardmore 
McAlester  WASHINGTON 
Bellevue 
NEW JERSEY

Issaquah 
Atlantic City
 OREGON 
Portland  Kirkland 
Belle Mead

Belleville
 Woodburn  Seattle 
Bridgewater
 Spokane 
Cape May
 PENNSYLVANIA  T ac oma 
Dumont  Doyles town  Toppenish 
Dune 11 en  State College

Edison  WEST VIRGINIA

Glassboro  PUERTO RICO  Charleston 
Hackensack  Ponce  Fairmont 
Newark 
Piscataway  RHODE ISLAN  WISCONSIN 
Somerville  Providence  Milwaukee 
Racine 
South Orange

Trenton  SOUTH CAROLINA 
Charleston 
WYOMING 
Rock  Springs 
NEW MEXICO 
Albuquerque SOUTH DAKOTA

Portales  Sioux Falls

Sisseton 
NEW YORK

Al bany  TENNESSEE 
Knoxville 
As toria

Bronx  Nashville 
Brooklyn  Wartburg 
Goshen 
Jamaica  TEXAS 
Manhattan  Austin 
Norwich  Dallas 
Rochester  Houston 
Rockaway Beach  Plainview 
Rome 
Staten Island  UTAH

Whi te Plains  Ogden

Woodstock 
VERMONT 
Montpelier 
NORTH CAROLINA

Charlotte 
Durham  " :
-: . :')
APPENDIX C

QUESTIONS ASKED BY YOUTH ABOUT SUICIDE

A church-affiliated organization of 200 youth meet once a week in 
concern. 
study groups of 20 to discuss issues of major  Each 
addressed. 
year, suicide has been identified as a topic to be 
Following are examples of issues and questions raised by one 
topic: 
study group in preparation for discussion of this 
How do you recognize the symptoms of suicide?

suicide.

I would like to know about what causes people to turn to 
si tuations around us.

This will make us more aware of the 
How do you deal with people who have tried and failed?

What sort of problems are bad enough to end it all?

How to make yourself better without dying?

What does it feel like to lose a person you love because that

I ;

person kills himself?

What can be done to prevent it?  The thought has sometimes

entered my mind.

Is teenage drinking and driving actually suicide?

si tuations.

Teach us how to cope with these 
suicide.

Explain other ways out besides 
What is the death rate for teen suicide?

How do you deal with a friend who is talking about suicide?

r: I  How to deal with a death of someone close to you and how they 
suicide.

would feel if you committed 
Are people who commit suicide very depressed and do it as a quick

thought or do these people think it out?

If someone calls and tells you they re going to kill themselves,

what do you tell. them? Do you just listen or try to give advice?

suicide.

I think there should be a course in high school on 
cope.

Problems tha t teens have and how to 
You say that suicide doesn t solve your problems, but doesn't it?

dead.

Everything is over...