Referring Student Self-Harm Cases to Community Providers

How do educators know when to involve emergency mental health services for evaluation and care?

A 9th-grade boy posts on Facebook that he sees no point in going on, has no reason to live and feels like a failure. A classmate informs the guidance counselor about his post.

Subsequently, the boy meets with the guidance counselor and tells her he feels he would be better off dead and has thoughts of taking an overdose of pills.

Following consultation with other staff, the guidance counselor notifies the student’s parents. Fearful that the child may hurt himself, the staff acts on the side of caution and refers the boy to the local hospital’s emergency department for an urgent mental health assessment. The evaluation results in an appointment for outpatient medical health services and formal clearance to return to school the following day.

Prompted by scenarios of this kind, school districts often defer to community-based mental health emergency services. Yet no consensus guidelines exist for when this action may be necessary or if it may, at times, be harmful to the student and family.

Helpful Indicators

Students who are at risk for serious self-harm and those who are not may use the same or comparable language. These include comments about “hating” one’s life, not knowing why he or she is “on the earth” and wishing to be dead.
These symptoms can reflect benign morbid rumination rather than suicidal risk. But this ambiguity contributes to uncertainty among school district staff about which students need an urgent mental health assessment.

Some indicators that the student ought to be sent on an emergency basis for a community-based evaluation are these:

• The student has engaged in a serious verifiable act of self-harm on school grounds;
• The student has made highly concerning and substantiated threats of self-harm during the school day, which appear to involve clear intent and a potentially lethal plan; and
• School staff members are privy to credible reports of alarming self-harm statements or behavior that has occurred recently outside the school setting.

School-Based Screening

Not all students will meet the above criteria. In these situations, the district should screen the child using a standard protocol before deciding whether to refer him or her for an emergency assessment.

A designated first responder would lead a semi-structured interview asking questions dealing with self-harm. The screening would be geared to the grade level, chronological age and developmental status of the student together with judicious use of self-report psychological screening tests.

Districts often turn to a risk-assessment screening expert or an attorney with specialization in school mental-health liability for help when developing the protocol.

Facilitating Referrals

For students warranting an urgent risk assessment in a clinical setting, the accuracy and use of such evaluations can be enhanced by the following actions:

 Establish relationships with community providers and emergency departments that conduct urgent risk assessments of school-age children, especially for “gray” cases. Many community mental health centers offer 24/7 call-in services. Talk through the case prior to making a formal decision on how to proceed.

 Maintain a list of community providers who offer prompt risk assessments. This is useful for the small number of students who are at recurrent or chronically elevated risk for serious self-harm and for whom multiple same-day evaluations in clinical settings have not been helpful in addressing the student’s at-risk status.

 Obtain a release of information from the parent or legal guardian after deciding to refer a student for assessment. This will permit communication with the clinician responsible for completing the evaluation.

 Designate a staff member to talk directly with the clinician handling the case and to be responsible for forwarding a referral form. The form should provide a checklist of concerns, behaviors and symptoms, as well as an account of the circumstances prompting the referral. Relevant e-mail, text messages and other communication by the student should be shared.

Liability for Self-Harm

In recent years, lawsuits have been filed against school districts by bereaved families after a child’s suicide. These suits usually involve claims of negligence, such as allegations that the school failed to take reasonable action in response to student threats or signs of self-harm behavior, notably by failing to notify parents in a timely manner about foreseeable or imminent self-harm.

For various reasons, most of these suits have failed. Nonetheless, school districts have legitimate concerns about negative publicity and potential liability over such cases. To err on the side of student safety and to minimize institutional liability, some districts have decided that nearly any concern about self-harm warrants a same-day assessment in a clinical setting and formal clearance in writing from the examining clinician before the student can return to school.

However, problems exist with this near-zero tolerance policy. Many clinical settings, like community mental health centers, lack the staffing for same-day urgent assessments. Even when students are current patients of mental health practices, it can be difficult to obtain a same-day appointment for an urgent evaluation. Hospital emergency departments usually do not have staff with the requisite knowledge and skills to conduct risk assessments with school-age children. When staff are available, they rarely have any working familiarity with the student, the family or the school.

Additionally, some families complain of heavy-handed tactics by school districts, claiming over-reactions to situations involving their children. In a few cases, these referrals inadvertently provoke negative outcomes, such as parent-child conflicts or animosity toward school staff. Nearly all students referred for evaluation are cleared to return to school the following day. Some students re-enter school embarrassed and upset, while their parents believe little, if any, benefit was achieved by the district’s referral for assessment.

Little is known about whether obtaining clearance for a return to school can deter or even reduce the probability of legal action against school departments in the event the student quickly re-engages in suicidal threats or behavior. It is prudent to assume that clearance confers little or no protective effect in view of the complexity of the law in these circumstances. From the perspective of attorneys, school districts are hardly blameless by dint of receiving a written OK from a clinician to have the student re-enter school.

Prevention Policies

School districts would benefit from having an official self-harm prevention policy that spells out the circumstances that should prompt staff, students and parents to report concerns about self-harm behavior or threats. The policy also should cover bullying, as this form of intimidation is an established risk factor for self-harm threats and behavior and has become the basis of lawsuits against school districts following a suicide.

A psychoeducational component should address the following:

 Problems that arise for all parties when students engage in suicidal threats and related behaviors as a proxy for other difficulties and issues;

 The importance of students reaching out to parents, school staff and supportive peers when they genuinely feel they could or already have resorted to self-harm;

 The value of school and community mental health clinicians working together to help students assess their potential for serious self-harm; and

 The need to teach strategies for managing/ communicating distress and obtaining appropriate support without resorting to alarming self-harm statements and actions.