The central underlying assumption of school-based programs for suicidal students is that subsequent suicidal thoughts and behavior can be reduced by enhancing protective factors, in particular, students' personal and social support resources.

The most comprehensive school-based programs are those developed and tested by Eggert, Thompson, and their colleagues (Eggert, Karovsky, & Pike, 1999; Eggert, Thompson, Herting, & Nichols, 1994, 1995; Thompson, Eggert, & Herting, 2000; Thompson, Eggert, Randell, & Pike, 2001), as part of the Reconnecting Youth (RY) Prevention Research Program. The interventions are directed at students who are deemed to be at risk of dropping out of high school, based primarily on school attendance data and observations of teachers, counselors, and other gatekeepers. Such students have been reported to have multiple co-occurring problems that, in addition to school performance difficulties, include depression, suicidality, drug involvement, and tendencies toward aggressive and violent behaviors (Eggert et al., 1994; Lewinsohn, Rohde, & Seeley, 1993).

The interventions are based on a theoretical model that rests essentially on improving students' personal resources, leading to an en hanced sense of personal control and self-esteem, improved decision making, increased use of social support resources, and reduced suicidal behavior. The early research involved systematic evaluation of a semester-long, school-based, small-group intervention called the Personal Growth Class (PGC). The intervention included life skills training using strategies of group process, teacher and peer support, goal setting, and weekly monitoring of mood management, school performance, and drug involvement.

Evaluation studies by Thompson, Eggert, and colleagues (Eggert et al., 1994, 1995; Thompson et al., 2000) involved approximately 100 high school students at risk for dropping out of high school, as determined by a set of defined criteria, who screened positive for suicidal behavior (as discussed in Chapter 22). The students were randomly assigned to one of three conditions: assessment protocol plus one semester of PGC, assessment protocol plus two semesters of PGC, and assessment protocol only. Participants were assessed at baseline and at 5 and 10 months postintervention. Participants in all three groups showed significant declines in suicidal behavior. Unlike the students who received the assessment protocol only, PGC participants showed significant improvement in self-perceived ability to manage problem circumstances. Also reported was a significant positive impact of both teacher and peer support in decreasing suicide risk behaviors and depression.

Thompson, Eggert, and colleagues (2001) subsequently tested two additional school-based prevention programs based on the PGC: a brief one-on-one intervention known as Counselors Care (C-CARE), and a small-group skills-building intervention program, Coping and Support Training (CAST), derived directly from the PGC program. Both interventions, compared to a usual care control group, were found to reduce suicide risk behaviors and depression, even at the 9-month follow-up assessment; CAST was most effective in enhancing and sustaining protective factors such as problem-solving coping.

Currently, the CARE intervention, expanded to include a parent intervention component, P-CARE (Randell, 1999), is being studied to determine the added benefit of this component to fur

ther reduce depression, anger, and suicide risk behaviors. Preliminary results suggest that C-CARE, coupled with the parent intervention, is associated with more rapid rates of decline in suicidal ideation, direct suicide threats, depression, hopelessness, and anxiety when compared to usual care (Thompson, 2003b).

These programs for suicidal students at risk of dropping out of high school have demonstrated efficacy in reducing suicidal behavior and depression. There is some indication that prolonged intervention results in the most positive outcomes related to suicide, although it is not clear whether these effects are due to repeated contact with the treatment or to the nature of the treatment itself. As is often the case with programs involving multiple components, identifying which component is most responsible for the outcomes reported by these programs is difficult. Preliminary reports suggest that the inclusion of parents in the intervention is particularly effective.

The target groups addressed by the studies of Eggert and Thompson may limit the generalizability of the findings to other populations of suicidal youth. From the outset, the focus of these programs has been on students at risk of dropping out of high school as principally defined through attendance records. There is some evidence that high school dropouts may come from more deviant and neglecting families and thus may not be representative of suicidal adolescents overall. In addition, the inclusion criteria for these programs are somewhat idiosyncratic in their use of gatekeeper identification of problematic students, which may limit the exportability and testing of the model.

In addition, it should be noted that these interventions were designed and implemented by highly skilled, university-based professionals, who devoted considerable attention to ensur-ing program fidelity, evaluating program results, and making improvements based on empirical findings. Although results appear promising, replication of the program in schools that do not have such resources may be difficult. A community-based dissemination of the CAST intervention is currently being implemented and evaluated in three sites (Randell, 2003), which will begin to address this concern.

A considerable number of youth who make suicide attempts obtain some form of medical intervention (Grunbaum et al., 2002), typically beginning in a hospital emergency department (ED). This suggests that the ED may be a prime location for initiating treatment programs aimed at suicidal youth.

Numerous studies have documented, however, that young suicide attempters' adherence to outpatient treatment recommendations made in the ED is poor, with over 15% never attending any recommended outpatient sessions, and fewer than half attending more than a few sessions (Spirito et al., 1992; Stewart, Manion, Davidson, & Cloutier, 2001; Trautman, Stewart, & Morishima, 1993). Poor adherence has been attributed to ED factors, such as long waits, repetitive evaluations, and poor communication by ED staff, and also to cultural factors including the perception that mental health treatment is shameful (Spirito, 2003).

Table 24.1 lists the key ED interventions that have been developed to date for young suicide attempters. The primary assumption underlying these interventions is that improved treatment adherence will result in decreased suicidal behavior. Thus, their goal is to develop mechanisms for engaging suicide attempters in the treatment process.

Rotheram-Borus and colleagues (1996, 2000) designed an intervention that targeted both the ED staff and families of Latino adolescent females who attempted suicide and followed participants over 18 months. Using videotapes and thera