Abstract
Suicide rates among youths in foster care are among the highest in the United States. Despite this fact, many foster-care agencies do not perform universal suicide-risk assessments as part of routine care. This commentary includes an argument for the importance of implementing universal suicide-risk assessments for youths in foster care. Important contextual information that prevents behavioral-health clinicians from implementing universal suicide screenings of youths in foster care is discussed. Several possible strategies for implementing universal suicide-risk assessments are offered; the pros and cons of each strategy are discussed. The perspectives of multiple stakeholders should be included in the consideration of universal suicide screening for youths in foster care, including behavioral-health providers, primary-care doctors, supervisors, directors of agencies, foster parents, and case managers. Although each of these stakeholders can improve suicide prevention, youths in foster care may not have regular access to each stakeholder. Case managers may be the optimal stakeholders for implementing universal suicide screening because of their frequent access to youths in foster care; therefore, case managers should receive training in suicide-risk assessment and prevention strategies.
Keywords
Suicide rates among youths in foster care are among the highest in the United States (Children’s Bureau, 2017); they are significantly more likely to die by suicide (37.5 deaths per 10,000 person years) than youths in the general population (8.3 deaths per 10,000 person years; relative risk = 4.3; 95% confidence interval = [2.8, 6.6]; Hjern, Vinnerljung, & Lindblad, 2004). A recent meta-analysis found that youths in out-of-home care, including foster care, were three to four times more likely to attempt suicide (3.6%) than the general population (0.8%; Evans et al., 2017).
Although the factors that precipitate suicide risk among youths in foster care remain unclear, likely contributors include reduced social support, trauma exposure and maltreatment, and depression (Taussig, 2002; Taussig, Harpin, & Maguire, 2014). In addition, the transition into foster care might constitute a high-risk period for suicide, as might ongoing encounters with the legal system that arise throughout placement. Despite the suicide crisis facing child-welfare agencies, many agencies do not have a strategy for implementing universal suicide screenings.
Treatment for Youths in Foster Care
Several treatment protocols have been designed to improve the mental health of youths in foster care. Examples include tuning into teens (Havighurst, Kehoe, & Harley, 2015), the Ripple Project (Herrman et al., 2016), early intervention foster care (Fisher, Gunnar, Chamberlain, & Reid, 2000), the incredible years (Nilsen, 2007), and other cognitive-behavioral therapy interventions (e.g., Dozier, Higley, Albus, & Nutter, 2002; Pallett, Scott, Blackeby, Yule, & Weissman, 2002). Although the Ripple Project mentions suicide prevention as a possible benefit of the program, suicide prevention is not the focus of this or any other existing published programs specifically tailored for youths in foster care. Multidimensional treatment in foster care was associated with marginally greater (i.e., nonsignificant) reductions in suicidal ideation compared with treatment as usual, with no effects on suicide attempts (Kerr, DeGarmo, Leve, & Chamberlain, 2014). In addition, a statewide gatekeeper training for suicide prevention among child welfare and juvenile justice (among other settings) in Tennessee focused on a question, persuade, and refer model (Quinnett, 1995) and resulted in significant increases in gatekeepers’ knowledge about suicide prevention (Keller et al., 2009), although effects on suicidal behavior were not reported. There are no other published, targeted suicide-prevention efforts tailored to youths in foster care, representing a clear need for more research in this area.
Child-welfare workers face enormous challenges in satisfying the basic needs of their youth clients, such as securing safe housing and access to food, clothing, and education. The demand for resources within the foster-care system continues to grow (Child Trends Databank, 2019), whereas the supply of resources has remained stagnant in many areas. Access to mental-health care, often considered a lower priority resource relative to housing stability, is not universally available to youths in child welfare because of limited resources. Many agencies refer youths in foster care for mental-health services, although the referral system is often unstandardized or undocumented. Given that (a) agencies often perceive suicide risk as solely in the domain of mental-health care and (b) not all youths in foster care are referred for mental-health care, this approach has resulted in a major gap in universal suicide-risk assessments in foster care. To correct this gap, there are several options for implementing universal suicide-risk assessments in child-welfare agencies.
Universal Suicide Screening in Foster Care
The first option for implementing universal suicide screening in foster care is to refer all youths for mental-health services. The benefit of this approach is that universal suicide screenings would be implemented by trained mental-health professionals who are theoretically experienced in offering suicide-prevention counseling. This would ensure that a youth who mentions thoughts of suicide would be available for immediate intervention. The downside of this approach is that it is likely not sustainable in most child-welfare agencies. This approach would substantially increase resource utilization in child-welfare agencies, which would result in longer wait times and reduced resources for other high-priority needs. In addition, not all youths in foster care require mental-health services. Therefore, although mental-health clinicians working with youths in foster care must assess their clients for suicide risk, it is unrealistic to assume that mental-health clinicians should be solely responsible for universal suicide screening among youths in foster care.
The second option for implementing universal suicide screening of youths in foster care is to rely on primary-care physicians to assess youths. However, limited data are available on access to primary care for youths in child welfare. Assuming that all youths in foster care have annual primary-care appointments, many of those youths will not be assessed until several months into foster-care placement. In reality, many youths in child welfare are unlikely to visit a primary-care doctor annually. Therefore, while primary care clinicians also must assess their clients for suicide risk, primary care also cannot be solely responsible for universal suicide screening of youths in foster care.
The third option for universal suicide screening is to train foster parents to ask their foster children about suicide risk. There is an extremely limited amount of research to guide parents in assessing suicide risk in general, let alone in foster parent–child relationships. More research is needed on this topic, but in light of the lack of precedent for this approach to suicide prevention, it is not an ideal option for foster care.
The fourth option for universal suicide screening relies on case managers. The benefit of implementing universal screening at this stakeholder level is that every youth in the child-welfare system is assigned to a case manager. This case manager coordinates the holistic placement needs and mental and physical health care for each youth. However, most case managers have not received training in mental-health care and are not clinicians. Fortunately, several brief and psychometrically validated suicide-risk assessments exist, including the Columbia–Suicide Severity Rating Scale (Posner et al., 2011), and nonclinicians can be readily trained in the use of these tools. This training would require child-welfare agencies to incur an upfront cost to ensure that their case managers are adequately prepared for conducting suicide assessments. However, the cost for this training would be substantially less than referring all youths to mental-health services and would preserve the goals of universal suicide screening.
Implementing universal suicide screening in child welfare will undoubtedly increase costs. For instance, even if universal suicide screening detects only an additional 5% of high-risk youths, the cost of this increase in mental-health-care utilization will be substantial for many agencies. If costs for mental-health services could be shared across the health-care system and the child-welfare agency, this would reduce the financial burden on agencies, although the feasibility of this approach would likely vary by local jurisdiction. One strategy for mitigating costs is to provide stakeholders with training in brief suicide-prevention tools, such as crisis-response planning. Crisis-response planning significantly reduces the likelihood of subsequent suicide attempts (Bryan et al., 2017) and takes approximately 30 to 45 min to complete. Clinicians and laypersons alike can be trained in this tool. As with training in suicide screenings, training case managers in crisis-response planning would result in an upfront cost for child-welfare agencies. However, this tool may reduce the cost of referring youths to mental-health services while significantly reducing the likelihood of suicide death among youths in foster care.
The implementation of universal suicide-screening programs is complex even in resource-dense organizations; the resource scarcity in child-welfare agencies presents an additional layer of complexity to universal suicide screening. As agencies grapple with the optimal implementation strategies for suicide screening, a few critical points require consideration:
Mental-health clinicians are mandated to assess for suicide risk. However, unless every child in foster care is referred for mental-health care, mental-health clinicians cannot be solely responsible for universal suicide screening among youths in foster care.
Primary-care physicians are also mandated to assess for suicide risk. However, not every child in foster care has annual appointments with a primary-care physician. Among children with annual appointments, the frequency of these appointments is not sufficient to detect children as they transition from low- to high-risk states.
There are no data to indicate that foster parents would be effective in suicide screening, although this is an area for future research.
Universal suicide screening necessitates standardizing assessments. Assessments should optimally occur at the time of placement into child welfare and frequently thereafter.
Free and brief universal suicide-screening measures are available. Brief suicide-prevention programs, such as crisis-response planning, are also available for implementation in foster care.
Future research efforts should focus on the optimal strategies for implementing universal suicide screenings across multiple stakeholder levels for youths in foster care. This research should include the perspectives of case managers, supervisors, directors, primary-care doctors, foster parents, and mental-health providers to ensure that universal suicide screening is thoughtful and sustainable. In addition, future research should explore organizational culture and individual stakeholder factors in foster-care agencies that may influence the likelihood of adopting universal suicide screening. Effects of training multiple stakeholders in universal suicide screenings should be systematically evaluated. Finally, as described above, more research is needed on suicide-prevention strategies, in addition to universal suicide screening, that are tailored to youths in foster care. Although some efforts have been successful in reducing suicidal behavior in schools (Wasserman et al., 2015), no published efforts have been successful in foster care specifically. The development of research efforts focused on universal suicide screening and prevention efforts should be simultaneously developed to ensure that once a youth is identified as high risk, the agency has optimal strategies for reducing that risk.
