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Helping schools support students struggling with suicidal thoughts and behaviors

Researcher: Marisa Marraccini
Marisa Marraccini feature image

It’s a bleak fact: Suicide is the second leading cause of death among school-aged youth in the United States.

The Edge

Suicide has been rising among young people, tripling since the 1940s to approximately 4,600 suicide deaths among school-aged youths per year. Many more attempt suicide or consider it. Schools are an ideal environment for helping youths dealing with suicidal thoughts and behaviors, especially during the period just after release from psychiatric hospitals. But, a survey conducted by Marisa Marraccini has identified that few high schools have formal protocols for reintegrating students into school environments after they’ve been psychiatrically hospitalized. Marraccini is leading new research to identify the components of reintegration protocols that would be effective in helping adolescents in their return to school after psychiatric hospitalization.

There’s a rising tide of suicide in the United States, with suicide among all age groups rising nearly 30% nationwide from 1999 to 2016, according to the Centers for Disease Control and Prevention. The rate of suicide among youth is rising even faster. Suicide among teens and young adults has nearly tripled since the 1940s, with approximately 4,600 lives lost each year.

But the scale of anguish extends well beyond the lost lives, with the hurt and questions left behind among family and friends. In 2013, 17% of high school students reported seriously considering a suicide attempt, 13.6% reported making a suicide plan, and 8% reported a suicide attempt. Each year, approximately 157,000 youth are treated in emergency departments for self-inflicted injuries.

Can schools do more to help students avoid suicide? What more can school personnel do?

Marisa Marraccini, assistant professor of school psychology, is leading research aimed at those questions. She has identified a key point at which students can be helped by schools: When they re-enter school after a psychiatric hospitalization. Her work provides some of the only examination of current practices around helping adolescents reintegrating into schools, and promises to develop the first research-based guidelines aimed at establishing protocols for reintegration after psychiatric hospitalization for suicidal thoughts and behaviors.

Research aimed at preventing suicide

Marraccini joined the School of Education in 2017, coming to Carolina from Rhode Island, where she served in a postdoctoral research fellowship focused at the Department of Psychiatry and Human Behavior in the Warren Alpert Medical School of Brown University.

Marraccini conducts research aimed at promoting child and adolescent mental health in the context of their school settings. Her research is focused on supporting vulnerable populations, including adolescents struggling with suicidal thoughts and behaviors, youth at risk for bullying, and other students with behavioral, social, and emotional difficulties.

In 2018, Marraccini won a National Institute of Mental Health grant to use data from a study conducted by a mentor, Nicole Nugent of the Warren Alpert Medical School of Brown University, to examine school factors that could influence recovery from suicidal thoughts and behaviors, in order to identify ways schools can better support these students.

The project is aimed at developing practical in-school supports and interventions to prevent suicide.

Marraccini also is supported by a grant from the American Foundation for Suicide Prevention for her research aimed at describing school protocols and services provided for high school students discharged from psychiatric hospitals, and at identifying critical information that can be shared between hospitals and schools.

The study aims to become the first to identify best practice recommendations for how to facilitate re-entry of adolescents into schools after discharge from psychiatric hospitals.

School re-integration: A high-risk period

During the three-month period following hospitalization for adolescents – a period in which most of them return to school – they are at extremely high risk for making a suicide attempt. Nearly one-third are re-hospitalized with suicidal thoughts and behaviors (STB).

And yet, few studies have examined school reintegration following psychiatric discharge of adolescents.

While being a primary post-discharge environment for adolescents leaving hospitalization, schools also offer associated risk and protective factors to at-risk youths:

  • Difficulties with academics has been associated with higher STB risk among adolescents and is one of the primary stressors for adolescents rejoining school after psychiatric treatment.
  • Peer reactions and perceptions of adolescent psychiatric hospitalization are considered to be a large source of difficulty for these youth.
  • School connectedness issues are important factors in the health of students with higher STB risk.

Schools, therefore, are ideally situated to support adolescents after being discharged from hospitals.

What can schools do to help?

In a study published in School Mental Health in January 2019, Marraccini led research to determine what are the current practices of high schools across the country to help youth being re-integrated into school. The survey of school psychologists found

  • Only 16.5% had written protocols for school reintegration of formerly hospitalized students.
  • 1% had informal procedures in place.
  • 38% had no protocols or procedures.

At the same time, nearly all of the school psychologists surveyed estimated that their schools refer one or more students to emergency departments for a mental or behavioral concern each year, with at least one psychiatrically hospitalized each year. While the majority of schools have students with students returning from psychiatric hospitals, very few have formal reintegration protocols in place.

Marraccini’s survey suggested that schools located in the Northeast and in suburban areas were more likely to have some sort of reintegration protocols or procedures. Given that some of the most vulnerable youth are not only more likely to live in urban and rural areas, and that they are also less likely to receive mental health care, the finding suggests increasing provisions for mental health crises should be a priority in these areas.

School psychologists reported three elements as being the most important for addressing reintegration needs: 1) meeting with the family, 2) communicating by phone with hospital staff, and, 3) developing an individualized re-entry plan.

Common components of individualized re-entry plans:

  • Specifying the timing and location for school return, such as a gradual return, a separate space of a step-down program to return to.
  • Identifying specific services and accommodations for students, such as counseling and tutoring.
  • A plan to complete missed course work that may include forgiveness, reduced workloads, or altered deadlines.
  • Passes to take breaks from classes and/or seek out support from school professionals.

Developing best practice recommendations

Little research has been done that would help guide school reintegration following hospitalization for STB.

In her study funded by the American Foundation for Suicide Prevention, Marraccini is working to establish a set of best practice recommendations for reintegrating adolescents into school following psychiatric hospitalizations.

Her study has three main objectives, aimed at bridging communication between the support systems of hospitals and schools to support adolescent recovery:

  • Identify and describe existing school-based protocols and procedures that may be used to support adolescents following psychiatric hospitalization.
  • Characterize school professional, hospital professional adolescent, and parent perceptions of school reintegration following hospitalization for STB to inform what should be shared between sites for successful reintegration.
  • Develop a prototype for guiding principles about school reintegration following hospitalization for STB.

Future areas of inquiry

In her School Mental Health paper, Marraccini points to additional areas of needed further inquiry:

What are current methods schools use to identify and support youth returning to school? How are schools accounting for school-related stressors, such as academic, social emotional, and school environment factors?

How should school psychologists be involved in school reintegration? School psychologists reported in Marraccini’s survey that they were frequently involved in risk assessments, but not necessarily in school reintegration efforts.

How effective are reintegration protocols in improving quality of care provided for students? School psychologists working at schools with formal protocols or informal procedures for school reintegration rated their schools’ reintegration services as higher quality than those working at schools without a protocol or procedure. But do formal protocols actually improve care?

What are the roles of school counselors in school reintegration after hospitalization? Marraccini’s survey found that school counselors are the most common school professionals involved in student re-entry. What roles should they play in reintegration protocols?

How well do reintegration protocols work? Studies are needed to establish the feasibility of and adherence to reintegration protocols and procedures, as well as the fidelity of implementing them. This information will provide additional information on the best methods for schools to approach reintegration of adolescents after psychiatric hospitalization.


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Horwitz, A.G., Czyz, E.K., & King, C.A. (2015). Predicting future suicide attempts among adolescent and emerging adult psychiatric emergency patients. Journal of Clinical Child and Adolescent Psychology, 44(5), 751-761.

Marraccini, M.E., Lee, S., Chin, A.J. (2019). School reintegration post-psychiatric hospitalization: protocols and procedures across the nation. School Mental Health.

Savina, E., Simon, J., & Lester, M. (2014). School reintegration following psychiatric hospitalization: An ecological perspective. Child and Youth Care Forum, 43(6), 729-746.

White, H., LaFleur, J., Houle, K., Hyry-Dermith P., & Blake, S.M. (2017). Evaluation of a school-based transition program designed to facilitate school reentry following a mental health crisis or psychiatric hospitalization. Psychology in the Schools, 54(8), 868-882.

Preyde, M., Parekh, S., Warne, A. et al. (2017). School Reintegration and Perceived Needs: The Perspectives of Child and Adolescent Patients During Psychiatric Hospitalization. Child and Adolescent Social Work Journal 34: 517.

Preyde, M., Parekh, S., Heintzman, J. (2018) Youths’ Experiences of School Re-Integration Following Psychiatric Hospitalization. Journal of the Canadian Academy of Child and Adolescent Psychiatry. Jan; 27(1): 22–32.

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By Michael Hobbs