The Suicide Test

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Bergenfield, N.J.—On March 11, 1987, Cheryl Burress broke a date, saying she was “going to see Joe.”

Her friend Joe Major had fallen to his death off the nearby Palisades Cliffs, overlooking New York City, six months earlier. Cheryl’s announcement was not surprising; Joe’s friends often visited his grave.

On this night, however, Cheryl, 18, and her sister, Lisa, 16, met up with Joe’s best friend and with Lisa’s boyfriend, Tommy. Lisa had just been suspended from Bergenfield High School; the others had already dropped out.

The four teens got drunk, took some cocaine and agreed on a plan to die. They signed a note on a paper bag asking to be buried together. They bought $3 in gas for Tommy’s Camaro. They pulled into garage number 74 in an apartment complex where they used to party. They closed the door and left the engine running.

Within hours, they were found dead.

Within a month, 35 more teens around the country killed themselves with carbon monoxide fumes. Two others tried in garage 74.

The country suddenly awoke to two scary realities: teens killing themselves in record numbers, and contagion – teen suicides spreading like a contagious disease. The nation’s teen suicide rate had been rising for years, going from four per 100,000 in 1964 to 10 per 100,000 in the mid-80s.

The middle-class suburb of Bergenfield, N.J., became Exhibit A for the problem. With local parents and reporters from around the country scrambling for answers, community leaders vowed to act.

Sixteen years later, Bergenfield and the country have come a long way in developing methods to prevent teen suicides. But while numerous approaches have been tried with countless thousands of teens in recent years, a new study in Adolescent & Family Health notes, “few ... have been subjected to rigorous scientific evaluation,” and those that have, “have produced mixed results.”

Which raises questions that are as crucial here as anywhere: What approaches work best, and who should try them?

Bergenfield employs one of the two most prominent strategies: a video-based suicide prevention curriculum that draws high schoolers into discussions about suicide. In addition, a Community Response Team that formed hours after the 1987 suicides is still together and has been replicated throughout New Jersey.

But Bergenfield did a few clumsy things that others might learn from. And youth-serving institutions here have not gone as far others around the country that use questionnaires to screen for depression and head off suicides. That includes Girls and Boys Town in Omaha, Neb., Covenant House in Florida, juvenile justice agencies in Oregon, Texas and Georgia, public schools and foster care and mental health agencies in several states, and even the elite Philips Exeter Academy in Exeter, N.H. In July, the President’s New Freedom Commission on Mental Health recommended screening youth for signs of mental distress to stave off more severe mental illness – and, potentially, suicide.

Seeking Out Troubled Kids

Back in 1987, Bergenfield was groping for answers that no one seemed to have. Police Chief William Burkhart asked the questions on everyone’s mind: “Why at all, and why in Bergenfield? Where did we go wrong?”

Police looked back and found four other recent teen deaths among the same crowd, including that of Joe Major, that might have been suicides.

“After the cluster, I think the community just focused,” says Linda Hausdorff, a social worker and director of the Care
Plus Foundation, a Paramus-based nonprofit that serves as the local mental health agency. “It was like after September 11th, when the community really came together. I hate to say that it was a positive event, but ...”

On the day of the suicides, the overlapping hodgepodge of government and community do-gooders that worked in what the Rev. Stephen Giordano calls “benign isolation” joined forces. They included the borough administrator, school superintendent, police chief, directors of the local mental health center and the county health department, and Giordano of the Clinton Avenue Reformed Church, who was also president of the Bergen County Council of Churches.

“People realized that it was a time of crisis, and we needed to work together in a collaborative style,” Giordano says.
Bergenfield opened a 24-hour suicide hotline. In the first month, it got 100 calls.

The borough spent $4,000 to hire a youth counselor to hit the streets that summer and talk to kids, hook up with the dropouts and give them some direction.

Fumbling for a way to reach youth, the workers posted fliers everywhere, even the roller rink frequented by prepubescents: “Troubled? Need a Direction - Advice or Just Someone to Listen? ... Talk to Someone Who Cares.”

Sociologist Donna Gaines, who spent a year with Bergen County youth seeking the social causes of the suicides, reported that the “burnout” kids didn’t think the programs connected to them.

“Meanwhile, the ‘Troubled?’ sign is posted everywhere you look,” she wrote in her book on the suicides, Teenage Wasteland: Suburbia’s Dead End Kids. “But I can’t really imagine a troubled teen on a night out at the lively rink with a pen and sheet of paper, inconspicuously jotting down this telephone number.”

And the community was not completely free of image concerns, which can hamper bold initiatives. The school system worked to deny blame and distance itself from the dead teens. The school that the kids had attended wouldn’t lower its flag to half-staff, and the school board barred the media from its property. Even today Bergenfield High School administrators refused to talk for this story, except to point out the teens were not students when they died.

Sociologist Gaines reported that the teens felt that the school, which officially had a low dropout rate, wanted to get rid of them in order to keep up its academic and other statistics. Gaines said the kids hanging around places like 7-Eleven had little to strive for. While earlier generations worked to have better lives than their parents, many of these kids felt that they faced a dead end.

16 Years Later

The “Troubled?” fliers are gone.

Bergenfield has a new look and feel. A new crop of Hispanic and Asian immigrants has arrived. They may not be better off economically than kids of the 1980s, but their situation seems better to them.

The effort not to glamorize the deaths seems to have succeeded. Teenagers here are mostly oblivious to the incident that made their town notorious. Even kids who live in the apartment complex where the teens died don’t know what happened.
“I don’t even know the whole story,” says one senior. “Four students got drunk and ran their car into a trailer.”

While the fliers and hotline (still in operation) worked like bait to attract the right kids to services, Bergenfield has joined many communities and youth-serving agencies around the country in focusing more on a giant net approach: educating kids about depression and suicide, hoping to bring in more youths who weren’t aware that they might need help.

That strategy has advanced through the work of two university-based psychiatrists. Dr. Douglas Jacobs, an associate clinical professor of psychiatry at Harvard Medical School, believed that suicidal risk fits the criteria that doctors use for other screening programs: It is detectable and treatable. He developed Signs of Suicide (SOS), a program that uses videos to educate kids to recognize and report signs of depression, either now or years later, and uses a questionnaire to screen them for danger signs.
The program is run by Screening for Mental Health, a nonprofit based in Wellesley, Mass.

Meanwhile, Dr. David Shaffer at Columbia University was coming to the same conclusions and developing his own questionnaire to screen for depression. Shaffer’s program is called TeenScreen.

The educational components are geared toward getting kids to recognize signs of trouble in themselves or others, and to talk to adults about it. The questionnaires are designed for adults to assess potential problems. They ask questions both subtle – such as whether the youths have trouble sleeping or no longer enjoy activities they used to – and direct, such as, “Have you ever thought of killing yourself?” The process typically takes five to 10 minutes.

Youths who are flagged as potentially at risk, based on their answers, go on to a more comprehensive test. TeenScreen uses a voice computer version of the Diagnostic Interview Schedule for Children (DISC). When those answers show signs of any one of 30 disorders, including major depression, eating disorders and substance abuse, the youth is referred for further help.

TeenScreen and SOS are two of the most widely use systems. The SOS video is in at least 1,000 schools, while TeenScreen is in dozens of schools, youth-serving agencies and churches.

Girls and Boys Town uses DISC at three of its facilities and wants to expand the practice, says Julie Almquist, national director of specialized clinical services and research. She says youth are screened on admission and one year later to assess not only depression and suicide risk, but also problems such as eating disorders and anxiety.

Covenant House Florida uses TeenScreen as part of the intake process at its two residential facilities for runaway and homeless youth, says Covenant House spokeswoman Paula Tibbets. She says youth workers there “have appreciated the quick assessment that will put up any kind of red flag for someone that needs to be seen face-to-face [by a counselor] but may be masking symptoms.”

The Bergenfield school district and Bergenfield High School did not return calls asking what they do to educate youth about suicide. Several high schoolers say they see videos about depression and suicide, but are not screened.

“I am astonished that having had this terrible tragedy, there would be any question that there’s any value in screening,” says Laurie Flynn, director of the Carmel Hill Center at Columbia University. The center developed Positive Action for Teen Health, a national umbrella group that promotes screening, specifically TeenScreen.

“Screening will always find kids that are suffering from undiagnosed mental illness and are at risk for suicide, but are not in treatment,” she says.

Does it Work?

Limited studies of education and screening programs have shown promise.

One recent study tracked SOS in 92 schools during the 2000-01 school year. The study, “An Evaluation of a School Based Suicide Prevention Program,” published in Adolescent & Family Health (Vol. 3, No. 2), found a 60 percent increase in “help-seeking” among participating youth. There was a smaller increase in youth seeking help on behalf of friends.

The study notes that because the screening can be implemented with a lot of kids at once by “health educators,” it does not require a lot of time or resources. Schools reported no extra burden on staff in administering the program or dealing with the youth who sought help.

At least two studies in counties where suicide prevention programs were provided in nearly all schools showed reductions in youth suicide rates, while rates in their states remained unchanged or increased. (For example, “The implementation and institutionalization of a school-based youth suicide prevention program,” Journal of Primary Prevention, 1999.)

At Girls and Boys Town, Almquist says, the screening helps the organization assess how well it is doing with its youth overall. When they are admitted, the youth average 2.5 diagnoses of disorders, she said. After a year, they average 0.5.

Crisis Management

Bergenfield’s main contribution to the effort to prevent teen suicide is in the area where it had the most trouble: social contagion.

The group of youth workers that formed within hours of the suicides has evolved into the Bergen County Traumatic Loss Coalition, run by Care Plus, which operates on state, county and private funding.

The response team meets regularly to go over research and act on a crisis, such as the death of a youth or a youth group leader. The team reaches out to siblings, close friends, current and former romantic interests, neighbors, classmates and teammates. It also visits the schools to teach about mental health.

When a religious youth group leader killed himself this year, the response team offered on-site counseling for a previously planned retreat of 300 kids.

New Jersey became such a believer in Bergenfield’s system that it started similar teams in all of its counties, which follow a manual written by social workers who worked on the Bergenfield crisis.

The manual, “Managing Sudden Traumatic Loss in The Schools,” prescribes steps to take when dealing with a death in the school population, suicide or not. It discusses both theories – such as maintaining a comforting structure while allowing those affected to grieve in a controlled way – and best practices. Even if the facts seem controversial, the manual says, it’s better to get them out so that rumors don’t spread.

“Have a script prepared,” says Stephanie Mulfinger, a social worker and coordinator of the Bergen County Traumatic Loss Coalition. “You want everybody, and I mean everybody … to have that same clip.”

Meanwhile, there’s good news nationwide. The suicide rate among 15- to 17-year-olds has been declining since about 1990, to about 7 per 100,000 in 2000. Nevertheless, according to the National Center for Health Statistics, suicide remains the third leading cause of death among 15- to 19-year-olds.


Dr. Douglas G. Jacobs, Executive Director
Screening for Mental Health
One Washington St., Suite 304
Wellesley Hills, MA 02481-1706
(781) 239-0071

Dr. David Shaffer
New York State Psychiatric Institute
1051 Riverside Drive
New York, NY 10032
(212) 543-5948

Positive Action for Teen Health (PATH)
c/o Columbia University
1775 Broadway, Suite 715
New York, NY 10019
(866) 833-6727

American Association of Suicidology
M. David Rudd, President
4201 Connecticut Ave. NW, Suite 408
Washington, DC 20008
(202) 237-2280

The National Hopeline Network

The Cost of Screening

The main cost of implementing the TeenScreen or SOS programs is the added use of existing facilities and staff time.

The SOS video and 500 questionnaires cost $200. Some schools have paid for it with federal Safe and Drug Free Schools funding.

For TeenScreen, Columbia University is offering free training for 400 schools or community groups to carry out the program, as long as they each promise to screen at least 500 youths. Columbia staff will go to the site to train the personnel (often volunteers) and help set up a system for referring teens to treatment.