A Multiple-Methods Exploration of the "School-to-Suicide Pipeline"

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"Being Black” is not a risk factor for suicide; rather, sociocultural factors and social determinants of health influence suicidal behavior among Black youth. Factors related to the school environment are critical in understanding and preventing this loss of life. The purpose of this multiple-method study was to examine the historical prevalence of school interventions among Black students who went on to die by suicide in our study setting and assess the availability of mental health resources and support available to school personnel to support Black students. Methods: We gathered school records from all county residents who died by suicide during the ten years from 2013 through 2022. We also conducted semi-structured key informant interviews with school district psychologists and social workers. Results: A total of 293 suicide decedents were included, most of whom were Black/African American. School issues were a contributing factor to suicide for several decedents. Four qualitative themes were developed, highlighting the impact of school-based factors, and particularly exclusionary discipline, on the mental health of students. Implications: There is an urgent need for trauma-informed, restorative, and non-punitive approaches behavioral issues in school, particularly for minoritized students. Suicide prevention exclusionary discipline public health school psychologists Introduction Suicide among Black youth is a significant public health concern. Between 2012 and 2020,(Ormiston et al., 2024 ) Black youth experienced a significant increase in suicide, particularly among Black boys between ages 15 and 17.(Lindsey et al., 2019 ) Data from the 2023 Youth Risk Behavior Survey (YRBS) demonstrate that Black students had higher prevalence of suicide attempt as compared with White students (10.3% versus 8.3%).(Verlenden et al., 2024 ) Recent studies have also determined that elementary school-aged children who die by suicide are most commonly Black males.(Sheftall et al., 2016 ) This incidence of suicide among youth in the Black community represents a significant number of years of potential life lost. According to the Centers for Disease Control and Prevention (CDC), suicide among youth ages 10 to 24 in the Black community in 2023 amounted to over 44,862 years of potential life lost before age 65.(Ring the Alarm: The Crisis of Black Youth Suicide in America, 2019) Despite this concerning evidence, “being Black” is not a risk factor for suicide; rather, sociocultural factors and social determinants of health influence suicidal behavior among Black youth in the United States. Emerging research points to risk and protective factors for suicide that are specific to Black youth.(Ring the Alarm: The Crisis of Black Youth Suicide in America, 2019) For instance, Black youth are disproportionately impacted by racism and discrimination, barriers to mental health care utilization, poverty, trauma, violence, and exposure to the death of individuals in their neighborhoods.(Bath & Njoroge, 2021 ; Meza & Bath, 2021 ; Pachter & Coll, 2009 ; Coleman et al., 2019) These exposures contribute to risk for suicide in this group.(Bath & Njoroge, 2021 ; Meza & Bath, 2021 ; Nguyen et al., 2007 ) Further, the risk factors commonly linked to suicide (e.g., depression) may present differently for Black youth and be misunderstood, preventing early identification and intervention for this population. Suicide is a complex issue, and in the context of youth suicide, factors related to the school environment are critical in understanding and preventing this loss of life. Research examining precipitating circumstances surrounding suicide among Black male youth found almost 35% reported a recent problem at school.(Sheftall et al., 2022 ) Black students are overrepresented in school discipline data; Black children are the most likely recipients of in-school suspensions, out-of-school suspensions, expulsions, and referrals to law enforcement.(Williams III et al., 2022) Importantly, such punitive school discipline is associated with greater risk for depressive symptoms, substance use, and death by suicide.(Duarte et al., 2023 a) Further, Black youth are exposed to, witness, and are left to process discriminatory and biased school interactions and disciplinary outcomes for themselves and peers, which may contribute to psychological problems, including suicide.(Saleem et al., 2022 ) From a life course perspective, the over-disciplining of Black youth within the school system contributes to the “school-to-prison pipeline”,(Verlenden et al., 2024 ) thereby placing Black adults who experienced discriminatory discipline practices during school at increased risk of incarceration, which can elevate risk for suicide. Data from the 2023 YRBS indicates that students who feel connected to others at school have lower prevalence of poor mental health, and Black youth report among the lowest levels of school connectedness.(Verlenden et al., 2024 ) Other research has similarly found that connectedness is lowest among youth who have experienced racism at school.(Mpofu et al., 2022 ) Recent research suggests that the availability of school support may also be associated with suicide risk; in one study, the presence of law enforcement officers within the school was positively associated with Black boys’ consideration of suicide and developing a suicide plan.(Williams III et al., 2022) Furthermore, school discipline risk was associated with suicide attempts for Black boys.(Williams III et al., 2022) In response to the disproportionate impact of suicide on Black male students as well as the influence of school-related factors on suicidal thoughts and behaviors, we conducted a study to obtain more comprehensive data on school-based factors preceding suicide among Black individuals in a diverse, urban setting. The purpose of this multiple-method study was twofold: first, we examined the historical prevalence of school interventions among Black students who went on to die by suicide in our study setting. Second, we assessed the availability of mental health resources and support available to school personnel to support Black students and identify ongoing staffing needs and potential avenues for support. This study was informed by Critical Race Theory (CRT), which conceptualizes racism as structural and systemic forces embedded in institutions, policies, and practices.(Ford & Airhihenbuwa, 2010; Graham et al., 2011) Specifically, we conceptualized school environments, including school disciplinary policies and exclusionary practices as structural forms of racism that can contribute to cumulative stress and psychological harm. This framework guided our inquiry into how school systems and practices may elevate suicide risk and how restorative interventions and policies might disrupt the school-to-suicide pipeline for Black youth. Findings from this study can be used to develop tailored school-based suicide prevention interventions and policies to support Black youth and disrupt the school-to-suicide pipeline. Methods Study Setting: This study takes place in an urban, diverse context in the Midwestern United States. Data collection took place between April 2024 and April 2025. Our study involved one public school district. This district is the largest in the state and is comprised of mostly students of color, and primarily Black students. More than 80% of the students in the district are considered “economically disadvantaged”.(Milwaukee Public Schools, 2025 ) This city is highly racially segregated, a direct result of systematic redlining,(Lynch & Meier, 2020 ) and concentrated violence is prevalent in various neighborhoods across the city.(City of Milwaukee Office of Violence Prevention, 2016 ) Additionally, 17% of county residents live below the poverty line,(United States Census Bureau, 2023) and those census tracts with the highest rates of poverty across the county also experience the highest levels of violence.(United States Census Bureau, 2023) Finally, poverty in the community is racialized. (Loyd & Bonds, 2018 ) There is a higher proportion of non-White residents living in census tracts with the highest levels of poverty when compared with non-White residents living in better-resourced areas. We employed a multiple-methods design using quantitative and qualitative approaches that addressed related but distinct research questions. Data were analyzed independently, but the findings were considered as a whole to aid in interpretation and inform next steps. Study Population: School Records Review We gathered school records from all county residents who died by suicide during the ten-year period from 2013 through 2022 who also attended school and had available records within our study district. We obtained information on all suicide decedents during our study period from our county’s medical examiner’s office and provided names and dates of birth to our school district partners for matching. School data were then provided back to the study team for those decedents with records in the school system. Assessment of Suspensions and Expulsions We gathered suicide investigation reports from our county’s medical examiner’s office for all suicide decedents ages 10 through 24 in our school records review sample to assess for reporting of school-related stressors and/or suspensions and expulsions as contributing factors to suicide. We selected these decedents because they were most likely to be enrolled in school at the time of their suicide. Again, we focused our review on suicides occurring from 2013 through 2022. Assessment of Mental Health Resources We conducted semi-structured key informant interviews with school district psychologists and social workers. Participants were recruited from a staff list provided by the school district, and we also employed snowball sampling methods to recruit additional participants. All interview participants were employed with the school district at the time of their interview. Interview participants were compensated with a $ 25 gift card. Data Collection and Analysis: School Records Review We examined information on a variety of student-level and school-based factors, including student demographics, attendance rate (the proportion of time students are present at school compared to the total time they were scheduled to be present at school), last known age and grade in the district, food service indicator (a proxy for household income), special education indicator and type, ESL (English as a Second Language) indicator, number of residence changes, graduation cohort, and school attended. Variables were selected based on our theoretical framework and the data available. We conducted an exploratory analysis, which included calculating descriptive statistics (e.g., frequencies, means) for all variables, and we also conducted bivariate analyses using Chi-square and Fisher’s exact tests and ANOVA to examine the relationship between race/ethnicity and the school-based factors listed above. Adjusted multivariate analyses were conducted using ANOVA to examine the relationship between student characteristics and school-based factors. All analyses were conducted using StataNow 18 SE. We hypothesize that student race will be associated the presence of school-related issues/stressors, the receipt of food services, receipt of special education services, English as a Second Language program participation, residence changes, and suspension or expulsion. Assessment of Suspensions and Expulsions We conducted manual keyword searches of all included suicide investigation reports and collected information on the presence of school-related issues (yes/no) and reported suspension or expulsion (yes/no). It is possible that decedents had school issues without a suspension or expulsion, but we indicated a school issue for all decedents with a reported suspension or expulsion. We tabulated data related to both these indicators for each decedent aged 10 to 24 and then included these two binary variables in our analysis of school records. Assessment of Mental Health Resources : Semi-structured key informant interviews with school staff were conducted using a protocol developed by our study team. Questions included the following: What are the primary mental health needs of students? How have you seen suicide, including thoughts and attempts, affect students? What happens when a teacher or staff member recognizes or learns that a student is having mental health challenges? How does response and intervention with students whose mental health challenges show up as ‘problem behaviors’ differ from a student whose mental health challenge looks more like withdrawal or lack of engagement? What resources are available for students with behavioral challenges? What are your perceptions around how out-of-school discipline affects the students involved? What are the primary barriers to school-based mental health care for students? What training and/or support do teachers and other staff need to support students struggling with mental or behavioral health challenges? Interviews were conducted either in-person or online via Zoom, depending on the preference of the participants. All interviews were audio recorded and transcribed by study team members. We analyzed the interviews using an inductive reflexive thematic analysis approach(Braun & Clarke, 2006 , 2022 ) grounded in a phenomenological framework. A subset of interviews was read by two study team members, and an initial codebook was developed. This codebook was then applied to two interview transcripts, and revisions to the codebook were made. The remaining interviews were coded by a study team member, and then three study team members met to collaboratively generate a set of themes that reflect the experiences of study participants. Qualitative data analysis was conducted using MAXQDA 2022. Positionality Statement: Interpretation of qualitative data is influenced by the positionality of those analyzing the data. Therefore, it is important for readers to understand the lived experience of authors as well as the context in which the authors conduct their work. The authors of this study are public health-trained researchers and experienced qualitative methodologists who live in the community in which this study was conducted. One author is also a trained suicidologist who conducts research and programming related to suicide prevention and postvention. All authors identify as White, non-Hispanic females, and acknowledge the privilege and lens that this brings to our work. At the same time, we as authors are immersed in community-engaged research on a daily basis and applied the lessons we have learned through that work to the interpretation of our results. Results School Records Review: A total of 293 suicide decedents were included in our sample. A majority of those (50.8%, n = 149) were Black/African American and male ( n = 242, 82.6%). The average last known age within the school district was 16.9 years ( SD = 2.6 years) 40 students (13.7%) received special education services while they were in the district, and of those students whose special education type was known, 28% ( n = 11) received services related to a specific learning disability. The average attendance rate (calculated by dividing the total days attended by the total possible school days, then multiplying by 100) for students was 0.78 ( SD = 0.28) and the mean number of residence changes (the number of residential moves reported for the student over the course of their time with the district) was 0.3 ( SD = 1.3). 30 students (10.2%) in the sample died by suicide while attending school in the district, and approximately 22% ( n = 64) dropped out of school. Full sample information is included in Table 1 . Table 1 Sample Characteristics ( N = 293) Characteristic Values n (%) Race/Ethnicity White American Indian Asian Black/African American Hispanic Multiple Races 65 (22.2%) 6 (2%) 15 (5%) 149 (50.8%) 57 (19.5%) 1 (0.3%) Gender Male Female 242 (82.6%) 51 (17.4%) Special Education Indicator Yes No 40 (13.7%) 253 (86.3%) Special Education Type Emotional Behavioral Intellectual Not Applicable Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Unknown 5 (1.7%) 2 (0.7%) 252 (86%) 4 (1.4%) 11 (3.7%) 1 (0.3%) 1 (0.3%) 15 (5.1%) Food Service Indicator (student was eligible to receive free or reduced lunch) Yes No 30 (10.1%) 263 (89.9%) English as a Second Language Indicator Yes No Former 16 (5.5%) 270 (92.1%) 7 (2.4%) Last Known Status in the District Death Expected transfer/promotion High school completion Dropout or Possible Dropout Transfer to another school Other 30 (10.2%) 8 (2.7%) 97 (33.1%) 64 (22%) 90 (30.7%) 4 (1.3%) School Issue Reported (n = 94) Yes No 13 (13.8%) 81 (86.2%) Suspension/Expulsion (n = 94) Yes No 4 (4.2%) 90 (95.8%) Characteristic Mean SD (range) Number of residence changes 0.3 1.3 (0–13) Last known age in the district 16.9 2.6 (5–22) Attendance rate 0.78 0.28 (0–1) Bivariate analyses revealed significant associations between race/ethnicity and gender (χ 2 = 12.9, p = 0.02), food service indicator (χ 2 = 12, p = 0.03), and ESL indicator (χ 2 = 69, p < 0.001). Full results from our bivariate analysis are displayed in Table 2 . Table 2 Bivariate analyses (associations with race/ethnicity) Variable Test statistic value p-value Gender 12.9 0.02* Last known status in the district 28.6 0.3 Last known age in the district 1.4 0.2 Food Service Indicator 12 0.03* Special Education Indicator 6.1 0.3 English as a Second Language Indicator 69 < 0.001* Number of Residence Changes 0.9 0.4 Average Attendance Rate 1.1 0.3 School Problems Reported 0.2 0.6 Suspension/Expulsion 4.2 0.4 However, analyses adjusted for age and gender did not reveal any significant relationships between race/ethnicity and school-related factors (Table 3 ). Table 3 Adjusted analyses Variable Partial SS df MS F p-value Gender 2.5 1 2.1 1.3 0.3 Last known age 11.9 9 1.3 0.7 0.7 Food Service Indicator 4.2 1 4.1 2.1 0.1 ESL Indicator 4.2 1 4.2 2.1 0.1 Assessment of Suspensions and Expulsions Of the 293 students included, we were able to review total of 94 investigation reports. The additional 199 students did not have investigation reports that were accessible to our team and were thus excluded from the assessment of suspensions and expulsions. Of the 94 students included in this subsample, 13 students (13.8%) were experiencing school-related issues at the time of their suicide. These issues included low grades or other academic issues ( n = 3), substance use related issues ( n = 2), fighting or other behavioral issues ( n = 7), bullying ( n = 1), and recent school changes ( n = 1). Additionally, four students (4.2%) experienced a suspension or expulsion from school prior to their suicide. In three of the four cases, the suicide occurred either the same day or the day immediately following the suspension or expulsion – the timing of the suicide in the context of the suspension in the fourth case is unclear. All four of the suspended or expelled students were Black. Reasons for suspension and expulsion included fighting with other students and possession of illegal substances. Assessment of Mental Health Resources We conducted a total of 14 semi-structured interviews with school district staff to obtain perspectives on the mental health challenges facing students and the availability of mental health resources in the schools. Of those, 12 participants were female; seven were school psychologists and seven were school social workers. In total, 16 schools across the district were represented, most of which are middle schools and high schools. We developed four themes which are grounded in our interview data and span a variety of considerations at the individual student, school, and community levels. Table 4 summarizes and defines these themes. These data are intended to provide context to the quantitative data presented above, highlighting the mental health challenges and needs of Black students. Table 4 Qualitative themes, definitions, and sample quotes Theme Definition Sample Quotes Trauma is a daily experience for many students and is a major contributor to poor mental health Exposure to community violence as well as poverty and housing instability are part of the lived experience of many students struggling with mental health concerns “And I think that a lot of the externalizing comes from physical safety concerns. Like will we have enough food? Will I have a place to stay? Are the adults in my life reliable? And I think there’s a lot of intersectionality in the externalizing behaviors we see. A lot of the boys I work with have been conditioned to stay angry and fight rather than express what’s really going on deep down.” Lack of trust and other barriers prevent students from seeking mental health support Many students lack trust in mental health support due to stigma, past negative experiences, or systemic failures. This is a hinderance to help-seeking among students. “It seems for our white kids, it seems more accepted where they can talk about it. Whereas for our African American kids they struggle, they’re a bit more reserved. And there is some definitive distrust.” “Just the classroom environment can be very triggering for some kids. So you offer them support, but then you throw them right back into the arena and they’re in an environment where they don’t feel safe.” School-based disciplinary actions contribute to a disruptive cycle that negatively impacts student mental health Suspensions and expulsions, along with other school disciplinary actions, exacerbate existing mental health conditions by creating academic and social challenges for students “I feel like suspensions just say we are passing you on. Like we’ve checked out, you can go home. We’re done. And I think that can be really hard for the kids.” “School ends up becoming this place where they’re not wanted and not welcome.” Persistent systemic challenges place a significant burden on students and educators Realities including burnout and insufficient capacity among school staff undermine the ability for students and educators to thrive in the school setting “I think that people are very burnt out and very stressed. So you’re sometimes not seeing people at their best. They’re dysregulated and we obviously know that kids need to co-regulate sometimes. I think that becomes a barrier to us being able to provide students quality socioemotional instruction.” “For students who externalize, it can be really challenging for staff who are already stretched thin. It escalates really quickly and then students end up suspended or expelled. I think we need better de-escalation skills.” Theme 1: Trauma is a daily experience for many students and is a major contributor to poor mental health. As noted, violence is prevalent in parts of the community, and the trauma associated with witnessing and living among this violence influences and impacts the mental health of young people living in those areas. Many interviewees were quick to highlight this reality as a major source of stress for students, impacting mental health as well as performance in school. One interviewee discussed the intersectional nature of these experiences, noting how physical safety is related to concerns around food security and housing: And I think that a lot of the externalizing comes from physical safety concerns. Like will we have enough food? Will I have a place to stay? Are the adults in my life reliable? And I think there’s a lot of intersectionality in the externalizing behaviors we see. A lot of the boys I work with have been conditioned to stay angry and fight rather than express what’s really going on deep down. This quote illustrates how exposure to violence and concern for one’s safety results in mental health challenges, represented through externalizing behaviors, which, when present in the school context, may result in disciplinary action. Another interviewee discussed how exposure to violence in the community results in a sense of fatalism among some students, and how this experience affects a specific group of students: I can't put my finger on it exactly, but there's this almost like cultural thing of, I'm not gonna live to see a certain age. The frequent exposure to community violence, in neighborhoods and families, and the subsequent death of loved ones as a result of this violence, results in this “cultural” experience. The choice of the term “cultural” in this quote highlights the racial disparities inherent in this community violence. Other interviewees focused on discussing the prevalence of trauma among students, linking community violence and the loss of loved ones to violence to mental health challenges: I think, definitely we have a lot of trauma-related too, whether it's, having been physically or sexually abused or having someone in their life who, having someone in their life who has, passed away or been killed. I would say that is a really big thing. And then I think a lot about like social emotional just like self-regulation and coping... I would say, yeah, the biggest ones are, like they lost a parent or, they lost a friend or a sibling to gun violence or, different accidents and things like that. Finally, participants discussed the impact both acute and chronic exposure to trauma have on students while they are in the school environment: Now they're behind or do they not understand what's going on in school. Because, if you're in high alert all day, you're not going to be learning because you're vigilant to other things in your environment. But then that sets you back and now you're embarrassed. This quote highlights not only the negative impacts that exposure to trauma can have on learning, but also the effects trauma has on the self-esteem and well-being of students. Theme 2: Lack of trust and other barriers prevent students from seeking mental health support. School-based mental health services are available across the district, and in some schools, community-based mental health providers offer mental health services within schools on a regular basis to augment the resources that already exist. However, mental health services are frequently not accessed by the youth who may need them the most, in part due to trust-related issues and in part due to other barriers. One trust-related element mentioned by an interviewee is the lack of cultural congruence between school-based mental health providers and students: I do feel like with our white kids, it seems more accepted to be able to talk about it where I think it can be a little bit more of a struggle for like our African American kids where they're just a little bit more reserved. And I do think, I recognize that as a White woman where there's definitely some distrust. In addition to the distrust mentioned here, this interviewee also highlights how mental health stigma varies among racial groups, and how help-seeking may be less acceptable in the African American community, which may discourage accessing support. When students are not able or willing to seek mental health support within the school, another option would be to seek help in the community. However, community- and policy-level barriers also inhibit help-seeking. This includes mental health provider shortages, a lack of providers who will accept Medicaid, and transportation: We have a hard time connecting our students, our families. So, we're seeing a long waiting list, struggling to find providers who are taking forward health or badger care of Medicaid, struggles with when we do find providers. Getting transportation, especially, from maybe some areas…to maybe where a lot of these folks [mental health providers] are practicing…on and on. Several interviewees highlighted how these issues are concentrated among certain groups of students, and particularly students of color: And so, we end up having pockets of young people, as opposed to individual cases. We end up having large groups that tend to struggle at the same time, which really, puts a strain on the resources. I think our black girls are suffering a lot. And I often, converse with this with my colleagues, how there was a huge period where we focus on the Black male and the Black boy, and not to say it wasn't necessary because they're still struggling as well. But there was a huge gap during that time. We forgot about our girls. And you can even see that in prison incarceration rates amongst women, they are skyrocketing. So I definitely think Black girls have been forgotten about. Especially for our Black and Brown students who are disproportionately unable to access mental health services in the city, that combined with a bunch of other factors leads to what I really think is an epidemic of under diagnosis of depression and anxiety in our Black youth, right?” This reality manifests in a vicious cycle, in which minoritized youth are not able to access appropriate mental health care, leading to underdiagnosed or undiagnosed mental health challenges, requiring additional mental health support that these youth are unable to access. Finally, there is a reality in which students are provided mental health support but then are sent back to the stressful environment of the classroom, limiting the potential benefit of the mental health services that are provided: Just the classroom environment can be very triggering for some kids. So you offer them support, but then you throw them right back into the arena and they’re in an environment where they don’t feel safe. This quote highlights how, even when mental health services are accessible for students, systemic challenges related to stressful classroom “arena” undermines this support if a student is repeatedly placed back into a setting that reactivates stress and trauma. Interestingly, the use of the word “arena” as a metaphor in this quote invokes a sense of the classroom being a place of challenge or even combat. This suggests that without systemic change, mental health support becomes a temporary fix rather than a sustainable solution. Theme 3: School-based disciplinary actions contribute to a disruptive cycle that negatively impacts student mental health Discipline occurring in the school setting, and particularly suspensions and expulsions, create significant challenges for students from both an academic and social perspective and contributes to poor mental health among students. One interviewee mentioned how suspending and/or expelling students sends a message to a young person that the school is no longer willing to invest in that student, potentially contributing to a sense of abandonment: I feel like suspensions just say we are passing you on. Like we’ve checked out, you can go home. We’re done. And I think that can be really hard for the kids. This sentiment is echoed by another participant: School ends up becoming this place where they’re not wanted and not welcome. This message may be particularly harmful for students who already experience a traumatic home environment, as highlighted by another participant: It's just a culmination of triggering factors. Like I'm not doing well at school. I don't think my dad loves me. I always get yelled at. I'm tired. I'm getting bullied. It's not good enough. It's like a whole combination of factors. It doesn't feel like one thing anymore. It feels like a myriad of things. As noted, suspensions and expulsions have many negative and intersecting impacts on students. This includes academic challenges resulting from missing school, social challenges resulting from isolation from peers, putting students further behind without an ability to catch up with their peers: Typically, the kids who are being suspended have academic issues. Now they're going to fall further behind, and they also typically have social emotional struggles. Maybe they don't have the skills yet of how to navigate things appropriately. So, they're definitely not going to learn that if they're out of school all the time. Notably, suspensions and expulsions may be used to eliminate difficult situations for adults in the school environment. Rather than investing in longer-term, potentially more beneficial strategies to manage student behavior, students are instead removed from the school entirely: It does feel like to me, the suspensions are more about giving the adults breaks. While this action may offer a temporary solution for adults in classroom spaces, the short- and long-term effects suspensions and expulsions have on students’ mental health can be severe: We've had those situations where it's like this kid, had something they weren't supposed to have at school, and they were going to get suspended for it, and then it turns into a mental health crisis. Any potential “upsides” to these disciplinary actions are far outweighed by the need to protect and support the mental health needs of students. Theme 4: Persistent systemic challenges place a significant burden on students and educators Students are not alone in experiencing stress in the school environment. In fact, teachers and administrators are also often overburdened and burned out, and this can undermine the ability for both students and educators to thrive in the school setting. The root cause of this distress is often systemic, sometimes stemming from the way the educational system is misaligned with the lived experiences of many students: I don't think it's a school issue. I think it's a systemic issue. I think we are still educating students as if they come from the two-parent household, the house with the picket fence, the mom and dad who, and when you're trying to do one teacher to 20 kids with various learning levels, with housing insecurity.... It's a system, teachers are taught to teach that way. And we've been teaching their way since the early 1900s, probably the 1800s. You can look at pictures of classrooms over 200 years ago, and they still look the same. And I think, in some environments that may still work because those children…have parents who are able to fill in those gaps when they're struggling…And when you don't have somebody checking in for your homework, because mom works two, three jobs, you got to watch your siblings. You don't have time to study. Yeah, and that's just a huge disconnect. So then what happens is they continue to fall behind as they progress…and they can't perform at a rate that is comparable to their peers, and in the world. This quote highlights how “the system” is only working well for a select set of students with abundant out-of-school support, which are often not available for many. Similarly, teachers are faced with large classrooms of students with varying complex needs, limiting their ability to adequately meet these needs: I think that people are very burnt out and very stressed. So, you’re sometimes not seeing people at their best. They’re [teachers are] dysregulated and we obviously know that kids need to co-regulate sometimes. I think that becomes a barrier to us being able to provide students quality socioemotional instruction. The emotional states of students and educators are interconnected in the classroom setting, and burnout among educators can unintentionally hinder the learning of students. Students, and particularly those with developing social emotional skills, may rely on learning to manage emotions by interacting with regulated adults. When teachers are dysregulated, they may unintentionally model stress or frustration, making it harder for students to feel safe and supported. Similarly, systemic issues like the overburdening of school staff may result in ineffective intervention for students who express distress through externalizing behaviors, including disruption. These behaviors can be difficult to manage in environments where staff are under-resourced, and can sometimes lead to exclusionary discipline: For students who externalize, it can be really challenging for staff who are already stretched thin. It escalates really quickly and then students end up suspended or expelled. I think we need better de-escalation skills. This quote reflects a call for trauma-informed, restorative, and non-punitive approaches to behavior management in the school setting. Arguably, these approaches would benefit the long-term mental health of not only those students experiencing mental health challenges but may improve overall school climate as well. Discussion The intent of this study was to use school records and interviews with key school staff members to characterize the relationship between school-related issues and suicide and to identify potential avenues for intervention to improve student mental health, which may ultimately prevent suicide. While there has been significant research examining the relationship between school discipline and mental health,(Duarte et al., 2023 b) little research has specifically examined how school discipline may affect suicidal thoughts and behaviors. While our analyses did not reveal any significant associations between school issues preceding suicide and race or ethnicity, we did find that every decedent in our sample with a reported history of a suspension or expulsion that contributed to suicide was Black. Similarly, we found evidence of mental health and suicide-related disparities by race, as well as unequal access to mental health services and supports in our qualitative analysis. Prior research has shown that school disciplinary policies have an impact on student mental health.(Perryman et al., n.d.; So et al., 2024 ) For example, in one study with Black high school students, researchers found that students who experienced in-school policing had greater levels of depression compared with students who did not experience school discipline or policing.(Perryman et al., n.d.) Additionally, punitive school discipline is associated with higher odds of depression, adjustment problems, and anti-social behaviors, particularly for Black students.(Duarte et al., 2023 b) Despite the small sample and limited findings from the current study, our data suggest a need for continued research in this area to further understand school-related issues that may contribute to suicidal behaviors among youth and unpack racial disparities in school discipline and the effects on mental health, particularly suicide. Our study also detailed the detrimental mental health, social, and academic impacts that suspensions and expulsions have on students. Importantly, as suspensions and expulsions primarily impacted Black students in our sample, the burden of the detrimental impacts of these actions also affects this minoritized group. Our qualitative data detail the social and structural barriers facing Black students in this school district, including high levels of violence and poverty. Staff noted that schools often lacked the resources needed to support students in these circumstances. As identified in our qualitative data, there is an urgent need for trauma-informed, restorative, and non-punitive approaches to behavior management in the school setting to support student mental health. Ultimately, policy and systems change approaches are needed to support Black youth both within the school setting and within the community. Policies and other strategies to decrease violence and other exposures to trauma in the community may result in the reduction of root cause-level stressors contributing to poor mental health among Black youth. School district-level policies that are specifically enumerated to protect Black students and other students of color from discriminatory and/or exclusionary discipline could be implemented as well. In addition, school-based programming, including training for educators and administrators on the detrimental mental health effects of exclusionary violence on Black students, is warranted. Additionally, current evidence-based school suicide prevention programming, including programs such as Sources of Strength,(Wyman et al., 2010 ) could be adapted to meet the unique needs of minoritized students to further support mental health. Universal suicide screening can also be implemented within schools to identify youth who are at risk for suicide without the need for those students to specifically seek help on their own. Finally, parents and caregivers play an important role in supporting the mental health of youth and in detecting potential thoughts of suicide or suicidal behavior. Programming, including education for parents and caregivers on how to identify signs of mental health challenges or suicide risk among youth, may improve early identification of youth in need of support, potentially enabling earlier access to appropriate services. Despite the importance of this study’s findings, there are limitations. First, this study took place in a single urban school district with a limited sample size. Additional research is needed that examines the school-to-prison pipeline with a larger, more diverse sample of schools and students. Second, this study used retrospective student data. While the quantitative data provide important insights into school experiences, we were limited to using existing data. Prospective studies could capture a greater range of data from students and schools. Finally, qualitative data from students could provide needed context for how school discipline impacts student mental health and behaviors. Qualitative data from teachers could similarly provide needed insights into school needs, resources, and teacher decision-making around disciplinary referrals. Conclusion Youth spend much of their time in the school environment, and as a result, school-based experiences can have a significant influence on their mental health and wellness. Research has demonstrated how disciplinary experiences, including suspensions and expulsions, can negatively impact student mental health, and as there are racial disparities in the disciplining of students, youth of color disproportionately bear the burden of the negative effects of school discipline. This is a social justice issue. To shift course and disrupt the “school-to-suicide pipeline”, innovative, public health-based strategies are necessary and should focus on policy and systems change to safeguard and improve the mental health of all youth, and particularly minoritized youth. Declarations Ethics Approval Declaration: All study activities were approved by the Institutional Review Board at the Medical College of Wisconsin (reference number PRO48705), and approval to obtain and utilize school and student-level data was obtained from the participating school district. All research was conducted in accordance with the Declaration of Helsinki. Consent to Participate Declaration: Human subjects research participants (e.g., interview participants) provided consent to participate. Research involving subjects under age 16 involved deceased individuals only, and therefore it was not practicable or possible to obtain informed consent. Similarly, the study team received de-identified data from our partnering school district, so it was not possible to obtain assent from parents of deceased youth subjects. Funding Statement: This study was funded through a seed grant from the Comprehensive Injury Center at the Medical College of Wisconsin. References Ormiston CK, Lawrence WR, Sulley S, et al. Trends in Adolescent Suicide by Method in the US, 1999–2020. JAMA Netw Open. 2024;7(3):E244427. 10.1001/jamanetworkopen.2024.4427 . Lindsey M, Sheftall A, Xiao Y, Joe S. Trends of Suicidal Behaviors Among High School Students in the United States: 1991–2017. Pediatrics. 2019;144(5). Verlenden JV, Fodeman A, Wilkins N et al. Mental Health and Suicide Risk Among High School Students and Protective Factors-Youth Risk Behavior Survey, United States, 2023. MMWR Suppl. 2024;(73). https://nccd.cdc.gov/youthonline/App/Default.aspx Sheftall AH, Asti L, Horowitz LM, et al. Suicide in elementary school-aged children and early adolescents. Pediatrics. 2016;138(4). 10.1542/peds.2016-0436 . Coleman BW. Ring the Alarm: The Crisis of Black Youth Suicide in America. Congressional Black Caucus, Emergency Taskforce on Black Youth Suicide and Mental Health;; 2019. Pachter LM, Coll CG. Racism and Child Health: A Review of the Literature and Future Directions. J Dev Behav Pediatr. 2009;30(3):255–63. 10.1097/DBP.0b013e3181a7ed5a . Bath E, Njoroge WFM. Coloring Outside the Lines: Making Black and Brown Lives Matter in the Prevention of Youth Suicide. J Am Acad Child Adolesc Psychiatry. 2021;60(1):17–21. 10.1016/j.jaac.2020.09.013 . Meza JI, Bath E. One Size Does Not Fit All: Making Suicide Prevention and Interventions Equitable for Our Increasingly Diverse Communities. J Am Acad Child Adolesc Psychiatry. 2021;60(2):209–12. 10.1016/j.jaac.2020.09.019 . Nguyen L, Huang LN, Arganza GF, Liao Q. The influence of race and ethnicity on psychiatric diagnoses and clinical characteristics of children and adolescents in children’s services. Cultur Divers Ethnic Minor Psychol. 2007;13(1):18–25. 10.1037/1099-9809.13.1.18 . Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black Youth Suicide: Investigation of Current Trends and Precipitating Circumstances. J Am Acad Child Adolesc Psychiatry. 2022;61(5):662–75. 10.1016/j.jaac.2021.08.021 . Williams IIIJ, Richardson S, Lewis CW, Alexander J. Investigating Disciplinary Risk in Urban High Schools as a Precursor for Suicide-Related Behaviors among Black Students. J Trauma Stud Educ. 2022;1(3):90–107. 10.32674/jtse.v1i3.5037 . Duarte Cd, Moses P, Brown C. Punitive school discipline as a mechanism of structural marginalization with implications for health inequity: A systematic review of quantitative studies in the health and social sciences literature. Ann N Y Acad Sci. 2023;1519(1):129–52. 10.1111/nyas.14922 . Saleem FT, Howard TC, Langley AK. Understanding and addressing racial stress and trauma in schools: A pathway toward resistance and healing. Psychol Sch. 2022;59(12):2506–21. 10.1002/pits.22615 . Mpofu JJ, Cooper AC, Ashley C et al. Perceived Racism and Demographic, Mental Health, and Behavioral Characteristics Among High School Students During the COVID-19 Pandemic — Adolescent Experiences and Behaviors Survey, United States, January–June 2021. CDC MMWR. 2022;3(71). https://www.cdc.gov/ Milwaukee Public Schools. Organizational Profile. Strategic Plan; 2025. Lynch EE, Meier HCS. The intersectional effect of poverty, home ownership, and racial/ethnic composition on mean childhood blood lead levels in Milwaukee County neighborhoods. PLoS ONE. 2020;15(6):1–15. 10.1371/journal.pone.0234995 . City of Milwaukee Office of Violence Prevention. Milwaukee Bluepr Peace.; 2016. https://city.milwaukee.gov/414Life United States Census Bureau. Milwaukee County, Wisconsin. County. 2023. https://data.census.gov/profile?g=050XX00US55079 Loyd J, Bonds A. Where do Black lives matter? Race, stigma, and place in Milwaukee, Wisconsin. Sociol Rev. 2018;66(4):898–918. Braun V, Clarke V. Thematic Analysis: A Practical Guide. First: SAGE; 2022. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Duarte Cd, Moses P, Brown C. Punitive school discipline as a mechanism of structural marginalization with implications for health inequity: A systematic review of quantitative studies in the health and social sciences literature. Ann N Y Acad Sci. 2023;1519(1):129–52. 10.1111/nyas.14922 . So M, Freese RL, Barnes AJ. Pushed Out and Drawn In: Exclusionary Discipline, Mental Health, and Protective Factors Among Youth in Public Schools. J Sch Health. 2024;94(2):128–37. 10.1111/josh.13405 . Perryman C, Platt S, Montiel Ishino F. Identifying the Mental Health Profiles of Black Adolescents Who Experience School Policing and School Discipline: A Person-Centered Approach . www.jaacap.org. Wyman PA, Brown CH, LoMurray M, et al. An outcome evaluation of the sources of strength suicide prevention program delivered by adolescent peer leaders in high schools. Am J Public Health. 2010;100(9):1653–61. 10.2105/AJPH.2009.190025 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 17 Apr, 2026 Editor assigned by journal 17 Apr, 2026 Editor invited by journal 16 Apr, 2026 Submission checks completed at journal 15 Apr, 2026 First submitted to journal 15 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Between 2012 and 2020,(Ormiston et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e) Black youth experienced a significant increase in suicide, particularly among Black boys between ages 15 and 17.(Lindsey et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e) Data from the 2023 Youth Risk Behavior Survey (YRBS) demonstrate that Black students had higher prevalence of suicide attempt as compared with White students (10.3% versus 8.3%).(Verlenden et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e) Recent studies have also determined that elementary school-aged children who die by suicide are most commonly Black males.(Sheftall et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e) This incidence of suicide among youth in the Black community represents a significant number of years of potential life lost. According to the Centers for Disease Control and Prevention (CDC), suicide among youth ages 10 to 24 in the Black community in 2023 amounted to over 44,862 years of potential life lost before age 65.(Ring the Alarm: The Crisis of Black Youth Suicide in America, 2019)\u003c/p\u003e \u003cp\u003eDespite this concerning evidence, “being Black” is not a risk factor for suicide; rather, sociocultural factors and social determinants of health influence suicidal behavior among Black youth in the United States. Emerging research points to risk and protective factors for suicide that are specific to Black youth.(Ring the Alarm: The Crisis of Black Youth Suicide in America, 2019) For instance, Black youth are disproportionately impacted by racism and discrimination, barriers to mental health care utilization, poverty, trauma, violence, and exposure to the death of individuals in their neighborhoods.(Bath \u0026amp; Njoroge, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Meza \u0026amp; Bath, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Pachter \u0026amp; Coll, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; Coleman et al., 2019) These exposures contribute to risk for suicide in this group.(Bath \u0026amp; Njoroge, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Meza \u0026amp; Bath, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Nguyen et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e) Further, the risk factors commonly linked to suicide (e.g., depression) may present differently for Black youth and be misunderstood, preventing early identification and intervention for this population.\u003c/p\u003e \u003cp\u003eSuicide is a complex issue, and in the context of youth suicide, factors related to the school environment are critical in understanding and preventing this loss of life. Research examining precipitating circumstances surrounding suicide among Black male youth found almost 35% reported a recent problem at school.(Sheftall et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e) Black students are overrepresented in school discipline data; Black children are the most likely recipients of in-school suspensions, out-of-school suspensions, expulsions, and referrals to law enforcement.(Williams III et al., 2022) Importantly, such punitive school discipline is associated with greater risk for depressive symptoms, substance use, and death by suicide.(Duarte et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003ea) Further, Black youth are exposed to, witness, and are left to process discriminatory and biased school interactions and disciplinary outcomes for themselves and peers, which may contribute to psychological problems, including suicide.(Saleem et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e) From a life course perspective, the over-disciplining of Black youth within the school system contributes to the “school-to-prison pipeline”,(Verlenden et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e) thereby placing Black adults who experienced discriminatory discipline practices during school at increased risk of incarceration, which can elevate risk for suicide.\u003c/p\u003e \u003cp\u003eData from the 2023 YRBS indicates that students who feel connected to others at school have lower prevalence of poor mental health, and Black youth report among the lowest levels of school connectedness.(Verlenden et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e) Other research has similarly found that connectedness is lowest among youth who have experienced racism at school.(Mpofu et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e) Recent research suggests that the availability of school support may also be associated with suicide risk; in one study, the presence of law enforcement officers within the school was positively associated with Black boys’ consideration of suicide and developing a suicide plan.(Williams III et al., 2022) Furthermore, school discipline risk was associated with suicide attempts for Black boys.(Williams III et al., 2022)\u003c/p\u003e \u003cp\u003eIn response to the disproportionate impact of suicide on Black male students as well as the influence of school-related factors on suicidal thoughts and behaviors, we conducted a study to obtain more comprehensive data on school-based factors preceding suicide among Black individuals in a diverse, urban setting. The purpose of this multiple-method study was twofold: first, we examined the historical prevalence of school interventions among Black students who went on to die by suicide in our study setting. Second, we assessed the availability of mental health resources and support available to school personnel to support Black students and identify ongoing staffing needs and potential avenues for support. This study was informed by Critical Race Theory (CRT), which conceptualizes racism as structural and systemic forces embedded in institutions, policies, and practices.(Ford \u0026amp; Airhihenbuwa, 2010; Graham et al., 2011) Specifically, we conceptualized school environments, including school disciplinary policies and exclusionary practices as structural forms of racism that can contribute to cumulative stress and psychological harm. This framework guided our inquiry into how school systems and practices may elevate suicide risk and how restorative interventions and policies might disrupt the school-to-suicide pipeline for Black youth. Findings from this study can be used to develop tailored school-based suicide prevention interventions and policies to support Black youth and disrupt the school-to-suicide pipeline.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eStudy Setting: This study takes place in an urban, diverse context in the Midwestern United States. Data collection took place between April 2024 and April 2025. Our study involved one public school district. This district is the largest in the state and is comprised of mostly students of color, and primarily Black students. More than 80% of the students in the district are considered “economically disadvantaged”.(Milwaukee Public Schools, \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e) This city is highly racially segregated, a direct result of systematic redlining,(Lynch \u0026amp; Meier, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e) and concentrated violence is prevalent in various neighborhoods across the city.(City of Milwaukee Office of Violence Prevention, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e) Additionally, 17% of county residents live below the poverty line,(United States Census Bureau, 2023) and those census tracts with the highest rates of poverty across the county also experience the highest levels of violence.(United States Census Bureau, 2023) Finally, poverty in the community is racialized. (Loyd \u0026amp; Bonds, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e) There is a higher proportion of non-White residents living in census tracts with the highest levels of poverty when compared with non-White residents living in better-resourced areas.\u003c/p\u003e\u003cp\u003eWe employed a multiple-methods design using quantitative and qualitative approaches that addressed related but distinct research questions. Data were analyzed independently, but the findings were considered as a whole to aid in interpretation and inform next steps.\u003c/p\u003e\u003cp\u003eStudy Population:\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eSchool Records Review\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eWe gathered school records from all county residents who died by suicide during the ten-year period from 2013 through 2022 who also attended school and had available records within our study district. We obtained information on all suicide decedents during our study period from our county’s medical examiner’s office and provided names and dates of birth to our school district partners for matching. School data were then provided back to the study team for those decedents with records in the school system.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eAssessment of Suspensions and Expulsions\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eWe gathered suicide investigation reports from our county’s medical examiner’s office for all suicide decedents ages 10 through 24 in our school records review sample to assess for reporting of school-related stressors and/or suspensions and expulsions as contributing factors to suicide. We selected these decedents because they were most likely to be enrolled in school at the time of their suicide. Again, we focused our review on suicides occurring from 2013 through 2022.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eAssessment of Mental Health Resources\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eWe conducted semi-structured key informant interviews with school district psychologists and social workers. Participants were recruited from a staff list provided by the school district, and we also employed snowball sampling methods to recruit additional participants. All interview participants were employed with the school district at the time of their interview. Interview participants were compensated with a \u003cspan\u003e$\u003c/span\u003e25 gift card.\u003c/p\u003e\u003cp\u003eData Collection and Analysis:\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eSchool Records Review\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eWe examined information on a variety of student-level and school-based factors, including student demographics, attendance rate (the proportion of time students are present at school compared to the total time they were scheduled to be present at school), last known age and grade in the district, food service indicator (a proxy for household income), special education indicator and type, ESL (English as a Second Language) indicator, number of residence changes, graduation cohort, and school attended. Variables were selected based on our theoretical framework and the data available. We conducted an exploratory analysis, which included calculating descriptive statistics (e.g., frequencies, means) for all variables, and we also conducted bivariate analyses using Chi-square and Fisher’s exact tests and ANOVA to examine the relationship between race/ethnicity and the school-based factors listed above. Adjusted multivariate analyses were conducted using ANOVA to examine the relationship between student characteristics and school-based factors. All analyses were conducted using StataNow 18 SE. We hypothesize that student race will be associated the presence of school-related issues/stressors, the receipt of food services, receipt of special education services, English as a Second Language program participation, residence changes, and suspension or expulsion.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eAssessment of Suspensions and Expulsions\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eWe conducted manual keyword searches of all included suicide investigation reports and collected information on the presence of school-related issues (yes/no) and reported suspension or expulsion (yes/no). It is possible that decedents had school issues without a suspension or expulsion, but we indicated a school issue for all decedents with a reported suspension or expulsion. We tabulated data related to both these indicators for each decedent aged 10 to 24 and then included these two binary variables in our analysis of school records.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003eAssessment of Mental Health Resources\u003c/em\u003e: Semi-structured key informant interviews with school staff were conducted using a protocol developed by our study team. Questions included the following: \u003cem\u003eWhat are the primary mental health needs of students? How have you seen suicide, including thoughts and attempts, affect students? What happens when a teacher or staff member recognizes or learns that a student is having mental health challenges? How does response and intervention with students whose mental health challenges show up as ‘problem behaviors’ differ from a student whose mental health challenge looks more like withdrawal or lack of engagement? What resources are available for students with behavioral challenges? What are your perceptions around how out-of-school discipline affects the students involved? What are the primary barriers to school-based mental health care for students? What training and/or support do teachers and other staff need to support students struggling with mental or behavioral health challenges?\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInterviews were conducted either in-person or online via Zoom, depending on the preference of the participants. All interviews were audio recorded and transcribed by study team members. We analyzed the interviews using an inductive reflexive thematic analysis approach(Braun \u0026amp; Clarke, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e) grounded in a phenomenological framework. A subset of interviews was read by two study team members, and an initial codebook was developed. This codebook was then applied to two interview transcripts, and revisions to the codebook were made. The remaining interviews were coded by a study team member, and then three study team members met to collaboratively generate a set of themes that reflect the experiences of study participants. Qualitative data analysis was conducted using MAXQDA 2022.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003ePositionality Statement:\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eInterpretation of qualitative data is influenced by the positionality of those analyzing the data. Therefore, it is important for readers to understand the lived experience of authors as well as the context in which the authors conduct their work. The authors of this study are public health-trained researchers and experienced qualitative methodologists who live in the community in which this study was conducted. One author is also a trained suicidologist who conducts research and programming related to suicide prevention and postvention. All authors identify as White, non-Hispanic females, and acknowledge the privilege and lens that this brings to our work. At the same time, we as authors are immersed in community-engaged research on a daily basis and applied the lessons we have learned through that work to the interpretation of our results.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSchool Records Review:\u003c/h2\u003e \u003cp\u003eA total of 293 suicide decedents were included in our sample. A majority of those (50.8%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;149) were Black/African American and male (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;242, 82.6%). The average last known age within the school district was 16.9 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.6 years) 40 students (13.7%) received special education services while they were in the district, and of those students whose special education type was known, 28% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11) received services related to a specific learning disability. The average attendance rate (calculated by dividing the total days attended by the total possible school days, then multiplying by 100) for students was 0.78 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.28) and the mean number of residence changes (the number of residential moves reported for the student over the course of their time with the district) was 0.3 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.3). 30 students (10.2%) in the sample died by suicide while attending school in the district, and approximately 22% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;64) dropped out of school. Full sample information is included in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample Characteristics (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;293)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValues\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace/Ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003cp\u003eAmerican Indian\u003c/p\u003e \u003cp\u003eAsian\u003c/p\u003e \u003cp\u003eBlack/African American\u003c/p\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003cp\u003eMultiple Races\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (22.2%)\u003c/p\u003e \u003cp\u003e6 (2%)\u003c/p\u003e \u003cp\u003e15 (5%)\u003c/p\u003e \u003cp\u003e149 (50.8%)\u003c/p\u003e \u003cp\u003e57 (19.5%)\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e242 (82.6%)\u003c/p\u003e \u003cp\u003e51 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecial Education Indicator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (13.7%)\u003c/p\u003e \u003cp\u003e253 (86.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecial Education Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional Behavioral\u003c/p\u003e \u003cp\u003eIntellectual\u003c/p\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003cp\u003eOther Health Impairment\u003c/p\u003e \u003cp\u003eSpecific Learning Disability\u003c/p\u003e \u003cp\u003eSpeech or Language Impairment\u003c/p\u003e \u003cp\u003eTraumatic Brain Injury\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (1.7%)\u003c/p\u003e \u003cp\u003e2 (0.7%)\u003c/p\u003e \u003cp\u003e252 (86%)\u003c/p\u003e \u003cp\u003e4 (1.4%)\u003c/p\u003e \u003cp\u003e11 (3.7%)\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003cp\u003e15 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood Service Indicator (student was eligible to receive free or reduced lunch)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (10.1%)\u003c/p\u003e \u003cp\u003e263 (89.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish as a Second Language Indicator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eFormer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (5.5%)\u003c/p\u003e \u003cp\u003e270 (92.1%)\u003c/p\u003e \u003cp\u003e7 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast Known Status in the District\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003cp\u003eExpected transfer/promotion\u003c/p\u003e \u003cp\u003eHigh school completion\u003c/p\u003e \u003cp\u003eDropout or Possible Dropout\u003c/p\u003e \u003cp\u003eTransfer to another school\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (10.2%)\u003c/p\u003e \u003cp\u003e8 (2.7%)\u003c/p\u003e \u003cp\u003e97 (33.1%)\u003c/p\u003e \u003cp\u003e64 (22%)\u003c/p\u003e \u003cp\u003e90 (30.7%)\u003c/p\u003e \u003cp\u003e4 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool Issue Reported (n\u0026thinsp;=\u0026thinsp;94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (13.8%)\u003c/p\u003e \u003cp\u003e81 (86.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuspension/Expulsion (n\u0026thinsp;=\u0026thinsp;94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4.2%)\u003c/p\u003e \u003cp\u003e90 (95.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e \u003cb\u003e(range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of residence changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3 (0\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast known age in the district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6 (5\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttendance rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.28 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBivariate analyses revealed significant associations between race/ethnicity and gender (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;12.9, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02), food service indicator (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03), and ESL indicator (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;69, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Full results from our bivariate analysis are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate analyses (associations with race/ethnicity)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTest statistic value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast known status in the district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast known age in the district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood Service Indicator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecial Education Indicator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish as a Second Language Indicator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Residence Changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage Attendance Rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool Problems Reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuspension/Expulsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHowever, analyses adjusted for age and gender did not reveal any significant relationships between race/ethnicity and school-related factors (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted analyses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartial \u003cem\u003eSS\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003edf\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eMS\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast known age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood Service Indicator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESL Indicator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAssessment of Suspensions and Expulsions\u003c/strong\u003e \u003cp\u003eOf the 293 students included, we were able to review total of 94 investigation reports. The additional 199 students did not have investigation reports that were accessible to our team and were thus excluded from the assessment of suspensions and expulsions. Of the 94 students included in this subsample, 13 students (13.8%) were experiencing school-related issues at the time of their suicide. These issues included low grades or other academic issues (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), substance use related issues (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2), fighting or other behavioral issues (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), bullying (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1), and recent school changes (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1). Additionally, four students (4.2%) experienced a suspension or expulsion from school prior to their suicide. In three of the four cases, the suicide occurred either the same day or the day immediately following the suspension or expulsion \u0026ndash; the timing of the suicide in the context of the suspension in the fourth case is unclear. All four of the suspended or expelled students were Black. Reasons for suspension and expulsion included fighting with other students and possession of illegal substances.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAssessment of Mental Health Resources\u003c/strong\u003e \u003cp\u003eWe conducted a total of 14 semi-structured interviews with school district staff to obtain perspectives on the mental health challenges facing students and the availability of mental health resources in the schools. Of those, 12 participants were female; seven were school psychologists and seven were school social workers. In total, 16 schools across the district were represented, most of which are middle schools and high schools.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eWe developed four themes which are grounded in our interview data and span a variety of considerations at the individual student, school, and community levels. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes and defines these themes. These data are intended to provide context to the quantitative data presented above, highlighting the mental health challenges and needs of Black students.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQualitative themes, definitions, and sample quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma is a daily experience for many students and is a major contributor to poor mental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposure to community violence as well as poverty and housing instability are part of the lived experience of many students struggling with mental health concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;And I think that a lot of the externalizing comes from physical safety concerns. Like will we have enough food? Will I have a place to stay? Are the adults in my life reliable? And I think there\u0026rsquo;s a lot of intersectionality in the externalizing behaviors we see. A lot of the boys I work with have been conditioned to stay angry and fight rather than express what\u0026rsquo;s really going on deep down.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of trust and other barriers prevent students from seeking mental health support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMany students lack trust in mental health support due to stigma, past negative experiences, or systemic failures. This is a hinderance to help-seeking among students.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;It seems for our white kids, it seems more accepted where they can talk about it. Whereas for our African American kids they struggle, they\u0026rsquo;re a bit more reserved. And there is some definitive distrust.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;Just the classroom environment can be very triggering for some kids. So you offer them support, but then you throw them right back into the arena and they\u0026rsquo;re in an environment where they don\u0026rsquo;t feel safe.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool-based disciplinary actions contribute to a disruptive cycle that negatively impacts student mental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuspensions and expulsions, along with other school disciplinary actions, exacerbate existing mental health conditions by creating academic and social challenges for students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I feel like suspensions just say we are passing you on. Like we\u0026rsquo;ve checked out, you can go home. We\u0026rsquo;re done. And I think that can be really hard for the kids.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;School ends up becoming this place where they\u0026rsquo;re not wanted and not welcome.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent systemic challenges place a significant burden on students and educators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRealities including burnout and insufficient capacity among school staff undermine the ability for students and educators to thrive in the school setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I think that people are very burnt out and very stressed. So you\u0026rsquo;re sometimes not seeing people at their best. They\u0026rsquo;re dysregulated and we obviously know that kids need to co-regulate sometimes. I think that becomes a barrier to us being able to provide students quality socioemotional instruction.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;For students who externalize, it can be really challenging for staff who are already stretched thin. It escalates really quickly and then students end up suspended or expelled. I think we need better de-escalation skills.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cu\u003eTheme 1: Trauma is a daily experience for many students and is a major contributor to poor mental health.\u003c/u\u003e As noted, violence is prevalent in parts of the community, and the trauma associated with witnessing and living among this violence influences and impacts the mental health of young people living in those areas. Many interviewees were quick to highlight this reality as a major source of stress for students, impacting mental health as well as performance in school. One interviewee discussed the intersectional nature of these experiences, noting how physical safety is related to concerns around food security and housing:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAnd I think that a lot of the externalizing comes from physical safety concerns. Like will we have enough food? Will I have a place to stay? Are the adults in my life reliable? And I think there\u0026rsquo;s a lot of intersectionality in the externalizing behaviors we see. A lot of the boys I work with have been conditioned to stay angry and fight rather than express what\u0026rsquo;s really going on deep down.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis quote illustrates how exposure to violence and concern for one\u0026rsquo;s safety results in mental health challenges, represented through externalizing behaviors, which, when present in the school context, may result in disciplinary action.\u003c/p\u003e \u003cp\u003eAnother interviewee discussed how exposure to violence in the community results in a sense of fatalism among some students, and how this experience affects a specific group of students:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI can't put my finger on it exactly, but there's this almost like cultural thing of, I'm not gonna live to see a certain age.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe frequent exposure to community violence, in neighborhoods and families, and the subsequent death of loved ones as a result of this violence, results in this \u0026ldquo;cultural\u0026rdquo; experience. The choice of the term \u0026ldquo;cultural\u0026rdquo; in this quote highlights the racial disparities inherent in this community violence.\u003c/p\u003e \u003cp\u003eOther interviewees focused on discussing the prevalence of trauma among students, linking community violence and the loss of loved ones to violence to mental health challenges:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think, definitely we have a lot of trauma-related too, whether it's, having been physically or sexually abused or having someone in their life who, having someone in their life who has, passed away or been killed. I would say that is a really big thing. And then I think a lot about like social emotional just like self-regulation and coping...\u003c/p\u003e\u003cp\u003eI would say, yeah, the biggest ones are, like they lost a parent or, they lost a friend or a sibling to gun violence or, different accidents and things like that.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFinally, participants discussed the impact both acute and chronic exposure to trauma have on students while they are in the school environment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNow they're behind or do they not understand what's going on in school. Because, if you're in high alert all day, you're not going to be learning because you're vigilant to other things in your environment. But then that sets you back and now you're embarrassed.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis quote highlights not only the negative impacts that exposure to trauma can have on learning, but also the effects trauma has on the self-esteem and well-being of students.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTheme 2: Lack of trust and other barriers prevent students from seeking mental health support.\u003c/span\u003e School-based mental health services are available across the district, and in some schools, community-based mental health providers offer mental health services within schools on a regular basis to augment the resources that already exist. However, mental health services are frequently not accessed by the youth who may need them the most, in part due to trust-related issues and in part due to other barriers. One trust-related element mentioned by an interviewee is the lack of cultural congruence between school-based mental health providers and students:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI do feel like with our white kids, it seems more accepted to be able to talk about it where I think it can be a little bit more of a struggle for like our African American kids where they're just a little bit more reserved. And I do think, I recognize that as a White woman where there's definitely some distrust.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition to the distrust mentioned here, this interviewee also highlights how mental health stigma varies among racial groups, and how help-seeking may be less acceptable in the African American community, which may discourage accessing support.\u003c/p\u003e \u003cp\u003eWhen students are not able or willing to seek mental health support within the school, another option would be to seek help in the community. However, community- and policy-level barriers also inhibit help-seeking. This includes mental health provider shortages, a lack of providers who will accept Medicaid, and transportation:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe have a hard time connecting our students, our families. So, we're seeing a long waiting list, struggling to find providers who are taking forward health or badger care of Medicaid, struggles with when we do find providers. Getting transportation, especially, from maybe some areas\u0026hellip;to maybe where a lot of these folks [mental health providers] are practicing\u0026hellip;on and on.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral interviewees highlighted how these issues are concentrated among certain groups of students, and particularly students of color:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAnd so, we end up having pockets of young people, as opposed to individual cases. We end up having large groups that tend to struggle at the same time, which really, puts a strain on the resources.\u003c/p\u003e\u003cp\u003eI think our black girls are suffering a lot. And I often, converse with this with my colleagues, how there was a huge period where we focus on the Black male and the Black boy, and not to say it wasn't necessary because they're still struggling as well. But there was a huge gap during that time. We forgot about our girls. And you can even see that in prison incarceration rates amongst women, they are skyrocketing. So I definitely think Black girls have been forgotten about.\u003c/p\u003e\u003cp\u003eEspecially for our Black and Brown students who are disproportionately unable to access mental health services in the city, that combined with a bunch of other factors leads to what I really think is an epidemic of under diagnosis of depression and anxiety in our Black youth, right?\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e This reality manifests in a vicious cycle, in which minoritized youth are not able to access appropriate mental health care, leading to underdiagnosed or undiagnosed mental health challenges, requiring additional mental health support that these youth are unable to access.\u003c/p\u003e \u003cp\u003eFinally, there is a reality in which students are provided mental health support but then are sent back to the stressful environment of the classroom, limiting the potential benefit of the mental health services that are provided:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eJust the classroom environment can be very triggering for some kids. So you offer them support, but then you throw them right back into the arena and they\u0026rsquo;re in an environment where they don\u0026rsquo;t feel safe.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis quote highlights how, even when mental health services are accessible for students, systemic challenges related to stressful classroom \u0026ldquo;arena\u0026rdquo; undermines this support if a student is repeatedly placed back into a setting that reactivates stress and trauma. Interestingly, the use of the word \u0026ldquo;arena\u0026rdquo; as a metaphor in this quote invokes a sense of the classroom being a place of challenge or even combat. This suggests that without systemic change, mental health support becomes a temporary fix rather than a sustainable solution.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTheme 3: School-based disciplinary actions contribute to a disruptive cycle that negatively impacts student mental health\u003c/span\u003e Discipline occurring in the school setting, and particularly suspensions and expulsions, create significant challenges for students from both an academic and social perspective and contributes to poor mental health among students. One interviewee mentioned how suspending and/or expelling students sends a message to a young person that the school is no longer willing to invest in that student, potentially contributing to a sense of abandonment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI feel like suspensions just say we are passing you on. Like we\u0026rsquo;ve checked out, you can go home. We\u0026rsquo;re done. And I think that can be really hard for the kids.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis sentiment is echoed by another participant:\u003c/p\u003e \u003cp\u003eSchool ends up becoming this place where they\u0026rsquo;re not wanted and not welcome.\u003c/p\u003e \u003cp\u003eThis message may be particularly harmful for students who already experience a traumatic home environment, as highlighted by another participant:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt's just a culmination of triggering factors. Like I'm not doing well at school. I don't think my dad loves me. I always get yelled at. I'm tired. I'm getting bullied. It's not good enough. It's like a whole combination of factors. It doesn't feel like one thing anymore. It feels like a myriad of things.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs noted, suspensions and expulsions have many negative and intersecting impacts on students. This includes academic challenges resulting from missing school, social challenges resulting from isolation from peers, putting students further behind without an ability to catch up with their peers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTypically, the kids who are being suspended have academic issues. Now they're going to fall further behind, and they also typically have social emotional struggles. Maybe they don't have the skills yet of how to navigate things appropriately. So, they're definitely not going to learn that if they're out of school all the time.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNotably, suspensions and expulsions may be used to eliminate difficult situations for adults in the school environment. Rather than investing in longer-term, potentially more beneficial strategies to manage student behavior, students are instead removed from the school entirely:\u003c/p\u003e \u003cp\u003eIt does feel like to me, the suspensions are more about giving the adults breaks.\u003c/p\u003e \u003cp\u003eWhile this action may offer a temporary solution for adults in classroom spaces, the short- and long-term effects suspensions and expulsions have on students\u0026rsquo; mental health can be severe:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe've had those situations where it's like this kid, had something they weren't supposed to have at school, and they were going to get suspended for it, and then it turns into a mental health crisis.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAny potential \u0026ldquo;upsides\u0026rdquo; to these disciplinary actions are far outweighed by the need to protect and support the mental health needs of students.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTheme 4: Persistent systemic challenges place a significant burden on students and educators\u003c/span\u003e Students are not alone in experiencing stress in the school environment. In fact, teachers and administrators are also often overburdened and burned out, and this can undermine the ability for both students and educators to thrive in the school setting. The root cause of this distress is often systemic, sometimes stemming from the way the educational system is misaligned with the lived experiences of many students:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI don't think it's a school issue. I think it's a systemic issue. I think we are still educating students as if they come from the two-parent household, the house with the picket fence, the mom and dad who, and when you're trying to do one teacher to 20 kids with various learning levels, with housing insecurity.... It's a system, teachers are taught to teach that way. And we've been teaching their way since the early 1900s, probably the 1800s. You can look at pictures of classrooms over 200 years ago, and they still look the same. And I think, in some environments that may still work because those children\u0026hellip;have parents who are able to fill in those gaps when they're struggling\u0026hellip;And when you don't have somebody checking in for your homework, because mom works two, three jobs, you got to watch your siblings. You don't have time to study. Yeah, and that's just a huge disconnect. So then what happens is they continue to fall behind as they progress\u0026hellip;and they can't perform at a rate that is comparable to their peers, and in the world.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis quote highlights how \u0026ldquo;the system\u0026rdquo; is only working well for a select set of students with abundant out-of-school support, which are often not available for many. Similarly, teachers are faced with large classrooms of students with varying complex needs, limiting their ability to adequately meet these needs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think that people are very burnt out and very stressed. So, you\u0026rsquo;re sometimes not seeing people at their best. They\u0026rsquo;re [teachers are] dysregulated and we obviously know that kids need to co-regulate sometimes. I think that becomes a barrier to us being able to provide students quality socioemotional instruction.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe emotional states of students and educators are interconnected in the classroom setting, and burnout among educators can unintentionally hinder the learning of students. Students, and particularly those with developing social emotional skills, may rely on learning to manage emotions by interacting with regulated adults. When teachers are dysregulated, they may unintentionally model stress or frustration, making it harder for students to feel safe and supported.\u003c/p\u003e \u003cp\u003eSimilarly, systemic issues like the overburdening of school staff may result in ineffective intervention for students who express distress through externalizing behaviors, including disruption. These behaviors can be difficult to manage in environments where staff are under-resourced, and can sometimes lead to exclusionary discipline:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor students who externalize, it can be really challenging for staff who are already stretched thin. It escalates really quickly and then students end up suspended or expelled. I think we need better de-escalation skills.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis quote reflects a call for trauma-informed, restorative, and non-punitive approaches to behavior management in the school setting. Arguably, these approaches would benefit the long-term mental health of not only those students experiencing mental health challenges but may improve overall school climate as well.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe intent of this study was to use school records and interviews with key school staff members to characterize the relationship between school-related issues and suicide and to identify potential avenues for intervention to improve student mental health, which may ultimately prevent suicide. While there has been significant research examining the relationship between school discipline and mental health,(Duarte et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003eb) little research has specifically examined how school discipline may affect suicidal thoughts and behaviors. While our analyses did not reveal any significant associations between school issues preceding suicide and race or ethnicity, we did find that every decedent in our sample with a reported history of a suspension or expulsion that contributed to suicide was Black. Similarly, we found evidence of mental health and suicide-related disparities by race, as well as unequal access to mental health services and supports in our qualitative analysis.\u003c/p\u003e \u003cp\u003ePrior research has shown that school disciplinary policies have an impact on student mental health.(Perryman et al., n.d.; So et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) For example, in one study with Black high school students, researchers found that students who experienced in-school policing had greater levels of depression compared with students who did not experience school discipline or policing.(Perryman et al., n.d.) Additionally, punitive school discipline is associated with higher odds of depression, adjustment problems, and anti-social behaviors, particularly for Black students.(Duarte et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003eb) Despite the small sample and limited findings from the current study, our data suggest a need for continued research in this area to further understand school-related issues that may contribute to suicidal behaviors among youth and unpack racial disparities in school discipline and the effects on mental health, particularly suicide.\u003c/p\u003e \u003cp\u003eOur study also detailed the detrimental mental health, social, and academic impacts that suspensions and expulsions have on students. Importantly, as suspensions and expulsions primarily impacted Black students in our sample, the burden of the detrimental impacts of these actions also affects this minoritized group. Our qualitative data detail the social and structural barriers facing Black students in this school district, including high levels of violence and poverty. Staff noted that schools often lacked the resources needed to support students in these circumstances.\u003c/p\u003e \u003cp\u003eAs identified in our qualitative data, there is an urgent need for trauma-informed, restorative, and non-punitive approaches to behavior management in the school setting to support student mental health. Ultimately, policy and systems change approaches are needed to support Black youth both within the school setting and within the community. Policies and other strategies to decrease violence and other exposures to trauma in the community may result in the reduction of root cause-level stressors contributing to poor mental health among Black youth. School district-level policies that are specifically enumerated to protect Black students and other students of color from discriminatory and/or exclusionary discipline could be implemented as well. In addition, school-based programming, including training for educators and administrators on the detrimental mental health effects of exclusionary violence on Black students, is warranted. Additionally, current evidence-based school suicide prevention programming, including programs such as Sources of Strength,(Wyman et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) could be adapted to meet the unique needs of minoritized students to further support mental health. Universal suicide screening can also be implemented within schools to identify youth who are at risk for suicide without the need for those students to specifically seek help on their own. Finally, parents and caregivers play an important role in supporting the mental health of youth and in detecting potential thoughts of suicide or suicidal behavior. Programming, including education for parents and caregivers on how to identify signs of mental health challenges or suicide risk among youth, may improve early identification of youth in need of support, potentially enabling earlier access to appropriate services.\u003c/p\u003e \u003cp\u003eDespite the importance of this study\u0026rsquo;s findings, there are limitations. First, this study took place in a single urban school district with a limited sample size. Additional research is needed that examines the school-to-prison pipeline with a larger, more diverse sample of schools and students. Second, this study used retrospective student data. While the quantitative data provide important insights into school experiences, we were limited to using existing data. Prospective studies could capture a greater range of data from students and schools. Finally, qualitative data from students could provide needed context for how school discipline impacts student mental health and behaviors. Qualitative data from teachers could similarly provide needed insights into school needs, resources, and teacher decision-making around disciplinary referrals.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eYouth spend much of their time in the school environment, and as a result, school-based experiences can have a significant influence on their mental health and wellness. Research has demonstrated how disciplinary experiences, including suspensions and expulsions, can negatively impact student mental health, and as there are racial disparities in the disciplining of students, youth of color disproportionately bear the burden of the negative effects of school discipline. This is a social justice issue. To shift course and disrupt the \u0026ldquo;school-to-suicide pipeline\u0026rdquo;, innovative, public health-based strategies are necessary and should focus on policy and systems change to safeguard and improve the mental health of all youth, and particularly minoritized youth.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics Approval Declaration:\u003c/em\u003e All study activities were approved by the Institutional Review Board at the Medical College of Wisconsin (reference number PRO48705), and approval to obtain and utilize school and student-level data was obtained from the participating school district. All research was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eConsent to Participate Declaration:\u0026nbsp;\u003c/em\u003eHuman subjects research participants (e.g., interview participants) provided consent to participate. Research involving subjects under age 16 involved deceased individuals only, and therefore it was not practicable or possible to obtain informed consent. Similarly, the study team received de-identified data from our partnering school district, so it was not possible to obtain assent from parents of deceased youth subjects.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eFunding Statement:\u0026nbsp;\u003c/em\u003eThis study was funded through a seed grant from the Comprehensive Injury Center at the Medical College of Wisconsin.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrmiston CK, Lawrence WR, Sulley S, et al. Trends in Adolescent Suicide by Method in the US, 1999\u0026ndash;2020. 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Pushed Out and Drawn In: Exclusionary Discipline, Mental Health, and Protective Factors Among Youth in Public Schools. J Sch Health. 2024;94(2):128\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/josh.13405\u003c/span\u003e\u003cspan address=\"10.1111/josh.13405\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerryman C, Platt S, Montiel Ishino F. \u003cem\u003eIdentifying the Mental Health Profiles of Black Adolescents Who Experience School Policing and School Discipline: A Person-Centered Approach\u003c/em\u003e. www.jaacap.org.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWyman PA, Brown CH, LoMurray M, et al. An outcome evaluation of the sources of strength suicide prevention program delivered by adolescent peer leaders in high schools. Am J Public Health. 2010;100(9):1653\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2009.190025\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2009.190025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Suicide prevention, exclusionary discipline, public health, school psychologists","lastPublishedDoi":"10.21203/rs.3.rs-9370524/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9370524/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Suicide among Black youth is a public health concern. \"Being Black\u0026rdquo; is not a risk factor for suicide; rather, sociocultural factors and social determinants of health influence suicidal behavior among Black youth. Factors related to the school environment are critical in understanding and preventing this loss of life. The purpose of this multiple-method study was to examine the historical prevalence of school interventions among Black students who went on to die by suicide in our study setting and assess the availability of mental health resources and support available to school personnel to support Black students.\u003c/p\u003e \u003cp\u003eMethods: We gathered school records from all county residents who died by suicide during the ten years from 2013 through 2022. We also conducted semi-structured key informant interviews with school district psychologists and social workers.\u003c/p\u003e \u003cp\u003eResults: A total of 293 suicide decedents were included, most of whom were Black/African American. School issues were a contributing factor to suicide for several decedents. Four qualitative themes were developed, highlighting the impact of school-based factors, and particularly exclusionary discipline, on the mental health of students.\u003c/p\u003e \u003cp\u003eImplications: There is an urgent need for trauma-informed, restorative, and non-punitive approaches behavioral issues in school, particularly for minoritized students.\u003c/p\u003e","manuscriptTitle":"A Multiple-Methods Exploration of the \"School-to-Suicide Pipeline\"","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-25 00:45:17","doi":"10.21203/rs.3.rs-9370524/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-08T07:49:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T15:04:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134235481144128535131536707473186372630","date":"2026-05-07T13:02:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T09:50:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300193696003079156521879204747033147647","date":"2026-05-06T17:32:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118028226911554552107155278681242850625","date":"2026-04-23T15:42:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-17T14:40:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-17T14:18:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-16T13:50:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-15T15:21:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-15T15:10:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec4d363b-b96e-48c8-aed4-b4b87bb5ed71","owner":[],"postedDate":"April 25th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-08T07:49:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T15:04:44+00:00","index":58,"fulltext":""},{"type":"reviewerAgreed","content":"134235481144128535131536707473186372630","date":"2026-05-07T13:02:17+00:00","index":57,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T09:50:02+00:00","index":52,"fulltext":""},{"type":"reviewerAgreed","content":"300193696003079156521879204747033147647","date":"2026-05-06T17:32:23+00:00","index":51,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T15:38:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-25 00:45:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9370524","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9370524","identity":"rs-9370524","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}