Can the Zero Suicide Framework be Applied to a Youth-Serving Behavioral Health System of Care?: Lessons Learned from a Statewide Implementation

The US is in the midst of a youth mental health crisis with rates of youth suicide rising 62% between 2007 and 2021. In 2023, the CDC reported 22% of high schoolers seriously considered suicide in the last year. Zero Suicide (ZS) is an evidence-based, suicide prevention model focused on creating organizational policies that help providers put an intentional focus on suicide prevention in their service delivery. Predominantly implemented in clinical care settings, the ZS framework has been shown to significantly decrease risk for repeated suicide attempts and positively impact organizations’ comfort and knowledge in suicide prevention within adult-serving, clinical settings. In 2022, New Jersey’s Department of Children and Families’ Children’s System of Care (CSOC) began integrating the ZS framework in a new context: one that serves youth within a public behavioral health system. We conducted a pilot evaluation of ZS’s implementation by CSOC to identify barriers, challenges and needed supports for integrating the ZS framework, specifically within primarily non-clinical, youth-serving, behavioral health programs.

The pilot implementation included 36 children’s behavioral health agencies with service reach across all 21 counties in NJ, including care management, family support, and out of home youth residential programs. An explanatory, sequential, mixed methods study that included quantitative analysis of a satisfaction survey and validated ZS survey instruments, as well as qualitative analysis of focus groups to interpret findings, was conducted. Baseline and follow-up validated assessments were used to measure organization and staff readiness to enact suicide prevention strategies. Focus groups with both frontline and leadership staff were conducted to better understand barriers and facilitators to implementing the ZS framework in this novel setting.

Quantitative data revealed 94% of providers felt more confident and competent addressing suicide with clients because of the ZS framework, with 72% believing their organization experienced a culture shift. While previous studies have shown adult-serving providers often report strong comprehensive suicide safety planning protocols, only 6% of responding providers in our study reported having strong practices in place related to safety planning and lethal means restriction. In focus groups, providers noted that specific, translational challenges arose within the youth-serving context, such as balancing both the youth and caregivers in care plans and decisions (e.g., needing family buy-in, navigating culturally specific suicide-related stigma, and providing resources like parent support groups). To adapt this framework to a statewide, public behavioral health system, focus groups also revealed support was needed to create more standardized processes within the network (e.g., creating more cohesion in hospital and crisis center triage and referral).

Zero Suicide is a promising model for preventing suicide within youth-serving behavioral health settings. When expanding the model to these settings, consideration should be given to family context, standardization of processes, and adaptation of risk reduction models. The context of this evaluation allowed DCF policymakers to measure organizational readiness, while giving providers opportunities to share areas of need in a collaborative approach to evaluation. We are continuing to measure the long-term outcomes of this program on reducing overall youth suicide risk, attempts and deaths.