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BMC Public Health

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Research article

Evaluating the SOS suicide prevention program: a replication and
extension
Robert H Aseltine Jr*1, Amy James1, Elizabeth A Schilling1 and
Jaime Glanovsky2
Address: 1Division of Behavioral Sciences and Community Health, University of Connecticut Health Center and Institute for Public Health
Research, University of Connecticut, 99 Ash Street, MC 7160, East Hartford, Connecticut, 06108, USA and 2Department of Statistics and Institute
for Public Health Research, University of Connecticut, 99 Ash Street, MC 7160, East Hartford, Connecticut, 06108, USA
Email: Robert H Aseltine* - [email protected]; Amy James - [email protected]; Elizabeth A Schilling - [email protected];
Jaime Glanovsky - [email protected]
* Corresponding author

Published: 18 July 2007
BMC Public Health 2007, 7:161

doi:10.1186/1471-2458-7-161

Received: 2 October 2006
Accepted: 18 July 2007

This article is available from: http://www.biomedcentral.com/1471-2458/7/161
© 2007 Aseltine et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Suicide is a leading cause of death for children and youth in the United States.
Although school based programs have been the principal vehicle for youth suicide prevention
efforts for over two decades, few have been systematically evaluated. This study examined the
effectiveness of the Signs of Suicide (SOS) prevention program in reducing suicidal behavior.
Methods: 4133 students in 9 high schools in Columbus, Georgia, western Massachusetts, and
Hartford, Connecticut were randomly assigned to intervention and control groups during the
2001–02 and 2002–03 school years. Self-administered questionnaires were completed by students
in both groups approximately 3 months after program implementation.
Results: Significantly lower rates of suicide attempts and greater knowledge and more adaptive
attitudes about depression and suicide were observed among students in the intervention group.
Students' race/ethnicity, grade, and gender did not alter the impact of the intervention on any of
the outcomes assessed in this analysis.
Conclusion: This study has confirmed preliminary analysis of Year 1 data with a larger and more
racially and socio-economically diverse sample. SOS continues to be the only universal school-based
suicide prevention program to demonstrate significant effects of self-reported suicide attempts in
a study utilizing a randomized experimental design. Moreover, the beneficial effects of SOS were
observed among high school-aged youth from diverse racial/ethnic backgrounds, highlighting the
program's utility as a universal prevention program.
Trial registration: clinicaltrials.gov NCT000387855.

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Background

Methods

Suicide among young people is one of the most serious
public health problems facing the United States. According to the National Center for Health Statistics, in 2003
the suicide rate was 7.3 per 100,000 among youth aged
15–19, making it the third leading cause of death among
adolescents [1,2]. Rates of completed suicides, however,
mask the actual extent of suicidal behavior among young
people. Major epidemiologic studies conducted over the
past decade in the US and Canada indicate that thoughts
about suicide over the past year have been reported by
17–24% of youth, with actual suicide attempts in the past
year reported by 5–10% [3,4]. In the year 2000, 32,655
patients aged 10–19 years were admitted to US hospitals
as a result of suicide attempts [5].

The intervention
SOS is a school-based prevention program developed by
Screening for Mental Health, Inc., a non-profit organization in Wellesley, Massachusetts. Fifteen national organizations specializing in youth mental health and suicide
prevention serve as sponsors of the SOS program, including the American School Counselor Association, National
Association of School Psychologists, National Association
of Secondary School Principals, and the National Association of Social Workers. SOS incorporates two prominent
suicide prevention strategies into a single program, combining a curriculum that aims to raise awareness of suicide
and its related issues with a brief screening for depression
and other risk factors associated with suicidal behavior.
The program focuses in particular on two of the most
prominent risk factors for suicidal behavior: underlying
mental illness, particularly depression, and problematic
use of alcohol. In the didactic component of the program,
SOS promotes the concept that suicide is directly related
to mental illness, typically depression, and that it is not a
normal reaction to stress or emotional upset [13]. The
basic goal of the program is to teach high school students
to respond to signs of suicide in themselves and others as
an emergency, much as one would react to signs of a heart
attack. Youths are taught to recognize the signs and symptoms of suicide and depression and to follow the specific
action steps needed to respond to those signs. The objective is to make the action step – ACT – as instinctual a
response as the Heimlich maneuver and as familiar an
acronym as "CPR." ACT stands for Acknowledge, Care,
and Tell. First, ACKNOWLEDGE the signs of suicide that
others display and take them seriously. Next, let that person know you CARE about him or her and that you want
to help. Then, TELL a responsible adult.

In response to this problem, a number of diverse
approaches to suicide prevention have been introduced
into high school curricula in the past 20 years. Few, however, have been subjected to rigorous evaluation, and
those that have been scientifically evaluated have had limited impact, with the benefits of such programs largely
confined to temporary improvements in knowledge and
more adaptive attitudes about depression and suicidal
behavior [6-9]. To date the only universal prevention program to curtail suicidal behavior in a randomized study is
Signs of Suicide (SOS), a program developed by the creators of National Depression Screening Day. Based on evidence from the first year of a 2 year study involving over
2100 students in 5 schools [10], the SOS program was
added to SAMHSA's National Registry of Effective Programs (NREP) and has been widely adopted, with 675
schools across the country implementing SOS during the
2004–05 school year. Findings regarding the benefits of
SOS were bolstered by a recent randomized trial that
found no evidence of iatrogenic effects of a similar suicide
screening program [11], thus allaying longstanding concerns about the potential negative effects of suicide prevention programs on emotionally vulnerable youth [12].
This article augments our previous evaluation of the SOS
program by including data from the second year of the
study and expanding the analysis to examine whether the
efficacy of the program varies among different types of
students. The study was conducted during the 2001–2002
and 2002–2003 school years and involved 4133 students
in 213 classrooms in 9 high schools in Hartford, Connecticut, western Massachusetts, and Columbus, Georgia.
The recruitment of schools from suburban communities
in western Massachusetts in Year 2 added a substantial
number of White, middle-class youth to sample. The primary goal of this outcome evaluation was to assess the
short-term impact of the program on suicidal behavior,
knowledge of and attitudes toward depression and suicide, and help-seeking in a diverse student population.

The SOS program has been described in detail in previous
publications [10,14]. Briefly, the program contains two
major components. The first component is a set of teaching materials that include a video, Friends for Life, and a
discussion guide. The video includes dramatizations
depicting the signs of suicidality and depression, recommended ways to react to someone who is depressed and
suicidal, as well as interviews with real people whose lives
have been touched by suicide. The second component is a
screening instrument that is used to assess the potential
risk of depression and suicidality. In the first year of this
study the Columbia Depression Scale (CDS), a 22-item
scale derived from the Diagnostic Interview Schedule for
Children IV [15], served as the screening tool. In second
year the CDS was replaced with the Brief Screen for Adolescent Depression (BSAD) [16], a shortened version of
this screening tool that was also derived from the DISC IV.
The screening forms were completed anonymously and
scored by the students themselves; a score of 16 or higher

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on the CDS or 4 or higher on the BSAD was considered a
strong indicator of clinical depression and students with
such scores were encouraged to seek help immediately
from a teacher or counselor, or to approach a trusted adult
outside of school. The anonymity of the screening process
precluded further evaluation or follow-up of those scoring
above the 'at risk' threshold, but the privacy it afforded
was considered critical to ensuring an honest assessment
of symptoms. Because the screening tools were used exclusively for self-evaluation and were not used to provide
baseline data on depression or suicidality, the change in
screening forms from year 1 to year 2 would not be
expected to have an impact on our analysis.
Study design
The experimental design consisted of randomized treatment and control groups and posttest-only data collection. In 8 of the 9 participating schools, students were
randomly assigned to health classes (Hartford and western Massachusetts) and social studies classes (Columbus)
by a computerized scheduling program. (In year 2, only
ninth-grade classes were eligible to participate in the
Columbus and Hartford sites, because all other grades
had received the program during the previous year.)
Because the semester in which students were assigned to
these half-year classes was determined randomly, all students who took these classes during the first half of the
school year were assigned to the treatment group and participated in the program over a 2-day period from October
through November. Students who took these classes during the second half of the school year were assigned to the
control group and did not participate in the program until
after the evaluation was completed. The single exception
was a technical-vocational high school in Hartford, where
students were clustered in health classes according to their
major area of study and where class composition did not
change at midyear. For this school, random assignment of
classes to both the intervention and the control conditions was achieved by flipping a coin.

Students in both the treatment and the control groups
were asked to complete a short questionnaire in a group
setting during class time approximately 3 months after
implementation of the program. Trained interviewers
from the University of Connecticut's Center for Survey
Research and Analysis and Columbus State University
read aloud the questions to each class, and students
recorded their confidential written responses on anonymous questionnaires. Because all data were collected
anonymously, a waiver of informed consent was obtained
from the University of Connecticut Health Center's Institutional Review Board, which approved all procedures
used in this study. Parents were notified in writing about
the objectives of the study and were invited to contact
their respective schools or the principal investigator

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(RHA) to ask questions or to withdraw their child from
the study. Questionnaires were completed by 4133 of the
4491 students eligible for the study (n = 2094 for the control group, n = 2039 for the treatment group), which
resulted in an overall response rate of 92%. Virtually all
non-response was due to absences from school as
opposed to parental refusal.
As indicated by the demographic profile of the sample
(Table 1), these schools provided a racially mixed and
economically diverse sample of youths. The addition of
schools in western Massachusetts in Year 2 resulted in a
substantial increase in the number of White, suburban
youth in the sample. Preliminary analyses were conducted
to assess the comparability of the intervention group and
control group in terms of gender, race/ethnicity, and
grade. Chi-square tests revealed no differences in the composition of intervention and control groups for any of
these characteristics.
Measures and instruments
The questionnaire included items relevant to 3 specific
categories of outcome: (1) self-reported suicidal ideation
and suicide attempts, (2) knowledge and attitudes about
depression and suicide, and (3) help-seeking behavior.
The primary endpoint for our study was a single-item
measure of self-reported suicide attempts taken from the
Centers for Disease Control and Prevention's (CDC)
Youth Risk Behavior Survey (YRBS): "During the past 3
months, did you actually attempt suicide (yes or no) [4]?"
Suicidal ideation also was assessed with a question taken
from the YRBS: "During the past 3 months, did you ever
seriously consider attempting suicide (yes or no)?"

The measures of knowledge and attitudes about depression and suicide were adapted from instruments previously used to evaluate school-based suicide prevention
programs [6,7,10]. Knowledge of depression and suicide
was measured with 10 true/false items that reflect the central themes of the SOS program (e.g., "People who talk
about suicide don't really kill themselves"; "Depression is
an illness that doctors can treat"). Scores on this variable
reflected the number of correct answers. The measure of
attitudes toward depression and suicide was an 8-item
summary scale that assessed attitudes toward suicidal people and suicidal behaviors (e.g., "If someone really wants
to kill him/herself, there is not much I can do about it"; "If
a friend told me he/she is thinking about committing suicide, I would keep it to myself"). Responses to these questions ranged from "strongly disagree" to "strongly agree"
on a 5-point scale, with higher values indicating more
adaptive attitudes about depression and suicide (Cronbach α = .74).

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Table 1: Demographic characteristics of the sample by location

Percent (%)

Race/Ethnicity
White, non-Hispanic
Black, non-Hispanic
Hispanic
Multiethnic
Other
Gender
Male
Female
Grade
Freshman
Sophomore
Junior
Senior
Wave
1 – 2002
2 – 2003

Hartford, CT

Columbus, GA

Massachusetts

5.8
27.2
50.6
8.5
8.6
100% (n = 2635)

38.5
36.5
8.1
12.4
4.6
100% (n = 665)

82.1
0.8
6.0
5.5
7.8
100% (n = 761)

48.7
51.3
100% (n = 2632)

51.6
48.4
100% (n = 659)

52.5
57.5
100% (n = 761)

45.5
22.6
15.5
16.3
100% (n = 2593)

100.0
0.0
0.0
0.0
100% (n = 665)

65.6
26.3
5.7
2.4
100% (n = 752)

53.0
47.0
100% (n = 2707)

100.0
0.0
100% (n = 665)

0.0
100.0
100% (n = 761)

Three questions were used to assess help-seeking behavior. Students were asked whether in the past 3 months, " .
. . you received treatment from a psychiatrist, psychologist, or social worker because you were feeling depressed
or suicidal (yes or no)"; whether ". . . you talked to some
other adult (like a parent, teacher or guidance counselor)
because you were feeling depressed or suicidal (yes or
no)"; and whether ". . . you talked to an adult about a
friend you thought was feeling depressed or suicidal (yes
or no)."
Participants who had missing values on any variable in a
particular analysis were excluded from that analysis.
Although 130 youths assigned to the treatment group did
not participate in either of the central elements of the program–the video and depression screening–mainly
because of absences from school, they were retained in the
analysis so that we could estimate intention-to-treat
effects. After exclusions for missing data, the effective sample size for these analyses ranged from 3,837 to 3,899.
Descriptive statistics for all dependent variables used in
this analysis are shown separately by intervention status
in Table 2.

Results
To account for the clustered sampling design in which students were nested within classrooms, we used SUDAAN
9.0.1 software [17] to perform regression analyses of intervention effects. SUDAAN was developed to address the
complicated variance estimation required in the analysis

of data obtained using complex sampling designs, including cluster-correlated data. In our analysis, the effect of
exposure to the intervention on the four outcomes in the
following three months (Y) was estimated with the following model:
Y = B0 + B1–9Controls1–9 + B10G1
where G1 is a dummy variable for intervention status; and
Controls1–9 refers to those variables that were significantly
related to suicide attempts in preliminary analysis. Controls included dummy variables for race/ethnicity (nonHispanic Black, Hispanic, multiethnic, and Other race vs.
non-Hispanic White), gender (female vs. male), grade
(10, 11, and 12 vs. 9), and study wave (2003 vs. 2002).
The effects of the SOS program on students' knowledge of
and attitudes toward depression and suicide, help-seeking
behavior, suicidal ideation, and self-reported suicide
attempts are shown in Table 3. For the analysis of attitudes
and knowledge, this table shows coefficients from a standard regression model; for suicidal ideation, suicide
attempts, and help-seeking behavior, coefficients are
derived from logistic regression models. The second row
in Table 3 shows the effects of exposure to the SOS program on the various outcome measures included in our
study. First and most important, the coefficients shown in
column 1 of Table 3 indicate that exposure to the SOS program was associated with significantly fewer self-reported
suicide attempts. The coefficient for the effect of the SOS

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Table 2: Descriptive characteristics of measures of suicidal behavior, knowledge, and attitudes

Treated for depression/suicidal ideation, %
Talked with adult about depression/suicidal ideation, %
Talked with adult about friends' emotional problems, %
Suicidal ideation during past three months, %
Suicide attempt during past three months, %
Knowledge of depression/suicide, mean (SD)
Attitudes toward depression/suicide, mean (SD)

Control (n = 2094)

Treatment (n = 2039)

Total Sample (N = 4133)

Valid N

9.6
19.5
12.4
11.5
4.5
4.36(1.44)
3.83(0.64)

9.3
18.4
12.8
10.1
3.0
5.00(1.41)
3.99(0.64)

9.4
18.9
12.6
10.8
3.8
4.68(1.46)
3.91(0.65)

4024
4026
4044
4036
4042
4029
4044

program on attempts is -.47, which when converted to an
odds ratio (OR) indicates that the youths in the treatment
group were approximately 40% less likely to report a suicide attempt in the past 3 months compared with youths
in the control group (OR = e-.47 = 0.63). This equates to a
3 month rate of suicide attempts in the SOS group of
3.0%, compared to 4.6% among controls.
Similarly, exposure to the SOS program resulted in greater
knowledge of depression and suicide and more adaptive
attitudes toward these problems (Table 3, columns 3 and
4). The effects of the SOS program on knowledge and attitudes were modest in magnitude and resulted in effect
sizes of one quarter to one third of a standard deviation
(e.g., attitudes: ES = .16/.65 = .25). The effects of the SOS
program on both attitudes and knowledge remained statistically significant when Holm adjustments were applied
to correct for multiple tests that involved these secondary
endpoints [18,19]. In contrast, the effects of the SOS program on suicidal ideation and help-seeking behavior did
not achieve statistical significance.
Finally, modest differences in the outcomes by students'
demographic characteristics were observed. For example,
the positive gender coefficients in Table 3 indicate that
girls have higher rates of suicidal ideation and suicide

attempts than boys, greater knowledge of and more adaptive attitudes toward suicide and depression, and higher
rates of help-seeking. Significant race differences were also
observed, mainly involving contrasts between Blacks and
students in the Other category and Whites, with these
effects consisting of lower rates of ideation and attempts
but also less knowledge of suicide and depression among
students in the first 2 categories. Notable age or grade
trends were confined to the knowledge measure and
favored older students, and base rates of suicide attempts,
help-seeking from adults, and knowledge of depression
differed by study wave (e.g., the WAVE coefficient).
Because of changes in the schools participating in the
study in year 2, this effect should be interpreted as an indicator of sample composition rather than a reflection of
actual changes in students' attitudes or behavior over this
short period of time.
Differences in intervention effects by students'
demographic characteristics
To examine whether the impact of the intervention varied
among different types of students, a series of conditional
models containing product terms capturing the interaction between exposure to SOS and students' race/ethnicity, sex, and grade were estimated for all seven outcome
measures in Table 3. Interactions were initially estimated

Table 3: Effects of SOS program on students' knowledge of and attitudes toward depression and suicide, help seeking, and suicidal
ideation and suicide attempts

Intercept
SOS Program
Female
Hispanic
Black
Multiracial
Other Race
Sophomore
Junior
Senior
Wave

Attempts

Ideation

Knowledge

Attitudes

Help Seeking
Treatment

Help Seeking
Adult

Help Seeking
Adult/Friend

B

SE

B

SE

B

SE

B

SE

B

SE

B

SE

B

SE

-3.17*
-0.47*
1.05*
0.01
-1.44*
0.13
-0.91*
-0.21
-0.37
-0.31
-0.42*

0.21
0.16
0.22
0.18
0.31
0.31
0.46
0.22
0.32
0.34
0.16

-2.17*
-0.17
0.80*
-0.10
-0.95*
0.17
-0.72*
0.01
-0.41*
-0.15
-0.04

0.14
0.10
0.12
0.12
0.16
0.17
0.26
0.13
0.20
0.18
0.11

4.52*
0.59*
0.24*
-0.63*
-0.54*
-0.38*
-0.49*
0.15*
0.13
0.22*
0.33*

0.06
0.05
0.04
0.06
0.06
0.08
0.09
0.06
0.07
0.07
0.05

3.80*
0.16*
0.12*
0.02
-0.01
-0.06
-0.05
-0.08*
0.03
0.04
-0.01

0.03
0.03
0.02
0.03
0.03
0.04
0.05
0.03
0.04
0.04
0.03

-2.29*
-0.01
0.33*
-0.18
-0.36
0.05
-0.21
-0.10
-0.18
0.04
0.12

0.15
0.12
0.12
0.14
0.18
0.21
0.23
0.16
0.22
0.18
0.12

-1.72*
-0.04
0.61*
-0.09
-0.27*
0.16
-0.25
-0.33*
0.00
-0.15
0.30*

0.11
0.08
0.11
0.10
0.11
0.14
0.17
0.12
0.14
0.14
0.08

-2.14*
0.01
0.52*
0.01
-0.27
-0.12*
-0.54
-0.10
0.01
-0.01
0.11

0.14
0.10
0.11
0.12
0.14
0.19
0.24
0.13
0.16
0.16
0.09

*p < .05
Note: P-values for intervention effects range from .0000 for knowledge and attitudes about suicide to .0075 for attempts.

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in separate models and subsequently aggregated into a
single model for each outcome containing all possible
intervention * demographic terms. None of the interaction terms achieved statistical significance at the .05 level.
However, it is possible that the failure to detect significant
conditional effects is due to inadequate statistical power
rather than the absence of substantively meaningful differences in response to the intervention. Although the
effects of the program on suicidal ideation and help-seeking were relatively weak, effect sizes for the impact of SOS
on attitudes, knowledge, and suicide attempts were modest, ranging between .25 and .40 in magnitude. Based on
these effect sizes, the power to detect significant interaction effects was calculated to exceed .90 in a sample of
4133 with 213 classrooms using software that accounts
for the interdependence of observations in cluster randomized designs [20]. Consequently we conclude that the
failure to observe differences in program effects among
different types of students is not attributable to insufficient statistical power for these analyses.

Discussion
This analysis of data from a two year study of 9 schools
implementing the SOS suicide prevention program confirms and expands Year 1 results that demonstrated the
program's efficacy in an urban, economically disadvantaged sample of youth [10]. The present analysis, which is
based on a more socially, economically, and geographically diverse group of high school students, found SOS to
be associated with significantly greater knowledge, more
adaptive attitudes about depression and suicide, and most
importantly, significantly fewer suicide attempts among
intervention youths relative to untreated controls 3
months post-intervention. The magnitude of intervention
effects in this more diverse group of students was virtually
identical to those reported in the Year 1 results. Moreover,
the addition of Year 2 data to the analysis, resulting in a
sample of over 4100 youths, provided greater statistical
power to examine whether the impact of the SOS program
is consistent across youths varying in race and ethnicity,
gender, and age. These results clearly indicate that the program has broad-based efficacy among high school students of different ages, races and ethnic backgrounds, and
for both boys and girls. Furthermore, these results are consistent with findings from previous studies demonstrating
the effectiveness of curriculum-based programs in
improving knowledge and fostering more favorable attitudes about depression and suicide [6-9].
In contrast to the impact of the program on knowledge,
attitudes, and suicidal behavior, SOS was not associated
with increased help-seeking among emotionally troubled
youth. This finding was also observed in our analysis of
Year 1 data and was attributed to the composition of the
sample given the numerous barriers to help-seeking in

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urban schools containing large numbers of disadvantaged
youth (e.g., staff shortages; poor visibility of mental
health resources; students' wariness of confiding in mandated reporters given past contact with social services). We
hypothesized that these barriers would be lessened
among youth from more suburban, middle-class districts
and expected their inclusion in the Year 2 sample to produce positive results, but a separate analysis of the impact
of SOS on help-seeking among students in the western
Massachusetts districts did not reveal any program effects
on help seeking. This issue merits further investigation
given previously published data from school counselors
indicating as much as a three-fold increase in the number
of students seeking counseling for depression and suicidality following exposure to SOS [14]. It is possible that the
conflicting data on help-seeking reflects a study design
issue, as the assignment of classrooms, not schools, to
experimental conditions raises the possibility that the
control group became contaminated by the intervention.
The focus of the SOS program makes this a very real possibility: Because youths are encouraged to "ACT" on
behalf of a troubled friend, participants in the control
groups may have sought help for emotional problems due
to their exposure to friends who had participated in the
program. If this is the case, a study design that assigns
schools to experimental conditions is more likely to produce student reports of help-seeking following exposure
to SOS that are more consistent with those reported by
school counselors.
The contributions of this study must be considered in
light of other limitations in addition to the design issues
raised above. The effects of this program were observed
over a very short post-intervention period. A longer term
follow-up of youths exposed to the SOS program is necessary to determine whether the observed effects are enduring. Second, pretest measures of the outcomes assessed in
this study would add confidence that the assignment of
classes to experimental conditions resulted in equivalent
groups, and would also allow for comparisons over time
within the experimental group to quantify the magnitude
of changes in attitudes and behavior that could be attributed to SOS. It should be noted, however, that previous
evaluations of suicide prevention programs in which a
Solomon four group design was employed to assess the
impact of pretest assessments on outcomes at posttest
found no impact of the pretest on measures of knowledge
and attitudes [9]. Finally, readers may question whether
our results are tainted by response bias, particularly the
desire of those exposed to the program to provide what
they perceive to be the "right answers" or the answers
desired by the investigators when responding to survey
questions about their attitudes and behavior. However,
suicide prevention programs have historically demonstrated very little in the way of efficacy, suggesting that

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previous research has not been plagued by this type of
response bias. There was nothing unique about this sample that would have lead students to have done so here.

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8.

9.

Conclusion
This replication and extension of our 2004 analysis [10]
provides confirmation that the SOS program is a potent
tool for curtailing suicidal behavior among diverse groups
of high school-aged youth in the United States. SOS continues to be the only universal school-based suicide prevention program for which a reduction in self-reported
suicide attempts has been documented with a randomized experimental design. As such it merits serious
consideration from teachers, school counselors, and
administrators seeking to bolster their school's health curricula and prevention portfolio.

10.
11.

12.

13.

14.

Competing interests
The author(s) declare that they have no competing interests.

15.

Authors' contributions

16.

RA conceived of the study and was responsible for writing
the manuscript; AJ supervised data collection and management and contributed to writing and revising the manuscript; ES supervised the analysis and contributed to
writing and revising the manuscript; JG conducted the
analysis.

17.
18.
19.

Acknowledgements
Support for this project was provided by the Center for Mental Health
Services/Substance Abuse and Mental Health Services Administration and
by a grant from the Robert Leet and Clara Guthrie Patterson Trust. We
would like to thank Barbara Kopans, Gene Wallenstein, Sharon Pigeon,
Christopher Lynch and the teachers and staffs at the participating schools
for assistance in carrying out this study.

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