628 Suicide and Life-Threatening Behavior 40(6) December 2010

2010 The American Association of Suicidology

Adolescent Help-Seeking and the Yellow

Ribbon Suicide Prevention Program:
An Evaluation
Stacey Freedenthal, PhD

The Yellow Ribbon Suicide Prevention Program has gained national and
international recognition for its school- and community-based activities. After the
introduction of Yellow Ribbon to a Denver-area high school, staff and adolescents
were surveyed to determine if help-seeking behavior had increased. Using a pre-
post intervention design, staff at an experimental school and comparison school
were surveyed about their experiences with student help-seeking. Additionally,
146 students at the experimental high school were surveyed. Staff did not report
any increase in student help-seeking, and students reports of help-seeking from
11 of 12 different types of helpers did not increase; the exception was help-seeking
from a crisis hotline, which increased from 2.1% to 6.9%. Further research with
larger, more inclusive samples is needed to determine whether Yellow Ribbon is
effective in other locations.

It is well-known that adolescent suicidal be-
havior imposes substantial social and finan-
cial burdens on individuals and communities
(Corso, Mercy, Simon, Finkelstein, & Miller,
2007; ODea & Tucker, 2005). Suicide is the
third leading cause of death for adolescents
ages 12 to 19 (Centers for Disease Control
and Prevention, 2007). Suicide attempts and
Stacey Freedenthal is Associate Profes-
sor in the Graduate School of Social Work at the
University of Denver.
This study was supported by the State of
Colorado Department of Public Health and Envi-
ronment, Office of Suicide Prevention. The find-
ings were originally reported in a paper presented
in April 2009 in San Francisco, CA, at the 42nd
American Association of Suicidology Annual Con-
ference. The author would like to thank Jarrod
Hindman, MS, Program Manager of the Office of
Suicide Prevention for the State of Colorado, for
his support.
Address correspondence to Stacey Free-
denthal, PhD, Graduate School of Social Work,
University of Denver, 2148 S. High St., Denver,
CO 80208; E-mail: Stacey.Freedenthal@du.edu
suicidal ideation are even more common.
Nationally, 14.5% of high school students se-
riously considered suicide in 2007, and 6.9%
made an attempt (Eaton et al., 2008). Along
with death and injuries, another potential
consequence of youth suicidal behavior is
contagion, as adolescents appear particularly
susceptible to imitating the suicidal behavior
of their peers (Gould, Jamieson, & Romer,
2003).
Research suggests that most suicidal
youth do not receive mental health care (Far-
and, Renaud, & Chagnon, 2004; Freeden-
thal, 2007) or even tell an adult about their
suicidal thoughts or behaviors (Freedenthal
& Gutierrez, 2007; Negron, Piacentini, Graae,
Davies, & Shaffer, 1997). Instead of telling
an adult, adolescents more often confide in
friends, who in turn rarely tell an adult when
a friend discloses suicidal thoughts or behav-
ior to them (Dunham, 2004; Kalafat & Elias,
1992). Numerous explanations can account
for the reluctance of high school students to
seek help from an adult. Cigularov, Chen,
Freedenthal
and Thurber (2008) surveyed 854 students
after the implementation of a suicide preven-
tion program and found that barriers to help-
seeking include a strong sense of self-reli-
ance; fears of psychiatric hospitalization;
uncertainty about how to talk with ones par-
ents, teachers, or school counselors about
problems; and a dearth of adults at school
with whom the student feels close. Instead of
confiding in an adult, adolescents at risk for
suicide often use harmful coping methods,
such as isolation and drug use (Gould et al.,
2004). When it comes to seeking help from
an adult for a troubled friend, adolescents
may fear angering the friend, causing the
friend to be hospitalized, or simply misread-
ing the situation (Cigularov et al., 2008).
Many adolescents also fear adults reactions,
in particular perceived overreactions (Freeden-
thal & Breslin, 2008).
In recent years, an increasing number
of suicide prevention measures has been tar-
geted at adolescents in schools. School-based
prevention programs hold particular promise
because teachers and other school staff can
serve as gatekeepers or gateway provid-
ers, spotting students who seem to be in tur-
moil and referring them to mental health ser-
vices (Stiffman, Pescosolido, & Cabassa, 2004;
U.S. Dept. of Health and Human Services,
2001). Most youth who receive mental health
services first receive them at school (Farmer,
Burns, Phillips, Angold, & Costello, 2003),
reinforcing the importance of school-based
programs.
A Colorado-based group, the Yellow
Ribbon Suicide Prevention Program (www.
yellowribbon.org), has gained national and
international stature for its school- and com-
munity-based activities. The group was
formed by Dale and Dar Emme in 1994,
after the suicide of their 17-year-old son
Mike. Yellow Ribbon programming includes
schoolwide assemblies, peer leadership train-
ing for students, staff training for adult gate-
keepers such as high school teachers, com-
munity presentations, and local chapters that
provide outreach and education. Yellow Rib-
bon programming includes distribution of
the Ask4Help card, which contains suicide
629
hotline numbers, instructions to youth to
give the card to somebody who can help, and
directions to potential helpers on how to
proceed. The overriding messages of the Yel-
low Ribbon programming are that youth
should tell an adult if somebody they know is
suicidal (Be a link) and seek help for them-
selves when necessary (Its OK to ask for
help).
Anecdotally, there are numerous re-
ports of Yellow Ribbons success. The pro-
grams Web site states that through the
efforts of the Yellow Ribbon Suicide Preven-
tion Program more than 2,500 lives have
been saved (retrieved April 14, 2009, from
www.yellowribbon.org/Lflstats.html). Accord-
ing to their Web site, some aspect of the Yel-
low Ribbon program has been adopted by all
states in the United States, all provinces in
Canada, and 47 other countries worldwide.
However, reports about Yellow Rib-
bons effectiveness have remained anecdotal.
A search of numerous databases, including
PsycInfo and Google Scholar, yielded no
published research reporting a systematic
study of the programs effectiveness at in-
creasing adolescents help-seeking behaviors.
The only reports located about the Yellow
Ribbon program were purely descriptive
(Omni Research and Training, 2003), pro-
vided only anecdotal information (Leahy,
2004), or addressed mainly attitudes toward
Yellow Ribbon and student help-seeking
(Bennett, 2003).
This pilot study sought to evaluate the
effectiveness of the Yellow Ribbon Suicide
Prevention Program at a Denver-area high
school. The outcome variablethe action
that Yellow Ribbon was hypothesized to posi-
tively affectwas student help-seeking, both
for oneself and for a suicidal friend.
METHOD
We used a pre-post intervention survey
design. In the fall of 2007, before the intro-
duction of Yellow Ribbon activities, and 6 to
8 months later in the spring of 2008, staff and
students at the experimental school were sur-
630
veyed about student help-seeking. Staff at a
comparison school, which received no Yellow
Ribbon programming, similarly completed the
surveys. The comparison schools principal
would not permit students to be surveyed.
Schools were recruited to participate
in the study with no random selection or as-
signment involved. Rather, at least 19 schools
in the area that had never used Yellow Rib-
bon programming were invited to take part
in the study. Sample selection concluded
when two school principals agreed to partici-
pate. The participating school district re-
quired that the schools names not be pub-
lished, so this paper refers to them as the
experimental school and control school.
The experimental school had an en-
rollment of 870 students at the time of the
study, and the control schools enrollment
was about 1,600. The experimental schools
demographics were more racially and ethni-
cally diverse than those of the control school.
Specifically, more than half of the experimen-
tal schools student body was Hispanic, whereas
almost 90% of the control school students
were White. The experimental school was
located in a less affluent and more racially di-
verse area than the control school. According
to school district statistics, more than half
(58.4%) of the experimental schools students
received a free or reduced lunch rate, com-
pared to only 9.8% at the control school.
Another difference between the exper-
imental and control schools concerned histo-
ries of student suicide. The experimental
schools principal could recall no student sui-
cides in the previous 5 years; the control
schools principal stated that several suicides
had occurred in that time period. An addi-
tional student suicide occurred at the control
school during this study.
Neither the experimental school nor
the control school had ever adopted Yellow
Ribbon programming prior to the study.
At each school, staff completed surveys
anonymously during a regularly scheduled
monthly staff meeting. They signed a con-
sent form before completing the survey, and
the consent forms and surveys were turned
in separately. For students, the study secured
active parental consent. Three weeks before
Yellow Ribbon Evaluation
data collection began, the researchers pro-
vided all study hall teachers with study infor-
mation sheets and consent forms to distribute
to students. The students were to return to
the teacher the consent form with a parent
or guardians signature. The parent could
provide or refuse consent on the form; re-
gardless, the student was asked to return the
form. Consent forms were provided in both
English and Spanish due to the high enroll-
ment of Hispanic/Latino students, many of
whom were children of Spanish-speaking im-
migrants. The consent forms included the
national suicide hotline number (1-800-273-
TALK).
Several incentives were provided in an
effort to increase the return of parental con-
sent forms. The three teachers who turned
in the highest proportion of student consent
forms were each awarded a $100 gift certifi-
cate to a local book store. To motivate stu-
dents, teachers were provided with candy to
give to students who returned a signed con-
sent form, regardless of whether consent was
granted or denied by the parent or guardian.
Also, drawings for an Ipod (digital music
player) were held three times in a 2-week pe-
riod before the study began. Only students
who returned a consent form could be eligi-
ble for the drawing; students were entered
regardless of whether their parent refused or
provided consent. Each drawing was tele-
vised live over the schools closed-circuit pro-
gramming, which is produced by students,
and students also were provided a flier noti-
fying them of the drawing.
Despite these incentives, about one
third (35.2%) of the schools 870 students re-
turned a signed and usable consent form. Of
those who returned usable consent forms, 87
(28.4%) were not permitted by their parent
or guardian to participate in the study. Stu-
dents whose parents consented were pro-
vided with an assent form to sign immedi-
ately before completing the survey in study
hall.
Sample
Staff. At the experimental school, 70
of the schools 76 staff members completed
the pre-intervention survey, representing a
Freedenthal 631

92.1% participation rate; this number dropped
to 57 (75.0%) for the post-intervention sur-
vey. At the control school, 98 (89.1%) of the
schools 110 staff members participated in
the first survey, and 85 (77.3%) completed
the second survey.
Staff characteristics are reported in Ta-
ble 1. Overall, teachers comprised three
quarters of school staff members in both the
pre- and post-intervention surveys. The staff
at each school shared similar characteristics
for all demographic and job variables assessed
with one exceptionstaff at the control
school had worked at their current school for
a longer period of time, on average, than ex-
perimental school staff.
Students. Although one quarter (24.1%;
n = 210) of the experimental schools students
completed the pre-intervention survey, only
146 of those students also completed the
post-intervention survey, reflecting a de-
crease of 30.4%. The attrition rate was due
to students leaving the school, being absent,
or choosing not to remain in the study. Over-
all, the student participation rate in both the
pre-test and post-test surveys was 16.8%. All
analyses were restricted to youth who partici-
pated in both the pre- and post-intervention
surveys. The demographic characteristics of
these students are reported in Table 2.
Analyses were undertaken to deter-
mine whether students who dropped out of
the study were different from those who
completed both surveys. Students in both
groups were similar in terms of key study
variablesgenerally equal proportions in
each group had endorsed suicidal thoughts,
suicide attempts, disclosures of suicidality,
and the different types of help-seeking in the
pre-intervention survey. There also was no
statistically significant difference in study re-
tention based on gender. However, compared
to students who completed both surveys,
larger proportions of students who dropped
out of the study were Hispanic, reported
problems with drugs or alcohol, earned lower

TABLE 1
Demographic Characteristics of Staff at Experimental and Control Schools for an Evaluation
of the Yellow Ribbon Suicide Prevention Program
Pre-Intervention Post-Intervention

Experimental Control Experimental Control

(n = 70) (n = 98) (n = 57) (n = 85)
Variable % (n) or Mean (SD) % (n) or Mean (SD)

Age 42.1 (12.2) 42.6 (11.2) 42.1 (10.7) 42.8 (9.9)

Gender
Male 40.0 (28) 52.0 (51) 45.6 (26) 47.1 (40)
Female 60.0 (42) 48.0 (47) 54.4 (31) 52.9 (45)
Race
White 82.9+ (58) 93.5 (92) 84.2 (48) 94.0 (79)
Latino/Hispanic 7.1 (5) 3.1 (3) 7.0 (4) 3.6 (3)
Other 10.0 (7) 3.2 (3) 8.8 (5) 2.4 (2)
Position at current school
Teacher 72.9 (51) 74.2 (72) 79.0 (45) 84.7 (72)
Administrator 8.6 (6) 6.2 (6) 3.5 (2) 5.9 (5)
Other Staff 18.5 (13) 19.6 (19) 17.5 (10) 9.4 (8)
# years at current school 4.5** (4.9) 6.8 (5.2) 4.7* (4.6) 7.4 (5.2)
# years at any school 12.4 (9.2) 14.4 (9.3) 12.5 (8.3) 14.4 (8.7)
# years taught at any school 10.9 (8.4) 12.3 (9.2) 11.1 (7.9) 13.2 (9.1)

Note. All bivariate comparisons are between schools during the same survey administration.
+
p < .10; *p < .05; **p < .01.
632 Yellow Ribbon Evaluation

TABLE 2 personal story of their sons suicide, coupled

Demographic Characteristics of Experimental with messages about asking for help when
School Students (N = 146) needed, telling an adult about a suicidal peer,
and not keeping secrets about a friends sui-
% (n) or cide risk. Students who completed the lead-
Variable N Mean (SD)
ership training distributed the Yellow Ribbon
Age 145 15.8 (1.2) Ask4Help cards after the assembly, as stu-
Grade level dents streamed out of the school gymnasium.
9 146 32.2 (47) School counselors continued to distribute the
10 146 32.2 (47) card throughout the school year to students
11 146 19.9 (29) with whom they worked. (A separate paper,
12 146 15.8 (23) currently in process, will report findings
Gender about students use of the card.)
Male 144 41.0 (59)
Female 144 59.0 (85)
Surveys
Race/Ethnicity
Hispanic 143 43.4 (62)
White 143 39.2 (56) The student and staff surveys were de-
Black 143 1.4 (2) veloped in consultation with two suicide pre-
Other 143 16.1 (23) vention experts and two school counselors
Free/reduced lunch 144 47.2 (68) and the principal at the experimental school.
The student survey was pilot tested in spring
Note. Only students who completed both 2007 in a series of focus groups with a total
the pre- and post-intervention surveys are in-
cluded in the study sample. of 27 youth, and modifications were made ac-
cording to youths recommendations.
Staff answered questions specifically
grades, and received a free or reduced price about students seeking help from them per-
lunch. All of these differences were statisti- sonally and about students disclosing their
cally significant (p < .05). own or a friends suicidal thoughts or behav-
ior. The student surveys assessed help-seek-
Intervention ing from a diverse array of helpers, both
inside and outside of school. The pre-inter-
The experimental school received sev- vention surveys assessed help-seeking behav-
eral components of the Yellow Ribbon Suicide iors in the prior year. The surveys after the
Prevention Program in the fall of 2007. These intervention assessed help-seeking in the cur-
included a 60-minute student leadership train- rent academic year.
ing program for about 15 students selected by At the study funders request, the study
school counselors; a 1.5 hour staff training for did not aim to assess attitudes or other sub-
teachers, counselors, administrators, and all jectively oriented variables due to the impor-
other school staff; and a 50-minute schoolwide tance of assessing actual behavioral out-
assembly. These activities were conducted by comes. Attitudes tend to be inconsistent
Dale and Dar Emme, the groups founders, or predictors of future behaviors (Glasman &
their daughter Becca Emme. Albarracn, 2006).
The student leadership and staff train-
ings included a digital slide presentation with Variable Measurement
information about the history of Yellow Rib-
bon; adolescent suicide, including statistics, Staff Surveys. Staff at the experimen-
myths, and warning signs; and the impor- tal and control schools answered survey items
tance of seeking help from an adult for one- related to demographic characteristics, years
self or for a suicidal peer. The schoolwide as- of teaching experiences, and several aspects
sembly presentation centered on the Emmes of student help-seeking. Specifically, staff
Freedenthal
were asked to specify the number of students
who had come to them in the prior year (pre-
intervention) or current academic year (post-
intervention) and:
Asked for help with problems re-
lated to stress, emotions, behavior, or
drug or alcohol use
Told you they were thinking about
attempting suicide
Told you they had attempted sui-
cide
Told you that another student was
thinking about attempting suicide
Told you that another student had
attempted suicide
The median number for each variable is re-
ported in the findings. Responses additionally
were categorized as Yes or No to reflect the
proportion of staff who had experienced the
specific type of student help-seeking or dis-
closure. The coefficient alpha for these six
help-seeking, dichotomous items was .74 in
the first staff survey and .69 in the second.
Student Surveys. Student surveys que-
ried youth about demographic characteris-
tics, personal history of suicidality, emotional
health, and help-seeking. The survey used
items from the Youth Risk Behavior Surveil-
lance Survey (Brener et al., 2004) to assess
the presence of suicidal thoughts or a suicide
attempt in the prior year or during the cur-
rent academic year. An additional item in-
quired about suicidal thoughts or a suicide
attempt in the prior week.
Survey items rated youths self-reported
frequency (Never, Almost never, Sometimes, Al-
most always, or Always) for discussing personal
problems with the following types of helpers:
(1) friend; (2) parent; (3) brother or sister; (4)
another relative; (5) teacher at school; (6)
school counselor or other adult at school
whos not a teacher; (7) psychiatrist, psychol-
ogist, social worker, or other type of counse-
lor, but not at school; (8) another type of
doctor; (9) a minister, rabbi, imam, or other
religious leader; (10) crisis hotline; (11) In-
ternet site; and (12) other adult. These items
were adapted from the Service Assessment
633
for Children and Adolescents (SACA) (Stiff-
man et al., 2000). Personal help-seeking was
operationalized three ways:
Scores for each help-seeking item
were summed to create a help-seek-
ing scale score, with a higher score
equaling greater help-seeking. Each
option was scored 0 (Never) to 4 (Al-
ways). For the first survey, the reli-
ability coefficient for this variable
was 0.71; it was .76 for the second
survey.
Responses to the different types of
help-seeking items were dichoto-
mized (Yes/No) so that youth who
noted at least some use (Almost Never
and higher) were coded as having
used the helper (Yes), and those who
answered Never were coded as not
having turned to the helper (No).
The number of types of helpers con-
sulted by a respondent was summed.
Youth who endorsed suicidal thoughts
or a suicide attempt were asked to indicate
on the survey whether they had told an adult
(yes/no). Adults were specified as parent,
teacher, school counselor or other school
staff, mental health professional, other physi-
cian, religious leader, or other adult.
Human Subjects Protections
To help ensure student safety, the
study team immediately scanned completed
surveys to discern whether students indicated
that they had thought about or attempted
suicide in the previous week. If yes, then the
team matched the survey number with the
corresponding number on an assent form,
which had the students name. The team no-
tified the school counseling office of the stu-
dents recent suicidality, and a counselor met
with the student within an hour. This process
occurred for six students before the interven-
tion and for nine after the intervention.
For both students and staff, the last
page of the survey contained the number for
the national suicide hotline and space to re-
634
quest a call or e-mail from the study investi-
gator. For students, the last page of the sur-
vey also provided instructions on how to
contact ones school counselor if needed.
About ten students from each survey session
left their e-mail address to request contact
from the study investigator, who contacted
each student and provided referrals as needed.
The current study was approved by the
Institutional Review Boards of both the par-
ticipating school district and the investiga-
tors university.
Data Analysis
For the staff data, data analyses com-
pared results for the outcome variables across
two categories. First, pre- and post-interven-
tion responses from the same school were
compared for within-group differences over
time. Second, the degree of change in help-
seeking from the pre-test to post-test was
compared between schools; comparing the
degree of change, rather than the difference
in results, took into account any baseline dif-
ferences. To test the significance of a differ-
ence in proportions, the z statistic was used
(Twisk, 2003). For continuous data, the
Mann-Whitney (rank sums) test compared
medians because the distributions were highly
skewed.
For the student data, the proportions
of students positively endorsing the respec-
tive help-seeking outcome variables in the
pre- and post-intervention surveys were
compared. To determine the statistical signif-
icance of pre- and post-intervention differ-
ences in proportions, z tests were used with
the prtest command in Stata. Where con-
tinuously measured variables were reported
(e.g., number of helpers), t tests or the rank
sum test of medians assessed statistical signif-
icance.
As noted earlier, analyses of students
responses were restricted to students who
completed both the pre- and post-interven-
tion surveys. The staff surveys were anony-
mous, so it was not possible to limit analyses
only to those staff who completed both sur-
veys. Statistical tests were completed using
Yellow Ribbon Evaluation
Stata statistical software (Stata Corp., version
9, 2003). All statistical tests were two-tailed.
RESULTS
Staff Surveys
As shown in Table 3, the experimental
schools staff reports did not indicate a statis-
tically significant increase, from the pre- to
post-intervention surveys, in student help-
seeking, disclosures of personal suicidal
thoughts or attempted suicide, or reports of
another students thoughts or attempt. Fur-
ther, the degrees of change from pre- to
post-intervention at the experimental school
did not differ from those of the control
school for any variable, except for the student
disclosure to staff of a personal student at-
tempt; the experimental school experienced a
decrease of 7.9% from the pre- to post-inter-
vention surveys, while the control school
experienced an increase of 7.7%, z = 4.6,
p < .001.
Student Surveys
The proportion of students who re-
ported having thought about or attempted
suicide during the current school year in-
creased slightly from 11.2% (n = 15) in the
year before the intervention to 14.7% (n =
19) in the year of the intervention. This in-
crease was not statistically significant, z =
0.85, p < .40.
One of 12 types of help-seeking in-
creased to a statistically significant degree
after the introduction of Yellow Ribbon pro-
gramming (Table 4). The number of youth
reporting that they called a crisis hotline for
help increased from 2.2% in the pre-inter-
vention survey to 6.9% post-intervention,
z(144) = 2.0, p < .05. These proportions re-
flect small numbers of students who called a
crisis hotline (3 and 10, respectively). Other-
wise, no other type of help-seeking increased
more than would be expected with random
variation, and two types actually decreased to
a statistically significant degree: help-seeking
Freedenthal 635

TABLE 3
Staff Reports of Student Help-Seeking Variables Before and After the Introduction of Yellow Ribbon
Suicide Prevention Program Activities at a Denver-Area High School
Experimental School Control School Both Schools

Within- Within- Between-

Pre- Post- school Pre- Post- school schools
Variable Test Test difference1 Test Test difference1 difference2

Student help-seeking3
% Staff (Yes) 60.0 64.9 +4.9 54.2 56.5 +2.3 +2.6
Median number of students4 5 4 1 4 4 0 1
Student disclosed suicidal
thoughts
% Staff (Yes) 16.2 15.8 0.4 16.7 21.2 +4.5 4.9*
Median number of students 2 2 0 1 2 +1 1
Student disclosed suicide attempt
% Staff (Yes) 25.4 17.5 7.9 14.7 22.4 7.7 15.6***
Median number of students 1 1 0 1 1 0 0
Student reported peer with
suicidal thoughts
% Staff (Yes) 24.6 22.8 3.4 19.8 19.1 0.9 2.5
Median number of students 2 1 1 1 2 +1 2
Student reported peer attempted
suicide
% Staff (Yes) 22.6 12.3 12.3+ 13.8 22.6 7.8 21.1
Median number of students 2 1 1 1 1 0 1
Student gave teacher the Yellow
Ribbon Ask-4-Help Card
% Staff (Yes)4 0 1.8 +1.8 1.0 1.2 +0.2 +1.6
1
Within-school difference reflects change in proportion from pre-test to post-test.
2
Between-school difference is the change in proportion, from pre-test to post-test, at the experi-
mental school minus the change in proportion at the control school. A negative number indicates that
the experimental school had a smaller increase or greater decrease in proportion than did the control
school.
3
Student help-seeking for problems related to stress, emotions, behavior, or drug or alcohol use.
4
All medians are limited to respondents who reported at least one student for the respective
variable. No median is reported for the number of students who gave a Yellow Ribbon card to staff,
because no more than one staff member per school endorsed this item.
+
p < .10; *p < .05; ***p < .001

from a friend and help-seeking from a par-
ent. Analyses restricted to students reporting
suicidality in either survey did not show any
increase in help-seeking (data not shown).
The mean score on the help-seeking scale
before the intervention (M = 12.0, SD = 0.5)
decreased after the intervention (M = 10.8,
SD = 0.5), indicating that students reported
seeking help less frequently than they did be-
fore the intervention, t(135) = 2.1, p < .05.
The mean number of helpers whom students
consulted did not differ to a statistically sig-
nificant degree before the intervention (M =
4.3, SD = 0.2) or afterward (M = 4.1, SD =
0.2).
The proportions of youth with suicidal-
ity in the prior (or current) year who told an
adult increased from 27.3% to 45.5%. How-
ever, this difference cannot be assumed to rep-
resent an actual increase, for two important
reasons. First, the difference in proportions
was not statistically significant, z(11) = 0.9,
636 Yellow Ribbon Evaluation

TABLE 4
Student-Reported Help-Seeking Before and After Introduction of Yellow Ribbon
Suicide Prevention Program Activities at a Denver-Area High School
Pre-Intervention Post-Intervention

Type of Helper N % (n) N % (n) z p

ANY 146 94.5 (138) 146 87.7 (128) 2.1 .04

Friend 145 91.0 (132) 142 83.1 (118) 2.0 .04
Parent 145 80.0 (116) 143 69.9 (100) 2.0 .04
Sibling 145 64.1 (93) 144 61.8 (89) 0.4 .68
Other relative 145 63.4 (92) 144 54.9 (79) 1.5 .14
Teacher 144 34.0 (49) 144 36.1 (52) 0.4 .71
School counselor 143 29.4 (42) 144 25.7 (37) 0.7 .49
Mental health professional1 145 15.2 (22) 144 13.9 (20) 0.3 .76
Other doctor 145 15.9 (23) 144 16.7 (24) 0.2 .85
Religious leader 145 18.6 (27) 144 16.0 (23) 0.6 .55
Crisis hotline 145 2.1 (3) 144 6.9 (10) 2.0 .05
Internet site 144 18.1 (26) 144 18.8 (27) 0.2 .88
Other adult2 144 28.5 (41) 144 22.2 (32) 1.2 .22
1
Mental health professional includes a psychiatrist, psychologist, social worker
or other type of counselor but not at school.
2
For this item, the survey specified, Another adult/elder not listed above.

p < .40. Second, 20.8% of participants who
reported suicidality in the pre-intervention
survey skipped this question, as did 42.1% of
participants who reported suicidality in the
post-intervention survey.
DISCUSSION
Based on both staff and student re-
ports, we found little indication that help-
seeking by students increased after the intro-
duction of the Yellow Ribbon program at a
Denver-area high school. School staff re-
ported no increase after the intervention in
students seeking help for themselves or their
peers, and a comparison with another school
also showed no difference between schools.
Students self-reported help-seeking rates re-
mained the same for nine types of helpers,
including professional, school-based, reli-
gious, and informal sources. Adolescents
help-seeking from friends and parents actu-
ally declined after the intervention. The lone
type of help-seeking to increase, based on
student reports, was calls to a crisis hotline.
The practical significance of the in-
crease in crisis hotline calls is questionable.
On the one hand, the proportion of students
using a crisis hotline tripled, from 2.1% to
6.9%. On the other hand, the numbers in
question were very small, with 3 out of 146
students using a crisis hotline before the in-
tervention and 10 calling one after the inter-
vention. Further, the study survey, consent
form, and student assent form all contained
the national suicide hotline number. It is pos-
sible that those study materials, rather than
the intervention itself, contributed to the in-
crease in calls to crisis hotlines. More re-
search is needed to determine the potential
impact of Yellow Ribbon on calls to crisis
hotlines.
The study had several methodological
limitations that could have obscured other
intervention effects. Although the staff sur-
veys had reasonable participation rates, the
student participation rate in the experimental
school was extremely low. The consent pro-
cess likely introduced sample bias into the
student component of the study because the
majority of students neglected to turn in a
Freedenthal
signed parental consent form, and research
suggests that youth who turn in consent
forms are, relative to those who do not turn
in a consent form, more likely to be White,
to earn better grades, and to live in a two-
parent home (Anderman et al., 1995). Even
among those who turned in a form, parents
often denied consent to participate. The high
rate of student attrition from the pre- to
post-intervention surveys exacerbated the
potential for sample bias, because students
who dropped out of the study were more
likely than those who remained in the study
to be Hispanic and to have psychosocial
problems.
It is impossible to know the direction
of any sample bias that might indeed exist.
We know that Hispanic and Black adoles-
cents at risk for suicide have lower rates of
help-seeking than White adolescents (Free-
denthal, 2007). This disparity suggests that
the study results might actually understate
the rates of help-seeking at this school, be-
cause the participants were disproportion-
ately White. However, youth with more psy-
chosocial problems seek help more often
than their counterparts (Zwaanswijk, Ver-
haak, Bensing, Van der Ende, & Verhulst,
2003), and those who dropped out of the
study had higher rates of substance use,
lower grades, and lower family income than
students who completed the study. The pre-
sumed higher need for help among study
drop-outs might balance any effect of racial
disparities.
As for other limitations, randomization
was not used to select the participating
schools or students, and the student sample
lacked a comparison group. The staff sam-
ples comparison school had markedly differ-
ent demographic characteristics among its
students, and the control school was situated
in a more affluent area. A student suicide oc-
curred at the control school in between the
pre- and post-intervention surveys, and this
event could have stimulated help-seeking
among students, limiting even more the
comparability of the schools.
Another potential problem concerns
the disparate periods of time assessed in the
637
pre- and post-intervention surveys. The first
survey covered student help-seeking in the
entire prior year, while the post-intervention
surveys addressed a smaller time period from
September to early May. It is possible that
student help-seeking would have shown an
increase in the remaining months of the cal-
endar year, although research indicates that
young people seek help for emotional prob-
lems more often in fall and spring than in
summer (Morken, Sund, & Linaker, 2004).
Taken alone, the student portion of
this study contains formidable limitations.
However, in combination with the staff data,
the student data can serve to triangulate find-
ings. With the exception of a small number
of students who used a crisis hotline after the
intervention, both the student and staff data
reflected essentially flat rates of help-seeking
at the experimental school from the times be-
fore and after the Yellow Ribbon programs
introduction. The congruence of staff and
student reports supports the staff reports that
student help-seeking from adults did not in-
crease following Yellow Ribbon activities.
This is especially true concerning student
help-seeking from school personnel, because
although only a fraction of students partici-
pated in the study, most staff at both schools
took part.
Methodological limitations aside, an-
other possible explanation for the study re-
sults is that student help-seeking was already
quite common even before Yellow Ribbon
was introduced. In the pre-intervention sur-
vey, almost all students indicated that they
had received help informally from friends or
family in the previous year, so there was not
much room for improvement. One quarter to
one half of youth had discussed emotional or
behavioral problems with a school staff mem-
ber, mental health professional, or physician.
In contrast, a longitudinal epidemiologic
study of 1,420 youth found that only 18% to
19% received help for mental health prob-
lems from any type of professional (Farmer
et al., 2003).
Although this studys findings must be
viewed tentatively, they point to two impor-
tant avenues for future research. One avenue
638
concerns investigating the reasons why al-
most all forms of help-seeking apparently did
not increase after the Yellow Ribbon pro-
gram, including barriers to help-seeking that
students may experience. Another avenue of
research would explore whether a program
evaluation of Yellow Ribbon yields different
results in a different location, with a higher
proportion of students participating in the
surveys.
CONCLUSION
Due to the studys limitations, the stu-
dent findings must be considered a snapshot
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Manuscript Received: January 2, 2010
Revision Accepted: January 8, 2010