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The Role of Parents in Safety Planning Interventions with Suicidal Adolescents

Kimberly H. McManama O’Brien^1,2,3*, Laika D. Aguinaldo^2,4, Joanna Almeida^1,5,6, Erina White²

¹Simmons School of Social Work, Boston, MA, USA

²Boston Children’s Hospital, Boston, MA, USA

³Harvard Medical School, Boston, MA, USA

⁴The Ethelyn R. Strong School of Social Work at Norfolk State University, Norfolk, VA, USA

⁵Harvard Youth Violence Prevention Center, Harvard School of Public Health, Boston, MA, USA

⁶Institute for Child, Youth and Family Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA

*Corresponding Author:

Kimberly H. McManama O’Brien
E-mail: obrik@simmons.edu

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Abstract

Suicide is the second leading cause of death for youth ages 10-24 in the United States. The time following discharge from an acute care setting represents a period of especially high risk for suicide among adolescents, but has not been matched by proportionate prevention and intervention efforts. Safety planning procedures, especially those which include means restriction counseling and family communication training, may be especially useful for suicidal adolescents and their parents during the discharge process. Brief interventions that actively involve parents in safety planning have the potential to reduce suicide-related outcomes among suicidal adolescents, and thus warrant an increased clinical and research focus.

Introduction

Suicide is a pervasive public health problem among adolescents in the in the United States, as it is the second leading cause of death for youth ages 10-24 (CDC, 2016). In the most recent national survey of high school students, 17.0% reported having seriously considered attempting suicide in the previous 12 months, 13.6% made a suicide plan, 8.0% attempting suicide at least once, and 2.7% made a suicide attempt that required medical attention (SAMHSA, 2014). Suicidal adolescents frequently present to acute care settings, such as an Emergency Department (ED) or inpatient psychiatric hospital, for psychiatric evaluation and/or clinical care. In fact, suicide-related thoughts and behaviors represent the primary presenting problem in the majority of ED visits for behavioral health among adolescents (Gabel, 2012) and the most common concern for adolescents admitted to an inpatient psychiatric unit (Wilson et al., 2012).

The time following discharge from an acute care setting represents a period of especially high risk for suicide among adolescents (Hunt et al., 2009; Knesper, 2010; Spirito & Esposito-Smythers, 2006). Safety planning interventions, which incorporate internal and external strategies and sources of support, have been developed for use with adults in this high risk period, and have been widely disseminated with a variety of populations (Stanley & Brown, 2012), including adolescents (Asarnow, Berk, Hughes, & Anderson, 2015; Brent et al., 2009). A brief safety planning intervention that enhances the ability to cope with crises can help reduce future suicidal events, increase motivation for treatment, and promote treatment linkage (Stanley & Brown, 2012). Comprehensive safety planning interventions typically employ six core steps: 1) recognize warning signs of crisis, 2) utilize coping strategies, 3) contact social supports, 4) enlist family members/adult figures to help, 5) contact mental health providers, and 6) remove lethal means (Stanley & Brown, 2012). However, because safety planning interventions are characteristically developed to address the needs of individual adults, they often do not focus on the critical role of parents in the case of suicidal adolescents. To reduce subsequent suicidal events among adolescents, it is important that safety planning interventions include parents and guardians and clearly delineate their role in keeping their suicidal adolescent safe upon discharge from acute care settings.

Brief interventions with safety planning components that actively involve parents have demonstrated the ability to improve clinical outcomes, and in some cases reduce suicide-related outcomes, among suicidal adolescents (Anastasia, Humphries-Wadsworth, Pepper & Pearson, 2015; Asarnow, Berk, Hughes & Anderson, 2015; Diamond et al., 2010; Harrington et al., 1998; Rotheram- Borus et al., 2000; Pineda & Dadds, 2013; Stanley & Brown, 2012; Wharff, Ginnis & Ross, 2012). For instance, specific to suiciderelated outcomes, Asarnow et al. (2015) found that a brief cognitivebehavioral family intervention administered in the ED demonstrated signiï¬Ã¯Â¿Â½cant reductions in reattempt rates and suicidal behavior, relative to an enhanced treatment as usual which included provider education. Similarly, a recent study by Anastasia et al. (2015) found that adolescents who received a family-centered brief intensive treatment (FCBIT) demonstrated reduced suicide-related thoughts and behaviors, relative to adolescents who received an intensive outpatient treatment without a family component.

There are some important aspects of safety planning interventions that are presently only cursorily addressed with suicidal adolescents and their parents. For example, one important but often neglected component of safety planning with suicidal adolescents is means restriction counseling with their parents. Conducting means restriction counseling has been shown to impact the likelihood of restricting access to multiple lethal means (Bryan, Stone & Rudd, 2011; Yip et al., 2012). For example, McManus et al., (1997) found that parents who received means-restriction counseling in an ED, were almost 3 times as likely (86%) to lock up or dispose of medication than parents who did not receive such counseling (32%). Similar effects have been found across a range of suicide methods, including prescription medications (75% vs. 48%), over-the-counter medications (48% vs. 22%), alcohol (47% vs. 11%), and firearms (63% vs. 0%) (Kruesi et al., 1999). Access to means is a distinguishing factor between adolescents hospitalized for suicidal risk and adolescents who die by suicide (Brent et al., 2011), suggesting its importance in the safety planning process. Parents of adolescents who have attempted suicide frequently report that they lack knowledge in assessing suicide risk and confidence in their ability to ensure the ongoing safety of their suicidal adolescent (O’Brien et al., in review). Engaging individuals in an educational conversation about means restriction can increase knowledge and confidence in suicide risk assessment and implementation of safety strategies (Britton, Bryan & Valentstein, 2014). Therefore, a stronger focus on means restriction within safety planning procedures may help parents of suicidal adolescents to more effectively restrict access to lethal means.

Evidence has increasingly elucidated the role that parents play in adolescent suicide attempts (Donath et al., 2014; Taliaferro & Muehlenkamp, 2014). Various parental variables such as marital status (Afifi et al., 2009; Fuller-Thomson & Dalton, 2011), satisfaction with family (An, Ahn & Bhang, 2010; Randell, Wang, Herting & Eggert, 2006) poor relationship between parents, and low maternal/paternal care (Beautrais, Joyce & Mulder, 1996) have also been associated with higher rates of suicide behaviors. Increasingly, research has demonstrated that low parental connectedness has been associated with psychological and social distress among adolescents (Townsend & McWhirter, 2005) while the parent-child connection is a protective factor for adolescent suicide (Resnick, Ireland & Borwsky, 2004). For example, recent findings indicate that youth with a strong connection their caregivers are less likely to report suicidal thoughts (He, Fulginiti & Finno-Velasquez, 2015) and that family support is protective against self-injurious thoughts and behaviors (Tseng & Yang, 2015). Similarly, Rrelative to other domains of connectedness (i.e., peer and school), a negative parent-child connection is among the strongest predictors of suicide among adolescents (Resnick, Ireland & Borwsky, 2004; Kaminski et al., 2010).

As suicide research continues to unveil the importance of interpersonal relationships (Van Orden et al., 2010), belongingness (Joiner et al., 2009), connection, and communication (Whitlock, Wyman & Moore, 2014), parent roles become especially critical to adolescent suicide prevention. Focusing on the role of parents in maintaining the safety of their suicidal adolescent upon discharge from acute care settings is therefore critical. Safety planning procedures with suicidal adolescents are enhanced by in-depth conversations between mental health providers, adolescents, and their parents (Wharff, Ginnis & Ross, 2012). Attention to the involvement of parents in the safety planning process has the potential to enhance family connection and communication and provide essential support to adolescents in acute suicidal distress. Therefore, current safety planning protocols warrant would benefit from the inclusion of developmental adaptations to include address the essential role of parents and guardians.

Research consistently demonstrates the importance of family to the effectiveness of interventions with suicidal adolescents (Asarnow, Berk, Hughes & Anderson, 2015; Diamond et al., 2010; Hughes & Asarnow, 2013; Wells & Heilbron, 2012). Therefore, the need for effective ways to incorporate parents into safety planning procedures is critical, especially at time of discharge from acute care settings. Specifically, if means restriction counseling and family communication training were augmented in the safety planning process, there may be a greater potential for reductions in suicide-related thoughts and behaviors among adolescents after discharge.

Funding Information

This research was supported in part by grant number YIG-1-097-13 (PI: O’Brien) from the American Foundation for Prevention and the Simmons College President’s Fund for Faculty Excellence (Co-PIs: O’Brien & Almeida).

References

1. Afifi, T.O., Enns, M.W., Cox, B.J., Asmundson, G.J.G., Stein, M.B., &Sareen, J. (2008). Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American journal of public health, 98(5), 946
2. An, H., Ahn, J.H., & Bhang, S.Y. (2010). The association of psychosocial and familial factors with adolescent suicidal ideation: A population-based study. Psychiatry Research, 177(3), 318-322
3. Anastasia, T.T., Humphries-Wadsworth, T., Pepper, C.M., & Pearson, T.M. (2015). Family centered brief intensive treatment: a pilot study of an outpatient treatment for acute suicidal ideation. Suicide Life Threat Behaviour, 45(1), 78-83
4. Asarnow, J.R., Berk, M., Hughes, J.L., & Anderson, N.L. (2015). The SAFETY Program: a treatment-development trial of a cognitive-behavioral family treatment for adolescent suicide attempters. Journal of Clinical Child&Adolescent Psychology, 44(1), 194-203
5. Beautrais, A.L., Joyce, P.R., & Mulder, R.T. (1996). Risk factors for serious suicide attempts among youths aged 13 through 24 years.Journal of the American Academy of Child and Adolescent Psychiatry, 35(9), 1174-1182.
7. Brent, D.A., Greenhill, L.L., Compton, S., Emslie, G., Wells, K., Walkup, J.T., et al. (2009). The treatment of adolescent suicide attempters study (TASA): Predictors of suicidal events in an open trial. Journal of the American Academy of Child & Adolescent Psychiatry, 48(10), 987-996.
9. Brent, D.A., Perper, J.A., Allman, C.J., Moritz, G.M., Wartella, M.E., & Zelenak, J.P. (1991). The presence and accessibility of firearms in the homes of adolescent suicides: A case-control study. Journal of the American Medical Association, 266(21), 2989-2995.
11. Britton, P.C., Bryan, C.J. &Valentstein,M. (2014).Motivational interviewing for means restriction counseling with patients at risk for suicide. Cognitive and Behavioral Practice
12. Bryan, C.J., Stone, S.L., & Rudd, D.M. (2011). A practical, evidence-based approach for meansrestriction counseling with suicidal patients.Professional Psychology: Research and Practice, 42, 339-346. Centers for Disease Control and Prevention. (2016). Web-Based Injury Statistics Query and Reporting System (WISQARS). Retrieved from
13. Diamond, G.S., Wintersteen, M.B., Brown, G.K., Diamond, G.M., Gallop, R., Shelef, K., et al. (2010). Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial. Journal of the American Academy of Child&Adolescent Psychiatry, 49(2), 122-131.
15. Donath, C., Graessel, E., Baier, D., Bleich, S., & Hillemacher, T. (2014). Is parenting style apredictor of suicide attempts in a representative sample of adolescents? BMC pediatrics, 14(1), 113
16. Fuller-Thomson, E., & Dalton, A.D. (2011). Suicidal ideation among individuals whose parentshave divorced: findings from a representative Canadian community survey. Psychiatry Research, 187(1-2), 150-155
17. Gabel, S. (2012). Innovations in practice: Child and adolescent psychiatrists and primary care:Innovative models of consultation in the United States. Child & Adolescent Mental Health, 17(4), 252-255.
19. Harrington, R., Kerfoot, M., Dyer, E., Mcniven, F., Gill, J., Harrington, V., et al. (1998). Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves. Journal of the American Academy of Child and Adolescent Psychiatry, 37(5), 512-518.
21. He, A.S., Fulginiti, A., & Finno-Velasquez, M. (2015). Connectedness and suicidal ideation among adolescents involved with child welfare: a national survey. Child Abuse & Neglect, 42, 54-62.
23. Hughes, J.L., & Arsenow, J.R. (2013). Enhanced mental health interventions in the emergency department: Suicide and suicide attempt prevention. Clinical Pediatric Emergency Medicine, 14(1), 28-34.
25. Hunt, M., Kapur, N., Webb, R., Robinson, J., Burns, J., Shaw, J., & Appleby, L. (2009). Suicide in recently discharged psychiatric patients: A case-control study. Psychological Medicine, 39(3), 443-449.
27. Joiner Jr, T.E., Van Orden, K.A., Witte, T.K., Selby, E.A., Ribeiro, J.D., Lewis, R., et al. (2009). Main predictions of the interpersonal–psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of abnormal psychology, 118(3), 634.
29. Kaminski, J.W., Puddy, R.W., Hall, D.M., Cashman, S.Y., Crosby, A.E., & Ortega, L.V.A.G. (2010). The Relative Influence of Different Domains of Social Connectedness on Self-Directed Violence in Adolescence. Journal of youth and adolescence, 39(5), 460-473.
31. Knesper, D.J. (2010). Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatric inpatient unit: American Association of Suicidology & Suicide Prevention Resource Center
32. Kruesi, M.J., Grossman, J., Pennington, J.M., Woodward, P.J., Duda, D., & Hirsch, J.G. (1999). Suicide and violence prevention: Parent education in the emergency department. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 2550-2555.
34. McIntire, M.S., Angle, C.R., & Schlicht, M.L. (1977). Suicide and self-poisoning in pediatrics. Advances In Pediatrics, 24, 291-309.
36. McManus, B.L., Kruesl, M.J., Dontes, A.E., Defazio, C.R., Piotrowski, J.T., & Woodward, P.J. (1997). Child and adolescent suicide attempts: An opportunity for emergency departments to provide injury prevention education. American Journal of Emergency Medicine, 15, 357–360
37. O'Brien, K. Almeida, J., Aguinaldo, L.D., & White, E. (in review). Understanding adolescentsuicide attempts to develop effective safety planning interventions. Oral paper submission to American Association of Suicidology annual conference
38. Pineda, J. & Dadds, M. (2013). Family intervention for adolescents with suicidal behavior: A randomized controlled trial and mediation analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 52(8), 851-862 .
40. Randell, B.P., Wang, W.L., Herting, J.R., & Eggert, L.L. (2006). Family factors predictingcategories of suicide risk. Journal of Child and Family Studies, 15(3), 247-262
41. Resnick, M.D., Ireland, M., & Borowsky, I. (2004). Youth violence perpetration: what protects?What predicts? Findings from the National Longitudinal Study of Adolescent Health. Journal of Adolescent Health, 35(5), 424. e421-424. e421
42. Rotheram-Borus, M.J., Piacentini, J., Cantwell, C., Belin, T.R., & Song, J. (2000). The 18-month impact of an emergency room intervention for adolescent female suicide attempters. Journal of Consulting and Clinical Psychology, 68(6), 1081-1093.
44. Spirito, A., & Esposito-Smythers, C. (2006). Attempted and completed suicide in adolescence. Annual Review of Clinical Psychology, 2, 237-266.
45. Stanley, B., & Brown, G.K. (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19(2), 256-264.
46. Substance Abuse and Mental Health Services Administration, Results from the 2013 NationalSurvey on Drug Use and Health: Mental Health Findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services, 2014. Available at
47. Taliaferro, L.A., & Muehlenkamp, J.J. (2014). Risk and protective factors that distinguishadolescents who attempt suicide from those who only consider suicide in the past year. Suicide and Life-Threatening Behavior, 44(1), 6-22
48. Townsend, K.C., & McWhirter, B.T. (2005). Connectedness: A review of the literature with implications for counseling, assessment, and research. Journal of Counseling and Development: JCD, 83(2), 191.
49. Tseng, F.Y., &Yang, H.J. (2015). Internet Use and Web Communication Networks, Sources of Social Support, and Forms of Suicidal and Nonsuicidal SelfâInjury Among Adolescents: Different Patterns Between Genders. Suicide and life-threatening behavior, 45(2), 178-191.
50. Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S.R., Selby, E.A., & Joiner Jr, T.E. (2010). The interpersonal theory of suicide. Psychological review, 117(2), 575.
51. Wells, K.C., & Heilbron, N. (2012). Family-based cognitive-behavioral treatments for suicidal adolescents and their integration with individual treatment. Cognitive and Behavioral Practice, 19(2), 301-314.
52. Wharff, E.A., Ginnis, K.M., & Ross, A.M. (2012). Family-based crisis intervention with suicidal adolescents in the emergency room: A pilot study. Social Work, 57(2), 133-143.
53. Whitlock, J., Wyman, P.A., & Moore, S.R. (2014). Connectedness and suicide prevention inadolescents: Pathways and implications. Suicide and Life-Threatening Behavior, 44(3), 246-272
54. Wilson, L.S., Kelly, B.D., Morgan, S., Harley, M., & O’Sullivan, M. (2012). Who getsadmitted? Study of referrals and admissions to an adolescent psychiatry inpatient facility over a 6-month period. Irish Journal of Medical Science, 181(4), 555–560
55. Yip, P.S., Caine, E., Yousuf, S., Chang, S.S., Chien-Chang Wu, K., & Chen Y.Y. (2012). Meansrestriction for suicide prevention.The Lancet, 379, 2393-2399.