Family-Based Cognitive-Behavioral Treatments for Suicidal Adolescents and Their Integration With Individual Treatment

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Cognitive and Behavioral Practice 19 (2012) 301-314 www.elsevier.com/locate/cabp

Family-Based Cognitive-Behavioral Treatments for Suicidal Adolescents and Their Integration With Individual Treatment Karen C. Wells Nicole Heilbron Duke University Medical Center A considerable research base underscores the importance of family functioning in the risk for and treatment of adolescent suicidal thoughts and behaviors. This paper reviews the extant empirical literature documenting associations between features of the family context and adolescent suicidal thoughts and behaviors. A case example is provided to illustrate how family factors may guide case conceptualization and treatment planning for suicidal adolescents. In light of the growing support for treatment approaches predicated on the principles of cognitive-behavioral therapy (CBT), the paper focuses on many of the common family treatment elements, notably interventions with parents across treatment studies with adolescent suicidal populations. A specific treatment known as CBT for Suicide Prevention (CBT-SP; Stanley et al., 2009) serves as an exemplar for how interventions with parents may be applied in the context of an integrated intervention for teen suicide. The paper reviews issues salient to the implementation of key components of treatment with parents and addresses specific treatment considerations and challenges.

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DOLESCENT suicide and suicidal behavior (i.e., ideation, plans, and attempts) represent a critically important public health problem worldwide. Suicide is the third leading cause of death among adolescents and young adults, and suicidal behavior is associated with significant risk for multiple attempts, increased health care costs, and teen and family suffering. Suicidal ideation is more prevalent than completed suicide and is considered to be a major risk factor for suicidal behavior (Lewinsohn, Rohde, & Seeley (1994). Moreover, nearly 90% of teen suicide completers have a diagnosable psychiatric disorder, the most common being a mood disorder (Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Shaffer et al., 1996). Recent years have seen major advances in the development of empirically supported, usually cognitivebehavioral therapy (CBT), interventions designed to reduce future risk for suicidal behavior and suicidal ideation in both adults and adolescents (see Brown, Jeglic, Henriques, & Beck, 2006; Rudd, Joiner, & Rajab, 2001, for reviews). Many of these interventions are presented in

Keywords: family treatment; cognitive-behavioral therapy; adolescence; suicidal behavior; suicide 1077-7229/11/301-314$1.00/0 © 2011 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

various articles in this special series. The purpose of this article is to focus specifically on intervention strategies that are useful with the parents of suicidal adolescents. Most clinicians would approach the treatment of suicidal teens using a comprehensive plan that integrates individual treatment for the adolescent with coordinated intervention with the parents, along with appropriate, efficacious pharmacologic treatment when indicated. As such, careful coordination and integration will be assumed throughout this paper; however, the discussion will focus primarily on parent interventions. There are a number of rationales for including interventions with parents in the treatment of a suicidal teen. First, there is at this point a rather extensive literature on family factors that can function as risk factors for suicidal ideation and suicidal behavior (see King & Merchant, 2008; Wagner, Silverman, & Martin, 2003, for reviews). Where such risk factors exist in a particular family, addressing and ameliorating those factors in treatment may reduce the risk of future suicidal behavior. Moreover, there is evidence that high levels of family conflict and low cohesion in the family are associated with poor treatment adherence (see Boergers & Spirito, 2003, for a review). There is considerably less research regarding the roles of other family members (e.g., siblings, grandparents) in the lives of suicidal adolescents. Although it is clear that the broader family context may have important implications for the treatment of adolescent suicidality, this paper is focused primarily on the role of parents/caregivers.

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Beyond reducing risk factors, at a personal level, the suicidal behavior or thinking of a teen can be a cause of great distress and anxiety or, alternatively, anger and rage on the part of parents. Addressing their anxiety and distress and providing them with validation and support is an important clinical issue. Parents often have misperceptions about the nature of teen suicidality and addressing those misperceptions with good psychoeducation is often critical to establishing and maintaining a treatment alliance. On a related note, parents are often the individuals who bring the teen for treatment and so engaging them in a collaborative treatment process can ensure continuity of care. Parents of minor adolescents still have the major moral, legal, and ethical responsibility for the care and supervision of their child and so including them in the treatment of high-risk behavior is appropriate to that role. Related to this point, an important early and ongoing treatment component for suicidal teens is establishment of a safety plan that the teen agrees to implement if future suicidal thoughts or impulses happen (Stanley et al., 2009). The parents frequently are involved in the teen's safety plan as either monitors of the teen or as people to whom the teen can go for support or assistance. Their cooperation in this initial and ongoing goal of establishing and ensuring safety is essential. Finally, by involving the parents in treatment, the parents and teen together can work on reducing family interaction patterns that contribute to conflict and painful emotions and on increasing positive family connection and support, the absence of which may contribute to feelings of hopelessness, loneliness, and isolation. The following case example provides an illustration of how family conflict, in conjunction with other known risk factors, may precipitate adolescent suicidal behavior. Specific risk and protective factors are then reviewed with a focus on possible treatment targets. This review is followed by description of an approach to treatment that is based on integrating interventions with parents that address salient family risk and protective factors with individual treatment of the teen. It is important to note that an exhaustive review of all known risk and protective factors for adolescent suicidal behavior is beyond the scope of this paper. As such, what is presented emphasizes relevant family factors and ways that parents, in particular, may be involved in the care of an adolescent at heightened risk of suicide. Case Example 1 Charlie is a 15-year-old male who lives with his single mother and two younger sisters. His mother has a stressful 1 Details about the case have been modified to protect the identity of the client.

and demanding job and frequently works 12 hour shifts, getting home around midnight. She is highly stressed with the demands of working to make ends meet and single motherhood, and she often feels very depressed about her circumstances. Charlie is in charge of babysitting his sisters during the afternoon and evening hours, getting dinner, supervising homework, and doing his own homework. He is a temperamentally shy boy, highly self-critical, has few friends in school, and feels he does not fit in with peers. Charlie's father is unavailable to support the family. As a young adult, Charlie's father made a suicide attempt; however, Charlie is not aware of this history. One of Charlie's sisters is extremely oppositional and has a great deal of conflict with Charlie when mother is absent. Charlie's mother often blames and criticizes him if chores are not completed when she returns from work. On the evening of his suicide attempt, Charlie had just had a fight with his sister who called him names and refused to clean up her dinner dishes. When he called his mother at work to explain the situation, she berated him for not just doing the dishes himself. Charlie went to his room, had feelings of hopelessness about his present and his future, and took all the over-the-counter pain medication that he could find. He did not call anyone but began vomiting several hours later after his mother had returned home. He told her what he had done when she inquired about his vomiting. Risk and Protective Factors with an Emphasis on Family Factors There are a number of risk factors for teen suicidal ideation and behavior, including aspects of the suicidal behavior itself, the presence of psychiatric disorders in the teen, especially mood disorders, personality, temperament and psychological factors, biological factors and familial and family environment factors (see Bridge, Goldstein, & Brent, 2006, for a review). The case example of Charlie illustrates several of these risk factors. For example, although the evidence is sometimes mixed, the literature on specific family factors has shown that parent psychopathology, especially parent depression, substance abuse, and antisocial behavior, function as risk factors (e.g., Melhem et al., 2007). Importantly, a history of suicidal behavior in family members has been related to suicidality in teens (Brent, Kolko, Allan, & Brown, 1990; Brent & Melhem, 2008; Cerel & Roberts, 2005) and a recent population-based study showed that among the strongest independent familial risk factors for youth suicide attempt were sibling, mother, and father suicide attempts (Mittendorfer-Rutz, Rasmussen, & Wasserman, 2008) and having a friend attempt or complete suicide (Borowsky, Ireland, & Resnick, 2001). The results of adoption, twin, and family studies also have generated a fairly extensive empirical literature documenting genetic explanations for familial aggregation of suicidality,

Family-Based Treatments for Suicidal Adolescents including possible intermediate phenotypes (e.g., impulsive aggression, neuroticism) (e.g., Brent et al., 2004; Brent & Melhem, 2008). Thus, the combination of risk factors from psychiatric, psychological, and family domains suggest complex interactions among individual and family biological vulnerabilities and environmental risk in the etiology of suicide and suicide behavior. Within this complex set of interacting risk factors, studies on family interactions and relationships as they relate to teen suicidal ideation and behavior are numerous, although only a subset use prospective designs and still fewer control for the possible influence of other factors. Despite these limitations, there seems to be consistent evidence linking family discord and negative family relationships to teen suicide behavior and ideation (e.g., Asarnow & Carlson, 1988; Brent et al., 2004 Fergusson & Lynskey, 1995; Gould, Fisher, Parides, Flory, & Shaffer, 1996; Kosky, Silburn, & Zubrick, 1990). Indeed, conflict with parents has been directly linked to later adolescent suicidality (Fergusson, Woodward, & Horwood, 2000), and family conflict and unsolved family problems are common stressful events reported just prior to completed and attempted suicides in teens (Berman & Schwartz, 1990; Spirito, Brown, Overholser, & Fritz, 1989). It is notable that generally less attention has been paid to examining how particular family dynamics or characteristics of family functioning may be implicated in adolescent suicidal behaviors. The following section will review findings related to several specific family factors (i.e., perceived support, parent-adolescent relationship quality, communication behaviors, and problem-solving), which have all been associated with adolescent suicidal behaviors. These factors pertain to the case example and inform the case conceptualization and corresponding treatment approach that follows. In the example of Charlie and his family, it is clear that several aspects of his family relationships were highly problematic, and family risk factors may have contributed to his suicidal behavior. Review of the relevant empirical literature on family functioning reveals factors that are present in Charlie's family. For example, Wagner and colleagues (2003) reported that although evidence from cross-sectional studies of family functioning is inconsistent, findings generally suggest that family cohesion, support, and conflict are factors that reliably discriminate between suicidal adolescents and both clinical and nonclinical control groups (e.g., Perkins & Hartless, 2002; Randell, Wang, Herting, & Eggert, 2006; Rubenstein, Halton, Kasten, Rubin, & Stechler, 1998). In terms of longitudinal findings, Lewinsohn and colleagues (1994) examined family support as a prospective predictor of later suicide attempts and found that after controlling for a history of prior suicide attempts, family support did not predict subsequent attempts. However, in a more recent

analysis of the same cohort, low family support predicted suicide attempts into young adulthood for girls, but only low peer support was a significant predictor for boys (Lewinsohn, Rohde, Seeley, & Baldwin, 2001). Results of a recent concurrent study noted similar findings in that for females, family support was negatively associated with suicidal ideation and also with perceived hopelessness, whereas the same association did not hold for boys (Kerr, Preuss, & King, 2006). With respect to relationship quality, Wagner et al. (2003) reviewed studies to date and suggested that problems within parent-teen relationships, especially father-teen relationships, are associated with completed suicide. Fergusson and Lynskey (1995) found that lower maternal emotional responsiveness and greater parental harsh disciplinary practices were prospectively associated with a higher likelihood of suicide attempts in a community sample. There also is some preliminary evidence that a lack of closeness with the father may be a stronger predictor of teen suicidality than is closeness with the mother (e.g., Barrera & Garrison-Jones, 1992; Cole & McPherson, 1993). When framed as a protective factor, there is evidence that a teen's perceptions of connectedness to parents, as well as a sense of connectedness to school, function to protect against suicide in vulnerable populations. This perception is related to feelings of belonging and safety in home and schools and the perception of being cared about (Borowsky et al., 2001). Likewise, family cohesion, wherein teens describe their family life as having a high degree of mutual involvement, shared interests, and emotional support is protective against suicidal behavior, even after controlling for depression and life stress (McKeown et al., 1998; Rubenstein et al., 1998). Several longitudinal studies have examined links between relationship quality and suicidal behavior (e.g., Fergusson et al., 2000; Garber, Little, Hilsman, & Weaver, 1998; Johnson et al., 2002); however, it is important to note that results are largely based solely on self-reported data, with a few notable exceptions. For example, Connor and Rueter (2006) reported that links between observed parental warmth and later adolescent suicidal behavior (i.e., a composite measure of suicidal ideation, suicide plans, and suicide attempts) were mediated by adolescent emotional distress. They also found that whereas observed maternal warmth did predict adolescent suicidality, it did not predict emotional distress (Connor & Rueter). More recent research also has highlighted the significance of cultural context in understanding links between parentadolescent relationship qualities, family functioning, and adolescent suicidal behaviors (e.g., Duarté-Vélez & Bernal, 2007; Greening, Stoppelbein, & Luebbe, 2010; Kuhlberg, Peña, & Zayas, 2010; Zayas, Lester, Cabassa, & Fortuna, 2005).

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Wells & Heilbron In addition to the dimensions of family support and parent-adolescent relationship quality, recent research on how emotionality is expressed within the family system has generated intriguing findings. Wedig and Nock (2007) examined theorized mediators and moderators of the link between parental expressed emotion (EE) and adolescent suicidal and self-harming behaviors. High levels of EE in the family, which may include hostility, emotional overinvolvement, and/or critical comments directed toward a particular member of the family, have been associated with negative outcomes for a range of clinical disorders (see Hooley, 2007, for a review). In a sample of adolescents, Wedig and Nock reported that parental EE was significantly associated with reported suicidal ideation, suicide plans, and suicide attempts. In an analysis controlling for the presence and comorbidity of mental disorders, links between high levels of parental criticism and three suicide-related measures were observed, whereas no associations were found for parental emotional overinvolvement (Wedig & Nock). Additional analyses revealed that self-criticism moderated the association between parental criticism and suicide-related outcomes such that high levels of self-criticism amplified the effect. (Wedig & Nock). With respect to family communication and problemsolving difficulties, an initial review of the empirical literature found limited evidence to support such difficulties as specific risk factors for youth suicidality (Wagner, 1997). Methodological limitations (e.g., reliance on selfreports, emphasis on correlational designs) made it difficult to establish the temporal nature of associations between specific qualities of family interactions and adolescent suicide-related outcomes. There was, however, some evidence that poorer communication, especially with fathers, may be a significant risk factor even after adjusting for other variables (Gould et al., 1996). Findings drawn from more recent, longitudinal studies have provided insights into theorized links between adolescent suicidal behaviors and dysfunctional family communication and problem solving. In a clinical sample of adolescents, Prinstein and colleagues (2000) reported an indirect association between adolescent perceptions of global family dysfunction and self-reported increases in suicidal ideation over time. Results indicated that high levels of family dysfunction predicted increases in adolescent oppositional behaviors and conduct problems, which were in turn associated with increases in depressive symptoms and suicidal ideation. Thus, links between family dysfunction and suicidality in teens may be attributable more specifically to poor family communication and deficits in problem solving ability. In terms of other key factors that are salient within the family context, it is very important to note that physical and sexual abuse, particularly the latter, are strong, largely unmediated risk

factors for attempted and completed suicide in teens (Brent et al., 1999, Fergusson, Horwood, & Lynskey, 1996; Martin, Bergen, Richardson, Roeger, & Allison, 2004; Salzinger, Rosario, Feldman, & Ng-Mak, 2007; Spokas, Wenzel, Stirman, Brown, & Beck, 2009; Wagner, 1997). Whenever suspected physical or sexual abuse is occurring this must be a top priority for reporting according to existing state reporting laws and for interventions aimed at stopping and preventing future abuse. In sum, there seems to be modest evidence in studies utilizing psychiatric controls and prospective designs that family communication and problem solving, family conflict and warmth and closeness in the parent/teen relationship are poorer among suicide attempters and ideators and function as risk/protective factors. The evidence is clear at this point that physical and sexual abuse are strongly associated with suicidality in youth. It should be noted that a number of the factors mentioned above are risk factors for a broad spectrum of child and teen behavior and emotional problems. Moreover, whereas studies often identify discrete family risk factors, the most likely clinical picture in adolescent suicidality is of a teen with multiple risk factors, including possible family risk factors that together expose teens to a high degree of cumulative risk and chronic stress. There also may be important ways that family functioning interacts with other social contexts (e.g., peer relationships) to heighten or mitigate risk of youth suicidal behaviors (e.g., Kidd et al., 2006). Of course, the strongest single predictor of a suicide attempt in youth is a previous suicide attempt (Lewinsohn et al., 1994) and so suicidal teens presenting for treatment who have a history of a previous suicide attempt(s) should be considered at very high risk and needing of timely, effective intervention. Case Example of Charlie: A Review of Risk and Protective Factors Several family factors are salient to the conceptualization of Charlie in the case example described above. Indeed, an assessment of the relevant contributory factors that is guided by the empirical literature on risk factors represents a key component of the development of a treatment plan. In Charlie's case, it appears from the description that numerous stressors have been present in his family environment (e.g., conflict with his mother and siblings, limited family support, parental psychopathology, absence of a connection with the father, financial stresses in the household, feelings of not belonging in school). A thorough developmental/clinical history was taken to explore other possible individual risk factors in Charlie's background, with particular attention to any previous suicide attempts or self-harm behavior, symptoms of depression or other forms of internalizing psychopathology, conduct problems, substance use, and

Family-Based Treatments for Suicidal Adolescents school performance. Assessment of Charlie's social functioning (e.g., peer and sibling relationships), careful assessment of parental psychopathology and family history of suicide, and a review of other psychiatric illness in the family was completed (see Rudd et al., 2001, for an example of guidelines for clinical assessment of suicide risk). Results of this assessment revealed that Charlie had no suicide attempts prior to the index attempt; however, he did report having been depressed and anxious for quite some time. He denied any substance use or history of physical or sexual abuse. Charlie's mother described her son as highly self-critical and said their relationship had been strained since his dad left the family. She described herself as an extremely stressed parent who has frequent verbal arguments and conflict with Charlie because he did not assume enough responsibility in the household. On the other hand, she acknowledged that her expectations of Charlie were probably too high. She said she felt significant anxiety, depression, and guilt about Charlie's suicide attempt. She also reported anxiety about the possibility that Charlie would make another suicide attempt and that she did not have the resources to monitor him while she was at work, which amplified her worry. Family-Based Interventions for Suicidal Youths The empirical literature on family-based treatments for depressed and suicidal youth is not voluminous although a brief overview of that literature is elucidating with regard to how interventions have developed to address risk factors outlined above. Goals of treatment in these studies have often focused broadly on improving parental knowledge about teen depression and suicidality (i.e., psychoeducation; Brent et al., 1993; Fristad, Gavazzi, Centolella, & Soldano, 1996), involving the parents/caregivers in safety monitoring and plans (Huey et al., 2004; Stanley et al., 2009), improving family communication and problemsolving thereby decreasing parent-teen hostile conflict, and increasing parent-teen positive interactions and closeness (Diamond et al., 2010; Harrington et al., 1998; Miklowitz & Taylor, 2006; Rotheram-Borus, Piacentini, Cantwell, Belin, & Song, 2000, Rotheram-Borus, Piacentini, Miller, Graae, & Castro-Blanco, 1994; Stanley et al., 2009). A variety of treatment approaches or programs have been designed to address some or all of the aforementioned treatment goals. These treatments include attachment-based family therapy (ABFT; e.g., Diamond, Reis, Diamond, Siqueland, & Issacs, 2002; Diamond et al., 2010), multisystemic family therapy (MST; e.g., Huey et al., 2004), a home-based family intervention (Harrington et al., 1998), a family-focused treatment for individuals with bipolar disorder and suicidal thoughts and behaviors (FFT; e.g., Miklowitz & Taylor, 2006), an intensive and highly structured, six-session family therapy program

(SNAP; e.g., Rotheram-Borus et al., 1994), and a YouthNominated Support Team (YST, e.g., King et al., 2006). A review of the various facets of all of these treatments is beyond the scope of this article; however, it is notable that there is considerable overlap in the treatment targets across these different approaches (see Fristad & Shaver, 2001; Spirito & Esposito-Smythers, 2008, for reviews). In addition, given that many of the family risk factors that have been linked to suicidality have also been associated with other difficulties, it is the case that some of the aforementioned treatment goals (e.g., improving family communication and problem solving) and corresponding treatments are applicable to treating a range of psychological disorders. That being said, there are several goals and treatment components that are specific to suicide (e.g., developing a safety plan for suicidal crises) and specific, identifiable risk factors for suicidal behavior (e.g., hopelessness, absence of future thinking, limited problem-solving ability, impulsivity) that are addressed within the context of these interventions. Moreover, because of the prominent role of familial conflict in the lives of many suicidal adolescents, it follows that involving the family, and specifically the parents/caregivers, in the treatment of adolescent suicidal behaviors is clearly warranted. The most comprehensive approach to the development of CBT-based treatment for decreasing suicidal behavior in teens, anchored in knowledge of the risk factors reviewed earlier and utilizing all of the treatment approaches reviewed above, was undertaken recently by the TASA study team (Treatment of Adolescent Suicide Attempters; e.g., Brent et al., 2009). The treatment, Cognitive-Behavioral Therapy for Suicide Prevention (CBT-SP), was developed using a risk reduction and relapse prevention approach and grounded in the principles of cognitive-behavioral therapy, dialectical behavior therapy, and targeted interventions for suicidal behavior (Stanley et al., 2009; TASA CBT Team, 2008). The treatment is an in-depth, manualized treatment that includes individual youth treatment and coordinated intervention with family (i.e., responsible caretakers) over the course of 6 months, with about 20 to 24 sessions over the 6 months (TASA CBT Team, 2008; see Stanley et al., for more detail). The treatment was developed to be delivered either with or without concurrent medication therapy. The treatment focuses specifically on prevention of future suicidal behavior in youth, and can be implemented with youth having a variety of other background psychiatric/psychological problems. CBT-SP was developed to be as comprehensive as possible in terms of addressing known teen and family risk factors and family interventions for suicidal youth behavior, and as such, it will be used as the template for discussion of family intervention for suicidal youth. Please note that the

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reader should assume that other interventions at the individual (e.g., individual CBT with the youth) and/or biological (e.g., pharmacologic treatment of major psychiatric disorder) and/or systemic levels (e.g., school consultation for the teen's academic problems) may also be occurring as indicated by the evaluation of the teen, and that intervention with the parents/family is integrated with these other treatments. The application of the CBT-SP treatment to the case example of Charlie and his family also will be described below. CBT-SP Family Intervention for Suicidal Teens Initial Sessions There are several goals for the initial meeting(s) with parents of a suicidal teen. The clinician should consider the possibility that parents are frequently anxious, scared, and sad and/or may be very angry or resentful following their teen's suicide attempt. Conversely, some parents may be in denial about the urgency of the situation, seeing it as an anomalous event that “won't happen again.” It is important for the clinician to meet with the parents initially to hear their story regarding the suicide attempt, listen to their thoughts and feelings about it, and assess their level of motivation for treatment. Listening to and empathizing with their experience is critical to establishing a working alliance with the parents that is based on mutual trust. This is crucial because parents have legal responsibility for their teen, for his/her future safety, and are often the ones who will insist that the teen continue to go to treatment or even drive the teen to treatment. Parents may need support as they grapple with feelings of responsibility, guilt, fear, or sadness, or conversely, blaming anger at the teen. Having someone initially to express these emotions to, and to provide coping assistance, can help the parents along a process of focusing on the teen and aiding in his/her treatment. Thus, it is useful to provide a session or sessions to the parents without the teen present in the initial week of treatment. Hearing the parents’ story is also useful in filling in the links in the “chain analysis,” which involves systematically identifying the vulnerability factors and precipitating events associated with the suicide crisis and the individual's thoughts, feelings, and behaviors in response (Stanley et al., 2009). Thus, by understanding the events surrounding the suicide attempt, the clinician develops an understanding of the sequence of proximal and distal cognitive, behavioral, and interactional events (often family interactions) that preceded the attempt. Parents can provide useful input on links in the chain that adolescents forget or fail to report. The chain analysis is used later in case conceptualization to aid in selection of treatment modules for use in the adolescent's treatment, some of which may be family interventions (Stanley et al.).

Another goal of the first two sessions with parents is to discuss their role in their teen's safety plan. In essence, the safety plan is a clear, prioritized list of steps that a person could take in an emergent suicidal crisis (see Stanley et al., 2009, Stanley & Brown, in press, for more detail). In this regard, the first item on the parents’ version of the safety plan is to specify exactly how they will make the home safe. This may involve a discussion of specific steps for removing any guns that may be present from the home, or securing them if the parents refuse to remove them entirely. Studies by Brent and others have demonstrated a clear association between the presence of guns in the home and completed suicides in adolescents and young adults in the United States (Brent et al., 1988; Brent et al., 1993; Miller, Azrael, Hepburn, Hemenway, & Lippmann, 2006). Accordingly, removal of guns from the home should be discussed with parents early in treatment. If the parents refuse to do so, then keeping the gun(s) unloaded, locked, and ammunition secured should be negotiated as part of a family safety contract. These recommendations are consistent with the clinical directives in the practice parameters for working with suicidal children and adolescents that are set by the American Academy of Child and Adolescent Psychiatry (AACAP, 2001), and a policy statement on firearms safety presented by the American Academy of Pediatrics (AAP Committee on Adolescents, 1992). Likewise, other potentially lethal means such as knives or other sharp objects, chemicals, or medications that could be used in a suicide attempt should be removed or secured. This may involve completely removing such items from the home, locking them in cabinets or cupboards to which only the parents have the key, or having parents buy lock boxes or safes for storing potentially lethal items (Stanley et al., 2009). A safety plan also begins to be constructed with the teen in the first session of teen treatment. The top steps of the safety plan usually involve individual strategies that the teen can employ when experiencing an increase in suicidal ideation or intent. However, in the event that individual strategies are not successful, it is useful and important to specify how the parents will be involved. This usually involves negotiating an agreement with the teen that if individual steps are not successful, the teen will tell his parents about his suicidal thoughts/intentions. Especially if the teen is unwilling to agree to inform his parents, the clinician should discuss with the parents the early behavioral warning signs of teen suicidality (such as acute increases in irritability or withdrawal) and ways the parents can address their observations and concern with the teen. There is explicit discussion of the plans for monitoring the teen in these circumstances (i.e., ensuring that the teen is not left unattended) and for contacting mental health professionals and/or bringing the teen to the emergency room if necessary (Stanley et al., 2009).

Family-Based Treatments for Suicidal Adolescents Once these elements of the parental role in the safety plan are discussed and negotiated, a decision is made whether to merge the two plans into one (i.e., the teen's plan and the parent's plan) or to have two separate plans. However, in either case, all parties know what is on the respective plans so that appropriate action can be taken in the event of a suicidal crisis. Thus, adolescent clients know, even if they do not agree, that their parents will take action to keep them safe if this becomes necessary. A third major goal of the first sessions of family intervention is to provide psychoeducation for the parents about teen suicidality and about CBT treatment. The former is especially important for parents who may be engaged in denial regarding the urgency of their teen's clinical situation or who may be dismissing the suicidal attempt as “only a gesture,” a way of getting attention, a way of manipulating the parents, or an event that could not possibly happen again. Information about the elevated risk for a future attempt in any adolescent who has made an attempt, about the fact that even seemingly manipulative kids sometimes kill themselves, and that a cry for attention may also be seen as a cry for help, should be presented. Likewise, the nature and rationale for CBT should be discussed with the parents, including a discussion of the collaborative nature of the treatment as it will involve the therapist, the teen, and the parents all working together on identified risk factors for the adolescent and the family system. Thus, the treatment will be personally focused and relevant, with all parties sharing responsibility to prevent future suicide attempts. In treating suicidal teens and their parents, our clinical team has frequently lamented that it is not possible to wave a magic wand and give families everything that they need in the first two sessions. Given this impossibility, it is frequently necessary to “negotiate a truce” around hot topics and conflicts that have been identified as links in the chain analysis for the suicide attempt. Family conflict around a hot issue (such as curfew violations) or unresolved problems (e.g., the teen breaks up with his girlfriend and his hopelessness about this event precipitated a suicide attempt) may be difficult to address in families early in treatment if the family has poor communication and problem-solving skills. While these skills will be addressed in later sessions, ongoing unresolved, especially hostile conflict could in the meantime be a trigger for another suicide attempt. Thus, gaining an agreement in the first session(s) that there will be a moratorium on any discussion of “hot topics” is crucial. That is, the family members agree to disengage from discussions of these topics when they arise at home, with the understanding that they will be addressed later when the family and clinician have worked on good communication and problem-solving skills. The specifics of how to disengage are discussed with

the parents and teen, such as the statement, “I'm not going to discuss this with you now; I'm going to another room, and let's just agree we will talk about this later.” Disengaging from discussions of hot topics might even be role-played in the session since practicing this skill could be useful in promoting implementation in a situation of high emotionality at home. It is important to note that although family members are discouraged from discussing “hot topics” outside of the therapy sessions, it remains critical that therapists work with families to establish guidelines for how particular “house rules” will be handled during the initial treatment phase. This is especially true for rules that pertain to ensuring an adolescent's safety. As noted above, if a “hot topic” is related to the enforcement of rules in the home (e.g., curfew times), it behooves the therapist to address this directly with the family at the outset of the therapy to ensure that both the parents and the adolescent are aware of the explicit plan for discussing these issues at a future time. It may be that the family can agree on a very specific set of rules with the clear understanding that the topic will be revisited later in therapy. Moreover, the family may agree that the consequences for any rule-breaking behavior will be discussed in therapy at a subsequent session. For example, the therapist may suggest that if a teenager breaks curfew, the parents could make a note of the details of the incident(s) and share that with the therapist as an agenda item for a future session. In many cases, parents should be encouraged to ignore relatively inconsequential rulebreaking behaviors during this moratorium on “hot topics.” In terms of the case example, treatment with Charlie was initiated that involved individual CBT with him and family intervention with him and his mother. In working with his mother initially, the therapist listened to her story of Charlie's suicide attempt, her feelings surrounding it (guilt, anxiety, fear) and her own feelings of being anxious, depressed, and overwhelmed. She was worried about Charlie, but also worried about her daughters and what they needed. She suspected that her oldest daughter in particular may have been abused, but she had not taken steps yet to have this evaluated. Early interventions for Charlie's mother involved referring her for her own evaluation for anxiety and depression, and referring her to a center specializing in child trauma for her daughter. In the meantime, the therapist empathized with Charlie's mother's extremely overstressed life, and understood why she would come to lean on Charlie, but discussed that the burdens of parenting his two sisters were also overwhelming for Charlie. Therefore, another early intervention focused on working with the mother to obtain help from adults (friends in the neighborhood and adult family members) who could come to the home and be with her

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children while she was at work, thus relieving Charlie of babysitting responsibilities. The therapist also worked with Charlie's mother on strategies to handle situations in which Charlie did not complete his chores. Charlie's mother was encouraged to praise Charlie's positive behaviors (e.g., “I really appreciated all of your help cleaning up after dinner.”) and to generally ignore behaviors that reflected noncompliance or rule-breaking related to relatively inconsequential issues (e.g., not doing all of his chores, not turning off the TV on time). Case Conceptualization and Treatment Goals in the Middle Phase of Treatment Once the family goals in the first phase of treatment have been addressed, it is then necessary to move on to interventions that address family factors identified in the conceptualization of the case. As discussed in this and other articles (e.g., Stanley et al., 2009), the case conceptualization arises out of the chain analysis that is performed at the beginning of treatment. In this analysis, proximate and distal antecedent and consequent events to the teen's suicide attempt have been explored. Family interactions are included in that assessment. Often those factors identified in our earlier review of family risk factors will play a part in a particular teen's suicide chain analysis (i.e., harsh discipline, family hostile conflict, unresolved family problems, lack of perceived support from parents/family cohesion). Once the details of all the proximal and distal antecedent events, including family interactional events, are detailed, the clinician constructs an individualized case conceptualization. This process involves highlighting the contributory events for the particular teen and planning how these events may be addressed in an integrative fashion. Interventions are selected that map onto the individual's precipitating events (e.g., problemsolving skills in a case in which conflictual interactions around unresolved problems was a precipitating event) and interventions are integrated in an overarching CBT approach. For example, in the case in which parent-teen conflict around an unsolved problem was a proximal event, the therapist might teach the parents and teen problem-solving skills in separate meetings and then bring them together to practice in a joint session. In selecting the type and order of interventions, priority is given to those risks deemed to be most closely related to the risk of a future suicide attempt. Thus, in the case conceptualization approach in working with parents, clinicians select and utilize interventions that map directly onto the family interaction variables or events that are relevant for the case. In addition to family problem solving, these might include interventions addressing family communication, improv-

ing family support and cohesion, skills for effective limit setting with teens, and so forth. Of course, intervention with parents assumes that the parent is motivated and involved enough with their teen and with treatment to participate actively in sessions. This is not always the case and when the parent cannot be engaged, treatment will shift more to individual work with the teen. Likewise, parents presenting with parent psychopathology such as depression or anxiety or substance abuse, may need a referral for their own treatment before they are available for involvement in their child's treatment or may need restricted homework assignments. For example, one anxious and depressed mother was not able to implement a full token economy system with her child. However, she was able to implement a much simpler system of delivering one reward per day for one behavior. Summary of Structuring the Family Intervention In summary, consistent with other CBT-based approaches, there is a clear session structure to family intervention sessions with a suicidal teen. As already discussed, the first 2 to 3 sessions with the parents involve inviting the parents to tell their story of the suicide attempt, developing the parents’ responsibilities in the safety plan, incorporating parent input into the chain analysis of the suicide attempt, and selecting possible interventions based on the chain analysis. Subsequent sessions always begin with collaborative agenda setting. In this process the therapist and parents together decide on the issues to be addressed in the session based on the ongoing situation with the particular teen as well as the case conceptualization. Agenda setting is guided by the goal of working on those issues that are most likely to prevent another suicide attempt. Accordingly, if hostile, angry interaction with parents was a proximal event to the teen's suicide attempt, family communication may be selected as an initial important skill to work on. It also should be noted that if the adolescent and parent(s) do not share the goal of reducing future suicidal behaviors, it is imperative that the clinician work with the family to sensitively address differing goals and address any issues that may arise regarding motivation for treatment. This is discussed in more detail below (see “Other Treatment Considerations and Challenges”). Once an agenda for the session is set, it is important to check in on the safety plan and any modifications or additions that are needed. Parents are asked about their reactions or questions regarding the previous sessions and how homework implementation, if any, has gone. Then, review of the new skill that has been selected or further practice and role-playing of a previously taught skill takes place as indicated by the agenda setting process. Likewise, previously taught skills can be brought to bear on real-

Family-Based Treatments for Suicidal Adolescents time events that are occurring in the family, as these are related to reducing factors related to possible future suicide attempts. Towards the end of the session, the work in that session is summarized and a homework assignment, if relevant, is given. The details of the homework practice are clearly discussed so that parents know precisely what, when and where they are practicing that week. Teens may or may not be present in meetings with parents. For example, it may be that teaching parents and teen the skill of problem-solving in separate sessions is most efficient for initial introduction of skills. Thereafter, parents and teen may be brought together for practice of family problem-solving together. The therapist should use flexibility with regard to the best approach with a particular family. But in all cases, the overarching goal is to implement those interventions that are most likely to be useful in prevention of future suicide attempts. Applying Key Components of CBT-SP Treatment to Families A central feature of CBT-SP is that the individualized case conceptualization is designed to target specific problem areas and to identify interventions that may be applied during times of pronounced emotional distress. Thus, although the treatment is manualized, clinicians are encouraged to administer therapy flexibly to address the styles, strengths, and needs of particular adolescents and their families. The most commonly used strategies that were detailed in the TASA project are described below (Brent et al., 2009; Stanley et al., 2009). Other manuals are also available that reference these skill areas and domains. Decreasing Family Negative Interactions High levels of negative and hostile family interactions usually emanate from poor family communication skills, poor family problem-solving abilities and high levels of negative emotions within and shared among family members. Addressing these problem areas seems to be among the most frequently utilized CBT approaches in treatment studies with suicidal youth across many of the empirical studies cited earlier. Often, it is necessary to begin with poor communication because initial efforts at problem solving often break down in families that cannot speak to one another without a high level of name-calling, blaming, threatening, lecturing, and so forth. Communication Skills In addressing communication, therapists can begin by talking with families about negative communication behaviors that cause problems in their family. Handouts listing negative communication behaviors can be useful in

providing structure and managing in session negative behaviors initially. Such behaviors (e.g., yelling, namecalling, blaming, use of “you” statements, sarcasm, putdowns) are likely to make others angry and defensive, which does not often lead to effective solutions. The list is reviewed and family members are asked to indicate which of the behaviors reflect problems in their family, how the use of these behaviors makes family members feel, and whether family members think these behaviors are useful in solving family problems. Alternatively, in highly guiltridden families, these can be presented as habits that occur in many families, but that can be especially problematic in families with interpersonal sensitivities related to depression and suicidality. Once an agreement is reached that these are change-worthy targets, the therapist then presents the skills involved in active listening and sending clear messages. Active listening involves listening calmly, quietly, and attentively; summarizing what the speaker has said (whether one agrees or not) asking the speaker if the summary is correct; and repeating the process until the listener gets it correct. It is very important to emphasize that a listener can listen without necessarily agreeing with the content of what is said. Negotiating and compromising on differences in opinion comes later. Listening skills are emphasized as an important starting point. Sending clear messages is a skill that involves keeping verbal and nonverbal messages consistent (do not laugh when you are saying you are sad); being specific rather than vague; and using “I” statements about what you want rather than “You” statements attacking the other person (Stanley et al., 2009). As easy as these skills may seem, they are really quite difficult and families need to practice them in order to gain control over negative communication. Therapists can role-play these skills initially using examples from lowconflict situations that come up at home and guide parents and teen through the role-play. The therapist should also ask the family's permission to stop them in subsequent sessions whenever they revert to negative communication and to allow the therapist to redirect the family to use positive communication skills. The homework assignment would be to begin to use positive communication skills at home, starting first with circumscribed, short-term practices, gradually building the use of these skills across time and content areas for discussion. Family Problem Solving Once families are better able to communicate, family problem solving can be used to help the family address unresolved problems that result in chronic or repeating hostility and conflict. Family problem solving involves teaching the family the steps involved in effectively addressing problems and then assisting them to role-

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play a low-level family problem in session followed by utilization of the model at home. We have used the RIBEYE method, first developed by Curry et al. (2000) and Wells and Curry (2000), which refers to:

Relax Identify the problem Brainstorm Evaluate say Yes to one Encourage yourself

Parents and teen are taught the steps in this model and then using worksheets, work together through a low-level problem in a session led by the therapist. In subsequent sessions, as problems come up for discussion, the therapist can continually utilize the problem-solving method to address the problem. Eventually, homework assignments are given to utilize this strategy at home. As always, good communication skills are prompted throughout the problem-solving discussion. Family Emotion Regulation Many teens with suicidal behaviors experience emotion dysregulation in high-conflict family situations and parents of teens may as well. A variety of emotion-regulation strategies are available for use with teens, such as the use of distraction, emotion thermometers, relaxation strategies, the use of “opposite action” (i.e., acting contrary to an emotion by changing posture and facial expressions; see Linehan 1993), mindfulness, etc. Parents can also be informed about these strategies: for example, in family meetings, the parents and teen can discuss how, when, and where they will all employ emotion-regulation strategies to calm themselves during discussions of problems or conflicts that are associated with negative emotions at home. As with previous skills, once these strategies are taught and selected, the therapist can then prompt the use of the skills and strategies in therapy meetings in which the family is discussing an issue. For example, if a parent and teen come to session with a hot topic involving curfew violations, the therapist can suggest the use of the problem-solving model to discuss the issue, and then prompt parent and teen to use emotion regulation and good communication when discussing the issue. In this way, three strategies are brought to bear with the overarching goal of reducing negative, hostile conflict. Increasing Positive Family Interactions As reviewed previously, a lack of family support and cohesion has been identified as another set of risk factors for teen suicide. When this is an issue for the teen, several approaches are available for use in sessions.

Family Pleasant Activities As part of a behavioral activation treatment component with depressed suicidal teens, therapists often will work on assisting the teen in increasing their engagement in pleasant activities. Behavioral activation refers to increasing participation in activities that are likely to create opportunities for reward in the environment (see Jacobson, Martell, & Dimidjian, 2001, for review of behavioral activation). The practice of teaching adolescents to monitor pleasant activities and thoughts using daily diaries or other means is a common feature of cognitive-behavioral treatments for depression and has been discussed in the context of selfharm behaviors (see Harrington & Saleem, 2003). Families are often involved in this as well for two reasons: first, so that parents can assist the teen as necessary in embracing pleasant activities (e.g., driving the teen to a movie theater); second, engaging in shared family pleasant activities can further behavioral activation in a depressed, suicidal teen but also work toward improving a sense of family cohesion that is protective against suicide behavior. Examples of shared family pleasant activities might be picking out and watching a movie at home together, going out to a movie or dinner together, going to a gym together, going on walks, hikes, or runs outdoors together, signing up for an organized race, training for it, and running it together. The latter activities have the additional feature of increasing exercise which itself has been demonstrated to be an efficacious treatment for depression, at least in adults. Addressing High Expectations and Low Reinforcement Often in families with depressed, suicidal teens, parents may display excessively high expectations for teen performance with commensurate low levels of praise or reinforcement of the teen. For example, we have worked with average-IQ teens whose parents nevertheless expect “all A's” from the teen at school. Because the teen cannot meet this expectation, the parents withhold praise or may even criticize the teen excessively for B's and C's that would be entirely predictable given the teen's IQ. Alternatively, depressed teens may experience a temporary decrease in school grades due to difficulty concentrating and low energy associated with depression and parents may withhold praise and criticize the teen. In either example, it is important to work with parents on adjusting their behavioral expectations to be more realistic and to work with them directly on increasing their praise and reinforcement of the teen. The procedure involved in “catch your child being good,” often utilized in the Parent Management Training literature, (e.g., Wells et al., 1996) can be brought to bear with parents of depressed suicidal teens as well. The therapist specifically discusses with the parents behaviors and performance levels to “catch” and then models and role-plays with parents specifically how to praise the teen at home. As with previous skills, the therapist can also prompt

Family-Based Treatments for Suicidal Adolescents this skill in every subsequent session once it has been introduced. For example, in the treatment studies conducted by Rotheram-Borus and colleagues (e.g., RotheramBorus et al., 1994; Rotheram-Borus et al., 1996; RotheramBorus et al., 2000), therapists begin every session by having parents and teens say something positive to each other. The interventions discussed above are the most commonly used interventions in treatment studies with the parents of suicidal teens. Other interventions that may be suggested by the case conceptualization also may be used. Examples are family emotion regulation for use in high-EE families. Parents are taught some of the same distress tolerance techniques that their teen learns in individual treatment and all family members are prompted to utilize these techniques in family interactions as needed. Contingency management strategies may also be needed in some families with limited ability to set limits with their teen. Modules describing these strategies are presented along with the others discussed above in the TASA CBT-SP manual (TASA CBT Team, 2008). In the case of Charlie and his mother, sessions initially focused on communication skills because the immediate precipitant to Charlie's suicide attempt had been an angry, blaming interaction with his mother. Charlie and his mother did an excellent job learning communication skills and began to practice them at home and in the car on the way to and from sessions. This was quickly followed by teaching Charlie's mother problem solving-skills at the same time that Charlie's individual therapist was addressing this with Charlie. The mother and son then used the problem-solving format to discuss problems that Charlie identified, such as needing time to himself away from his sisters. Subsequently, the therapist also worked with Charlie's mother on implementing effective contingency management strategies with Charlie and her daughters at home. An important aspect of this plan was removing Charlie from the responsibility of administering consequences to his sisters. A plan was developed in which mother decided on house rules and expectations, Charlie tracked whether his sisters performed their expectations in mother's absence, and mother delivered back-up consequences when she got home, thus removing Charlie from this conflictual role with his sisters. Charlie's mother was encouraged to follow through with more work on effective family management practices with the therapist at the child trauma agency that had accepted the daughter as a patient. Ending Phase of Treatment In the final phase of treatment, the work with parents revolves around discussions with parents and teen about the importance of continuing to employ new skills and modes of interaction as therapy is faded. The therapist can help the family to anticipate new issues that may develop over the

next years and ask the parents and teen to discuss how they might approach new issues with new skills. Likewise, the importance of being alert to signs that the teen may become suicidal again and to be ready to implement safety plan procedures in the future should be discussed. This is particularly important for teens who have a potentially recurring disorder such as major depression. Finally, careful consideration should be given to disposition planning in the final phase of treatment. Many suicidal teens will need ongoing monitoring for recurrence of suicidal thinking, booster sessions and/or treatment for other issues or disorders not necessarily addressed in the treatment described here. Therefore, once the intensive treatment phase is over, appropriate ongoing contact or referral should be provided. With respect to the case example, over the course of the individual and family treatment, Charlie's depressed mood and anxiety decreased significantly and thoughts of suicide receded. His grades improved during the 6 months of treatment as he was able to devote more time to his own homework with the relief from responsibilities towards his sisters. The disposition included continued individual treatment, albeit on a less frequent basis, to continue to monitor Charlie's mood and suicidal ideation and to assist him in continuing to address his social isolation. This case illustrates the parent/family intervention component of working with a suicidal teenager. As can be seen, treatment with the parent, in this case an extremely stressed single parent, focused on the proximal (angry, hostile parent-teen interactions; poor parent-teen problem solving) and distal (mother's anxiety, depression and overburdened approach to parenting) family factors that were most directly relevant in the chain analysis of this teen's suicide attempt. Parent/family interventions were brought to bear on these factors, while Charlie simultaneously addressed individual factors related to his feelings of hopelessness about the present and the future in his individual treatment. The resulting combination treatment produced a diminution of depression and suicidal thoughts and urges. Charlie continued to do well at 12-month followup, albeit continuing in individual therapy where he was addressing issues related to social skills and engagement. Other Treatment Considerations and Challenges Although CBT-SP provides a framework for integrating individual and family-based intervention strategies, it is important to note that work with suicidal adolescents often presents significant challenges that require careful consideration within the context of the manualized treatment. Adolescents who are suicidal may also present with comorbid diagnoses, complex psychiatric histories, and highly conflict-ridden family systems. Such cases require careful assessment and management of suicide

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risk, as well as appropriate referrals for additional services when indicated. It also has been acknowledged that as many as half of all adolescents who make suicide attempts do not receive follow-up clinical services, and a significant proportion of adolescents who do receive care do not complete the full course of treatment (Spirito et al., 1989; Trautman, Stewart & Morishima, 1993). Accordingly, engaging adolescents and their parents early in treatment is imperative. It is important to note that failure to adhere to treatment recommendations may be as a result of parent and/or adolescent nonengagement. Berman, Jobes, and Silverman (2006) strongly suggest that clinicians be careful not to collude with parents who wish to forgo recommended family therapy and instead have the adolescent seen only individually. Notwithstanding the caution above, other challenges relate to situations in which family therapy may be contraindicated for the adolescent. Although there are no established guidelines for making such determinations, Berman et al. (2006) describe circumstances in which involvement of parents or other family members may not be in the best interest of the adolescent. For example, they suggest that a clear lack of motivation or adherence on the part of parents may warrant a focus on individual treatment. They also recommend that individual therapy may be more appropriate for older adolescents and for those cases in which peer issues are the primary therapeutic concerns. Clinicians must also evaluate a parent/caregiver's capability of providing the care and monitoring needed to ensure the adolescent's safety, and refer parents/caregivers for individual treatment when necessary (Berman et al.). All being said, family involvement, even at a minimal level, is essential for practicing within the standards of care published by the American Academy of Child and Adolescent Psychiatry (AACAP, 2001). Conclusions In summary, many questions remain unanswered regarding the most effective treatments for reducing adolescent suicide attempts; however, empirical evidence linking family functioning variables (e.g., parent-adolescent conflict, family cohesion) and adolescent suicidal behaviors provides a clear rationale for interventions directed to parents in the overall treatment for suicidal teens. Moreover, a growing research literature supports the use of treatment approaches predicated on the principles of cognitive-behavioral therapy, such as the CBT-SP protocol. The CBT-SP is a manualized treatment designed to reduce risk and prevent relapse of suicidal behaviors by combining individual therapy and a coordinated parent-based intervention. Although this comprehensive treatment shows much promise, research efforts aimed at extending our knowledge base on how to most effectively intervene with

suicidal adolescents and their families remains a critical research imperative.

References American Academy of Child and Adolescent Psychiatry. (2001). Practice parameters for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 40(Suppl), 24S–51S. American Academy of Pediatrics Committee on Adolescents. (1992). Firearms and adolescents. Pediatrics, 89, 784–787. Asarnow, J. R., & Carlson, G. (1988). Suicide attempts in preadolescent child psychiatry inpatients. Suicide and Life-Threatening Behavior, 18, 129–136. Barrera, M., & Garrison-Jones, C. (1992). Family and peer social support as specific correlates of adolescent depressive symptoms. Journal of Abnormal Child Psychology, 20, 1–15. Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). Adolescent suicide: Assessment and intervention (2nd ed). Washington, DC: American Psychological Association. Berman, A. L., & Schwartz, R. H. (1990). Suicide attempts among adolescent drug users. American Journal of Diseases of Children, 144, 310–314. Boergers, J., & Spirito, A. (2003). The outcome of suicide attempts among adolescents. In A. Spirito & J.C. Overholser (Eds.), Evaluating and treating adolescent suicide attempters: From research to practice (pp. 261–276). New York: Academic Press. Borowsky, I. W., Ireland, M., & Resnick, M. D. (2001). Adolescent suicide attempts: Risks and protectors. Pediatrics, 107, 485–493. Brent, D. A., Baugher, M., Bridge, J., Chen, T., & Chiappetta, L. (1999). Age- and sex-related risk factors for adolescent suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1497–1505. Brent, D. A., Greenhill, L. L., Compton, S., Emslie, G., Wells, K., Walkup, J. T., . . . Turner, J. B. (2009). The treatment of adolescent suicide attempters study (TASA): Predictors of suicidal events in an open treatment trial. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 987–996. Brent, D. A., Kolko, D. J., Allan, M. J., & Brown, R. V. (1990). Suicidality in affectively disordered adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 586–593. Brent, D. A., & Melhem, N. (2008). Familial transmission of suicidal behavior. Psychiatric Clinics of North America, 31, 157–177. Brent, D. A., Oquendo, M., Birmaher, B., Greenhill, L., Kolko, D., Stanley, B., . . . Mann, J. J. (2004). Familial transmission of mood disorders: Convergence and divergence with transmission of suicidal behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 1259–1266. Brent, D. A., Perper, J. A., Goldstein, C. E., Kolko, D. J., Allan, M. J., Allman, C. J., & Zelenak, J. P. (1988). Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45, 581–588. Brent, D. A., Poling, K., McKain, B., & Baugher, M. (1993). A psychoeducational program for families of affectively ill children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 770–774. Bridge, J. A., Goldstein, T. R., & Brent, D. (2006). Adolescent suicide and suicidal behavior. Journal of Child Psychology and Psychiatry, 47, 372–394. Brown, G. K., Jeglic, E., Henriques, G. R., & Beck, A. T. (2006). Cognitive therapy, cognition, and suicidal behavior. In T. E. Ellis (Ed.), Cognition and suicide: Theory, research, and therapy (pp. 53–74). Washington, DC: American Psychological Association. Cerel, J., & Roberts, T. A. (2005). Suicidal behavior in the family and adolescent risk behavior. Journal of Adolescent Health, 36, 9–16. Cole, D. A., & McPherson, A. E. (1993). Relation of family subsystems to adolescent depression: implementing a new family assessment strategy. Journal of Family Psychology, 7, 119–135. Connor, J. J., & Rueter, M. A. (2006). Parent-child relationships as systems of support or risk for adolescent suicidality. Journal of Family Psychology, 20, 143–155.

Family-Based Treatments for Suicidal Adolescents Curry, J. F., Wells, K. C., Brent, D. A., Clarke, G. N., Rohde, P., Albano, A. M., . . . March, J. S. (2000). Treatment for Adolescents with Depression Study (TADS). Cognitive behavior therapy manual: Introduction, rationale, and adolescent sessions. Retrieved from. https://trialweb.dcri.duke. edu/tads/tad/manuals/TADS_CBT.pdf Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L., & Issacs, L. (2002). Attachment-based family therapy for depressed adolescents: A treatment development study. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 1190–1196. Diamond, G. S., Wintersteen, M. B., Brown, G. K., Diamond, G. M., Gallop, R., Shelef, K., & Levy, S. (2010). Attachment-based family therapy for adolescents with suicidal ideation: A randomized control trial. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 122–131. Duarté-Vélez, Y., & Bernal, G. (2007). Suicide behavior among Latino and Latina adolescents: conceptual and methodological issues. Death Studies, 31, 425–455. Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood, II: Psychiatric outcomes of childhood sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1365–1374. Fergusson, D. M., & Lynskey, M. T. (1995). Childhood circumstances, adolescent adjustment, and suicide attempts in a New Zealand birth cohort. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 612–622. Fergusson, D. M., Woodward, L. J., & Horwood, L. J. (2000). Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood. Psychology Medicine, 30, 23–39. Fristad, M. A., Gavazzi, S. M., Centolella, D. M., & Soldano, K. W. (1996). Psychoeducation: A promising intervention of strategy for families of children and adolescents with mood disorders. Contemporary Family Therapy, 18, 371–383. Fristad, M. A., & Shaver, A. E. (2001). Psychosocial interventions for suicidal children and adolescents. Depression and Anxiety, 14, 192–197. Garber, J., Little, S., Hilsman, R., & Weaver, K. R. (1998). Family predictors of suicidal symptoms in young adolescents. Journal of Adolescence, 21, 445–457. Gould, M. S., Fisher, P., Parides, M., Flory, M., & Shaffer, D. (1996). Psychosocial risk factors of child and adolescent completed suicide. Archives of General Psychiatry, 53, 1155–1162. Greening, L., Stoppelbein, L., & Luebbe, A. (2010). The moderating effects of parenting styles on African-American and Caucasian children's suicidal behaviors. Journal of Youth and Adolescence, 39, 357–369. Harrington, R., Kerfoot, M., Dyer, E., McNiven, F., Gill, J., Harrington, V., Woodham, A., & Byford, S. (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, 512–518. Harrington, R., & Saleem, Y. (2003). Cognitive behavioral therapy after deliberate self-harm. In R. A. King & A. Apter (Eds.), Suicide in children and adolescents (pp. 251–270). Cambridge, England: Cambridge University Press. Hooley, J. M. (2007). Expressed emotion and relapse of psychopathology. Annual Review of Clinical Psychology, 3, 329–352. Huey, S. J., Jr, Henggeler, S. W., Rowland, M. D., Halliday-Boykins, C. A., Cunningham, P. B., Pickrel, S. G., & Edwards, J. (2004). Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. Journal of the American Academy of Adolescent Psychiatry, 43, 183–190. Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8, 255–270. Johnson, J. G., Cohen, P., Gould, M. S., Kasen, S., Brown, J., & Brook, J. S. (2002). Childhood adversities, interpersonal difficulties, and risk for suicide attempts during late adolescence and early adulthood. Archives of General Psychiatry, 59, 741–749. Kerr, D. C., Preuss, L. J., & King, C. A. (2006). Suicidal adolescents' social support from family and peers: Gender-specific associations with psychopathology. Journal of Abnormal Child Psychology, 34, 103–114. Kidd, S., Henrich, C. C., Brookmeyer, K. A., Davidson, L., King, R. A., & Shahar, G. (2006). The social context of adolescent suicide

attempts: Interactive effects of parent, peer, and school social relations. Suicide and Life-Threatening Behavior, 36, 386–395. King, C. A., Kramer, A. C., Preuss, L., Kerr, D. C. R., Weisse, L., & Venkataraman, S. (2006). Youth-Nominated Support Team for suicidal adolescents (Version 1): A randomized control trial. Journal of Consulting and Clinical Psychology, 74, 199–206. King, C. A., & Merchant, C. R. (2008). Social and interpersonal factors relating to adolescent suicidality: A review of the literature. Archives of Suicide Research, 12, 181–196. Kosky, R., Silburn, S., & Zubrick, S. R. (1990). Are children and adolescents who have suicidal thoughts different from those who attempt suicide? Journal of Nervous and Mental Disease, 178, 38–43. Kuhlberg, J. A., Peña, J. B., & Zayas, L. H. (2010). Familism, parentadolescent conflict, self-esteem, internalizing behaviors and suicide attempts among adolescent Latinas. Child Psychiatry and Human Development, 41, 425–440. Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1994). Psychosocial risk factors for future adolescent suicide attempts. Journal of Consulting and Clinical Psychology, 62, 297–305. Lewinsohn, P. M., Rohde, P., Seeley, J. R., & Baldwin, C. L. (2001). Gender differences in suicide attempts from adolescence to young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 427–434. Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press. Martin, G., Bergen, H. A., Richardson, A. S., Roeger, L., & Allison, S. (2004). Sexual abuse and suicidality: Gender differences in a large community sample of adolescents. Child Abuse and Neglect, 28, 491–503. McKeown, R. E., Garrison, C. Z., Cuffe, S. P., Waller, J. L., Jackson, K. L., & Addy, C. L. (1998). Incidence and predictors of suicidal behaviors in a longitudinal sample of young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37(6), 612–619. Melhem, N. M., Brent, D. A., Ziegler, M., Iyengar, S., Kolko, D., Oquendo, M., Birmaher, B., Burke, A., Zelazny, J., & Stanley, J. J. (2007). Familial pathways to early-onset suicidal behavior: Familial and individual antecedents of suicidal behavior. The American Journal of Psychiatry, 164, 1364–1370. Miklowitz, D. J., & Taylor, D. O. (2006). Family-focused treatment of the suicidal bipolar patient. Bipolar Disorders, 8, 640–651. Miller, M., Azrael, D., Hepburn, L., Hemenway, D., & Lippmann, S. J. (2006). The association between changes in household firearm ownership and rates of suicide in the United States, 1981–2002. Injury Prevention, 1, 178–182. Mittendorfer-Rutz, E., Rasmussen, F., & Wasserman, D. (2008). Familial clustering of suicidal behavior and psychopathology in young suicide attempters: A register-based nested case control study. Social Psychiatry and Psychiatric Epidemiology, 43, 28–36. Perkins, D. F., & Hartless, G. (2002). An ecological risk-factor examination of suicide ideation and behavior of adolescents. Journal of Adolescent Research, 17, 3–26. Prinstein, M. J., Boergers, J., Spirito, A., Little, T. D., & Grapentine, W. L. (2000). Peer functioning, family dysfunction, and psychological symptoms in a risk factor model for adolescent inpatients’ suicidal ideation severity. Journal of Clinical Child Psychology, 29, 392–405. Randell, B., Wang, W., Herting, J., & Eggert, L. (2006). Family factors predicting categories of suicide risk. Journal of Child and Family Studies, 15, 255–270. 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 attempts. Journal of Consulting and Clinical Psychology, 68, 1081–1093. Rotheram-Borus, M. J., Piacentini, J., Miller, S., Graae, F., & CastroBlanco, D. (1994). Brief cognitive-behavioral treatment for adolescent suicide attempters and their families. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 508–517. Rotheram-Borus, M., Piacentini, J., van Rossem, R., Graae, F., CastroBlanco, D., et al. (1996). Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 654–663. Rubenstein, J. L., Halton, A., Kasten, L., Rubin, C., & Stechler, G. (1998). Suicidal behavior in adolescents: stress and protection in

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Wells & Heilbron different family contexts. American Journal of Orthopsychiatry, 68, 274–284. Rudd, M. D., Joiner, T., & Rajab, M. H. (2001). Treating suicidal behavior: An effective, time-limited approach. New York: Guilford Press. Salzinger, S., Rosario, M., Feldman, R. S., & Ng-Mak, D. S. (2007). Adolescent suicidal behavior: associations with preadolescent physical abuse and selected risk and protective factors. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 859–866. Shaffer, D., Gould, M. S., Fisher, P., Trautman, P., Moreau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339–348. Spirito, A., Brown, L., Overholser, J., & Fritz, G. (1989). Attempted suicide in adolescence: A review and critique of the literature. Clinical Psychology Review, 9, 335–363. Spirito, A., & Esposito-Smythers, C. (2008). Evidenced-based therapies for adolescent suicidal behavior. In R. G. Steele, D. T. Elkin, & M. C. Roberts (Eds.), Handbook of evidence-based therapies for children and adolescents: Bridging science and practice (pp. 177–194). New York: Springer. Spokas, M., Wenzel, A., Stirman, S. W., Brown, G. K., & Beck, A. T. (2009). Suicide risk factors and mediators between childhood sexual abuse and suicide ideation among male and female suicide attempters. Journal of Traumatic Stress, 22, 467–470. Stanley, B., & Brown, G. K. (in press). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice. Stanley, B., Brown, G., Brent, D., Wells, K., Poling, K., Curry, J., Kennard, B., Wagner, A., Cwik, M., Brunstein Klomek, A., Goldstein, T., Vitiello, B., Barnett, S., Daniel, S., & Hughes, J. (2009). Cognitivebehavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 1005–1013. TASA CBT Team. (2008). Cognitive behavior therapy for adolescent suicide attempters manual. Unpublished manual. Available from NIMH.

Trautman, P., Stewart, N., & Morishima, A. (1993). Are adolescent suicide attempters non-compliant with outpatient care? Journal of the American Academy of Child and Adolescent Psychiatry, 32, 89–94. Wagner, B. M. (1997). Family risk factors for child and adolescent suicidal behavior. Psychological Bulletin, 121(2), 246–298. Wagner, B., Silverman, M. A. C., & Martin, A. E. (2003). Family factors in youth suicidal behaviors. American Behavioral Scientist, 46, 1171–1191. Wedig, M. M., & Nock, M. K. (2007). Parental expressed emotion and adolescent self-injury. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1171–1178. Wells, K. C., & Curry, J. F. (2000). Treatment for Adolescents with Depression Study (TADS) Cognitive behavior therapy manual: Parent and conjoint parent-adolescent sessions. Retrieved from: https://trialweb.dcri. duke.edu/tads/tad/manuals/TADS_CBT.pdf Wells, K. C., Abikoff, H., Abramowitz, A., Courtney, M., Cousins, L., Del Carmen, R., Eddy, M., Eggers, S., Fleiss, K., Heller, T., Hibbs, T., Hinshaw, S., Hoza, B., Pelham, W., & Pfiffner, L. (1996). Parent training for attention deficit hyperactivity disorder. MTA Study. Unpublished manuscript. Zayas, L. H., Lester, R. J., Cabassa, L. J., & Fortuna, L. R. (2005). Why do so many Latina teens attempt suicide? A conceptual model for research. American Journal of Orthopsychiatry, 75, 275–287. Address correspondence to Karen Wells, Ph.D., Duke University Medical Center, Psychiatry, Child and Family Study Center, 718 Rutherford Street, Durham, NC 27705; e-mail: [email protected]. Received: May 4 2010 Accepted: June 4 2011 Available online 29 June 2011