Designing Interventions for Adolescents

A group of researchers conducted a critical review of existing research studies to provide guidance on developing interventions to reduce repeat episodes of suicidal behaviors and self-harm in adolescents. They recommend that such interventions begin as early as possible, with treatment “front-loaded” to protect the adolescent during the period following the initial crisis. They also suggest that adolescents should receive treatment that directly addresses suicidal behavior, and stress the importance of integrating all treatments being provided. Finally, the authors name five key factors to focus on in treatment: motivation to change; sobriety; familial support; positive affect; and healthy sleep.

The authors undertook this analysis in light of the fact that there are “no empirically validated treatments that prevent the repetition of adolescent suicidal behavior” and that “observational data suggest that the receipt of mental health services does not protect against subsequent suicidal episodes.” 

Their review suggests that people designing interventions to deter the recurrence of suicidal behaviors and self-harm among adolescents should optimize the following factors:

Timing. It is important to provide an adequate “dose” of an intervention in the period following the initial suicidal crisis, as this is the period when adolescents are at greatest risk for repeat suicidal behaviors. The authors suggest that treatment begin in the hospital psychiatric unit or emergency department, and that it include “a follow-up appointment within seven days, availability of 24-hour crisis intervention, and assertive outreach to non-adherent individuals.

Sequence and integration of care. The authors recommend that priority be given to interventions that explicitly target suicidal risk (such as cognitive behavioral therapy designed to address suicidal thinking). It is essential to explicitly coordinate these with any other treatment given to the patient (e.g. therapy targeting anxiety or depression) by, for example, using a case manager to communicate with the family and the treatment providers.

Treatment orientation and targets. The authors identify “five key factors that should be considered for future interventions to prevent recurrent adolescent suicidal behavior”:

1. Patients’ motivation to change, which predicts responsiveness to treatment and is critical given the tendency of adolescents not to comply with treatment. The authors suggest using motivational interviewing to promote adherence to treatment.

2. Sobriety, as “a high proportion of adolescents who attempt suicide do so either during or immediately after use of alcohol or drugs.”

3. Familial or non-familial support, which helps protect adolescents from suicide risk. All of the interventions that had positive effects on risk included activities to improve the relationships between adolescents and their parents or other adults.

4. Promotion of positive affect, as there is increasing evidence that positive affect is a protective factor against suicide.

5. Healthy sleep, since insomnia has been shown to be a risk factor for suicide among adults and has an impact on mood, affect, and impulsivity. The authors suggest that it is important to address sleep difficulties in the period immediately after a suicide attempt or crisis, when risk is highest.

This summary is based on: Brent, D.A., McMakin, D.L., Kennard, B.D., Goldstein, T.R., Mayes, T.L., & Douaihy, A.B. (2013). Protecting adolescents from self-harm: A critical review of intervention studies. Journal of the American Academy of Child and Adolescent Psychiatry 52(12), 1260-1271.