Family-based crisis intervention with suicidal adolescents in the emergency room: a pilot study.
Abstract: The prevailing model of care for psychiatric patients in the emergency room (ER) is evaluation and disposition, with little or no treatment provided. This article describes the results of a pilot study of a family-based crisis intervention (FBCI) for suicidal adolescents and their families in a large, urban pediatric ER. FBCI is an intervention designed to sufficiently stabilize patients within a single ER visit so that they can return home safely with their families. Of the 100 suicidal adolescents and their families in the sample, 67 met eligibility criteria for FBCI. Demographic and clinical characteristics and disposition outcomes from the sample were compared with those obtained retrospectively from a matched comparison group (N = 150). Statistical analyses compared group inpatient admission rates and disposition outcomes. Patients in the pilot cohort were significantly less likely to be hospitalized than were those in the comparison group (36 percent versus 55 percent). Only two of the patients in the FBCI cohort were hospitalized immediately after receiving the intervention during their ER visit. FBCI with suicidal adolescents and their families during a single ER visit is feasible and safely limits the need for inpatient psychiatric hospitalization, thereby avoiding disruption of family, academic, and social activities and increasing use of less intrusive and more cost-effective psychiatric treatment.

KEY WORDS: crisis intervention; family intervention; suicidal adolescents; suicide
Article Type: Report
Subject: Crisis intervention (Psychiatry) (Usage)
Crisis intervention (Psychiatry) (Methods)
Suicide (Prevention)
Authors: Wharff, Elizabeth A.
Ginnis, Katherine M.
Ross, Abigail M.
Pub Date: 04/01/2012
Publication: Name: Social Work Publisher: Oxford University Press Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0037-8046
Issue: Date: April, 2012 Source Volume: 57 Source Issue: 2
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 302403781
Full Text: As the adolescent suicide rate has been increasing over the last several decades (Centers for Disease Control and Prevention, 1998, 2007a, 2007b, 2008; Office of Disease Prevention and Health Promotion, 2000), there has been a parallel increase (as high as 59 percent) in pediatric emergency room (ER) usage rates by adolescents in need of mental health evaluations in the United States (Breslow, Erickson, & Cavanaugh, 2000; Ellison, Hughes, & White, 1989; Hughes, 1993; Page, 2000; Sills & Bland, 2002; Stewart, Spicer, & Babl, 2006). Suicidality in adolescents has been the most significant factor in the majority of ER visits for behavioral health concerns (Stewart et al., 2006) and the most common presenting problem for adolescents subsequently admitted to an inpatient psychiatric unit (Brooker, Ricketts, Bennett, & Lemme, 2007).

Although the number of psychiatric ER visits has increased substantially (Bruffaerts, Sabbe, & Demyttenaere, 2004; Hughes, 1993; Larkin, Claassen, Emond, Pelletier, & Camargo, 2005), child mental health service availability has not kept pace, resulting in longer ER wait times and stays for patients (American College of Emergency Physicians, 2008), likely contributing to a phenomenon termed psychiatric "boarding" (Mansbach, Wharff, Austin, Ginnis, & Woods, 2003) that has gained notoriety in the popular press (Holmberg, 2007; Katz, 2006; Kowalczyk, 2007; Trafford, 2000). Boarding describes a patient who is in psychiatric crisis and requires inpatient hospitalization but for whom there is no available inpatient psychiatric bed (Mansbach et al., 2003). In a recent survey of ER medical directors, over 70 percent reported boarding psychiatric patients as a routine practice, with nearly 40 percent doing so a minimum of once a week (American College of Emergency Physicians, 2008).

In current practice, the standard of care in emergency psychiatry is evaluation and disposition with little or no treatment provided at the time of presentation (Bruffaerts, Sabbe, & Demyttenaere, 2008). Psychiatric ER protocol is a noteworthy deviation from triage practice in standard emergency care, in which the most acute patients are prioritized and receive the most rapid and intensive care. Historically, there has been little focus on psychiatric treatment within the emergency setting, often due to time pressures to move patients through the ER and the prevailing treatment philosophy that psychiatric treatment of suicidal patients requires admission to a locked inpatient facility.

A number of studies evaluating specialized interventions occurring within the context of the ER have yielded significant increases in after-care treatment compliance among psychiatric patients (Rotheram-Borus et al., 1996; Spooren, Van Heeringen, & Jannes, 1998) and reductions in depressive symptomology (Rotheram-Borus, Piacentini, Cantwell, Belin, & Song, 2000) and suicide attempts (Huey et al., 2004). None, however, have piloted or evaluated a single-session intervention that occurs exclusively within the ER.

Though limited data on the cost-effectiveness of alternatives to inpatient hospitalization are available (Lamb, 2009; Shepperd et al., 2009), community-based interventions like multisystemic therapy (MST) show promising results; specifically, in a randomized controlled trial of 116 adolescents meeting criteria for inpatient hospitalization receiving either home-based MST or inpatient hospitalization, higher levels of patient satisfaction, improvement in family functioning, and reductions in externalizing symptoms were reported in the MST group than in the group receiving inpatient hospitalization (Henggeler et al., 1999). Because the ER is frequently a critical point of contact for suicidal adolescents to receive access to services, we developed a family-based crisis intervention (FBCI) for use exclusively in the ER, with the explicit goal of decreasing acute symptoms and sending more suicidal adolescents home safely with their families.

FBCI is based on the assumptions that an inpatient hospitalization is not necessarily the most helpful level of psychiatric care for adolescents with suicidal ideation/behavior, that families and caregivers are able to provide support to an adolescent family member if given both an opportunity and effective tools to use, and that a family that learns to support an adolescent while he or she is in crisis will be empowered to provide ongoing support once the acute psychiatric crisis subsides. Based on an integration of cognitive-behavioral skill building, psychoeducation, therapeutic readiness, and safety planning, FBCI uses nonjudgmental collaboration (Madsen, 1999) to stabilize patients and provide psychiatric intervention in the ER for both the adolescent and the family, thereby decreasing a patient's level of risk and increasing the capacity of the family to maintain the patient at home with appropriate therapeutic supports.

This two-part pilot study explored (1) the safety and feasibility of FBCI in a population of adolescents presenting with suicidal complaints in a large urban pediatric ER and (2) disposition outcomes between the pilot sample and a comparison sample obtained retrospectively during the identical calendar period immediately preceding the FBCI study period. It was hypothesized that FBCI during an ER visit would prove both feasible and safe and that rates of inpatient psychiatric hospitalization in the sample of patients presenting during the FBCI study period would be lower than those in the retrospective cohort sample.

METHOD

Study Design

This pilot study was conducted in the Boston Children's Hospital ER, in which approximately 1,000 patients in psychiatric crisis are seen annually. Nearly 40 percent of these patients present with chief complaints of depression or suicidal ideation/behavior. During an 18-month period (January 1, 2001, through June 30, 2002), 100 suicidal adolescents and their families were recruited to participate in the pilot study of FBCI when presenting to the ER. The sample was obtained consecutively. Patients were excluded when they met at least one of the following five criteria: (1) not currently living with a family, (2) presenting to the ER unaccompanied by a family member, (3) intoxicated/sedated at the time of ER presentation, (4) presenting with cognitive limitations that prohibited FBCI participation (that is, severe psychosis or significant developmental delay), and (5) presenting during an overnight shift (11:00 P.M. through 8:00 A.M., Monday through Friday) or during weekend hours (5:00 P.M. Friday through 8:00 A.M. Monday), because FBCI-trained staff were not available to administer the intervention during these ER shifts. Informed consent and assent were obtained from all patients and families prior to patients receiving both a standard psychiatric evaluation and FBCI. After finishing the standard psychiatric evaluation with the child and family, the social worker used her best clinical judgment to make the decision about whether the patient could benefit from FBCI. If the evaluating social worker had any uncertainty about whether the patient was appropriate for FBCI, a supervisor was available for consultation.

A pilot design was selected because the entire ER psychiatry staff was trained in the intervention protocol, rendering random assignment of families to standard or specialized ER care impossible. Prior to commencing the study, all ER psychiatry social work staff members were trained in FBCI protocol by the creators of the intervention. FBCI staff were required to attend weekly meetings to review cases with the creators of the intervention. Fidelity to the intervention was measured using a checklist requiring completion of each of the four core essential components of FBCI. Interrater reliability was established prior to study start. FBCI staff met weekly during the 18-month pilot study period to maintain interrater reliability. The safety of FBCI was measured by the number of FBCI patients who reported incidence of a suicide attempt or completion during the three-month follow-up period. Feasibility was measured by our ability to adequately train ER staff in FBCI protocol and implement the single-session intervention within the context of a busy ER. Fidelity to the intervention was measured using a checklist requiring completion of each of the four core essential components of FBCI. Demographic and clinical characteristics and disposition data from the pilot sample were then compared with data obtained retrospectively from a cohort of suicidal adolescents presenting consecutively to the ER during the previous 18-month calendar period (January 1, 1999, through June 30, 2000). The Boston Children's Hospital institutional review board approved the pilot study.

Recruitment and Consent for the Pilot Study

All patients and families presenting to the ER during the study period received standard emergency care, or treatment as usual (TAU). This process began with a medical examination by an ER physician. Once medical clearance was obtained and a psychiatric consultation was requested, participants were approached by a psychiatry research assistant to obtain informed consent/assent. Once consent was obtained, the patient and family were asked to complete some brief psychometric measures--the Children's Depression Inventory (CDI) (Kovacs, 1982), the Hopelessness Scale for Children (HSC) (Spirito, Williams, Stark, & Hart, 1988) and the Family Adaptability and Cohesion Evaluation Scale II (FACES II) (Olson, Portner, & Lavee, 1982)--to assess depression, hopelessness, and flexibility of family system, respectively. All psychometric measures used have demonstrated strong reliability and validity (Kazdin, Rogers, & Colbus, 1986; Kovacs, 1992; Olson et al., 1983). Families were also asked to complete a comprehensive family self-report form, which collected demographic and historical information. Patients and families were not excluded if the family or adolescent did not complete the assessment forms. All forms were available in Spanish and English. Interpreters were available for families whose first language was other than English or Spanish. The Study Flow is depicted in Figure 1.

Determination of Inclusion for FBCI

On completion of the standard emergency psychiatry evaluation with the adolescent and family, the evaluating clinician, either a licensed master's- or doctoral-level social worker, reviewed the case with the attending psychiatrist to determine the appropriate level of psychiatric care. Families were offered FBCI only if the evaluating social worker, attending psychiatrist, and family were in agreement that FBCI might enable the adolescent to return home safely. The decision to offer FBCI was based on both the acuity of the adolescent's suicidality and the capacity for galvanizing environmental supports available to and within the family system. If the evaluating social worker, attending psychiatrist, and family concurred that FBCI might help the adolescent return home safely with his or her family, the social worker then proceeded with FBCI. Adolescents who were not offered FBCI were hospitalized at an inpatient psychiatric facility.

FBCI

The theoretical underpinnings of this single-session ER intervention come from cognitive-behavioral, narrative, and family systems therapies, with an overall approach of nonjudgmental collaboration, as described by Madsen (1999). First, the social worker holds separate meetings with the adolescent and family to assess the sequence of events and differing perceptions leading to the suicidal problem. During these meetings, the social worker uses a narrative approach to help each party tell his or her story. The social worker also explores what each party feels would be necessary for the adolescent to return home safely with his or her family. Next, the social worker meets with the whole family together, attempting to construct a single, unified perception of the problem using the same narrative approach. We refer to unified perception of the problem as the "joint crisis narrative." During the meeting, the social worker assesses family roles and the potential flexibility and adaptability of the family system, using clinical interventions to both facilitate and improve communication among family members. The social worker uses cognitive-behavioral therapeutic approaches, including relaxation, problem-solving, and cognitive reframing techniques to shift negative attributions. The social worker also works with the child and family to problem solve around any specific dilemmas as needed. In the family meeting, the social worker tries to help the family and adolescent work together to improve intrafamilial communication, to safety plan, and to effect additional changes that will enable the adolescent to feel safe at home. The goal of FBCI is to effect changes that will reduce the acute symptoms that brought the adolescent to the ER and increase the family's awareness of the problem and sense of efficacy to help their child, thereby avoiding inpatient admissions and further disruptions of the adolescent's life. After completing FBCI, the social worker again consults with the supervising psychiatrist to review the case and obtain consensus that the patient is able to return home safely. Patients are discharged home only when the patient, family, attending psychiatrist, and assessing social worker agree that this is the best disposition for the adolescent.

[FIGURE 1 OMITTED]

Follow-up Assessments

Five follow-up assessments were completed by a study clinician via telephone at one-day, one-week, two-week, one-month, and three-month intervals from the date of the ER visit. Follow-up assessments served the dual purpose of obtaining information about the patient's level of functioning and facilitating acquisition of additional supportive services as needed. Follow-up assessments were completed only for those adolescents and families who were discharged home after their ER visit. Data on incidence of subsequent psychiatric evaluations and inpatient hospitalizations were also collected at these five follow-up intervals.

Retrospective Comparison Group

Demographic and clinical characteristics and disposition outcomes of patients in the pilot sample were compared retrospectively with adolescents (N= 150) who presented consecutively to the same ER with complaints of suicidal behavior/ ideation during the corresponding 18-month calendar period immediately preceding the pilot study period (January 1, 1999, through June 30, 2000). Retrospective cohort patients met the same inclusion and exclusion criteria as those in the pilot sample. Standard psychiatric assessment information--including demographic information, Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) (American Psychiatric Association, 1994) diagnoses, and disposition determination--that pertained to each patient in the retrospective comparison group was obtained through a medical record review.

Statistical Analyses

Frequency distributions and means were calculated for demographic data in both the pilot and retrospective cohort comparison samples (see Table 1). Mean CDI, HSC, and FACES II adaptability and cohesion scores were computed for the sample using a dichotomous disposition outcome (inpatient hospitalization/all others) as the dependent variable (see Table 2). Between-groups differences in mean CDI, HSC, and FACES II scores were examined using independent sample t tests (see Table 2).

Chi-square analyses were used to examine differences in demographic variables and disposition outcomes between the pilot and retrospective cohort samples. Disposition outcomes were categorized by level of support (inpatient, intensive outpatient, and outpatient services). Analyses of disposition outcome rates between the pilot and retrospective cohort samples are reported in Table 3.

RESULTS

Demographics

The pilot sample included 100 adolescents ages 13 to 18 years presenting to a large urban ER with symptoms of suicidality. A total of 144 suicidal adolescents presented to the ER during the FBCI study period, 44 of whom were excluded from participating in the study due to aforementioned exclusion criteria, lack of available research assistants, or lack of available FBCI-trained staff.

Among the 100 adolescents participating in the pilot study, 76.0 percent were female. Mean patient age was 15.6 (SD = 1.5) years. Sixty-five percent of patients self-identified as white, 16 percent self-identified as black, 11 percent self-identified as Hispanic/Latino, 3 percent self-identified as biracial, 2 percent self-identified as Asian, and 3 percent self-identified as being of another race. Demographic data obtained retrospectively from the comparison sample (150 suicidal adolescents presenting consecutively to the ER during the corresponding previous 18-month calendar period) are presented in Table 1. Patients in the comparison sample did not differ significantly in age, race and ethnicity, living arrangements, primary language, legal custody status, caregiver relationship status, primary DSM-IV diagnosis, or reported family history of depression from their counterparts in the pilot study. Exclusionary criteria were matched between samples.

On completion of the initial psychiatric evaluation, 67 percent of adolescents (n = 67) were eligible to receive FBCI. The remaining 33 percent (n = 33) who did not receive FBCI were hospitalized due to the acuity of their suicidality. Of the 67 patients who received FBCI, 97.0 percent (n = 65) were not hospitalized. Only two patients who received FBCI were hospitalized after their ER visit. These patients were unable to engage in safety planning during FBCI and thus required hospitalization. Statistically significant differences in depressive symptom severity occurred between patients who were admitted to an inpatient unit and those who were not. Mean CDI scores for 34 patients with an inpatient disposition (31.50 [SD = 69.86]) were significantly greater than the mean CDI scores for 60 patients who did not (23.26 [SD = 9.83]). CDI scores were not available for two patients who were ineligible for FBCI and for three who received the intervention and were discharged home. Similarly, mean HSC scores were higher among patients who were hospitalized (n = 27 [p = .001]). HSC scores were not available for eight patients deemed ineligible for FBCI and for five patients who received FBCI and were discharged home.

Neither CDI nor HSC scores differed significantly between patients receiving an inpatient hospitalization and those receiving intensive outpatient treatment. Differences in patient and family FACES II cohesion or adaptability subscales did not approach significance for any disposition category (see Table 2).

Suicidal adolescents and families who presented to the ER during the FBCI pilot period were significantly less likely to be admitted to an inpatient psychiatry unit than were members of the matched sample who presented during the comparison period. Sixty-five percent of suicidal patients presenting during the study period were discharged home, whereas only 44.7 percent of the comparison cohort (n = 67) were discharged home. Adolescents and their families presenting to the ER during the pilot study period were significantly more likely to receive a referral to intensive outpatient services (acute day treatment programs and intensive home-based therapies) at discharge from the ER (21.0 percent [n=21] versus 5.3 percent [n = 8], p < .001) than were their TAU counterparts in the retrospective cohort (see Table 3).

Of the 65 patients and families who received follow-up assessments at five separate intervals as a component of the intervention protocol, 43 (66.1 percent) were reached at one day, 44 (67.7 percent) were reached at one week, 42 (64.6 percent) were reached at two weeks, 44 (67.7 percent) were reached at one month, and 36 (55.4 percent) were reached at three months. A total of 55 patients (84.6 percent) were reached at least once during the follow-up period. Pearson chi-square tests revealed no significant differences between patients reached at follow-up and those unable to be reached in age, gender, primary axis I diagnosis, CDI or HSC scores, or insurance categories. No patients reported incidence of attempted or completed suicide during the three-month follow-up period.

None of the patients for whom data was collected at the one-day follow-up required an inpatient hospitalization. At the three-month follow-up, seven patients reported requiring an inpatient hospitalization since the initial ER visit (12.7 percent), only two (3.6 percent) of whom were hospitalized because of suicidal complaints. Other reasons for hospitalization included transition between partial hospitalization placements, decompensation due to schizophrenia, self-injurious behavior (nonsuicidal), and psychiatric evaluation required prior to entering child protective custody.

DISCUSSION

Considering the increasing rates and high costs of adolescent psychiatric hospitalization and an increasingly overburdened health-care system, investigations evaluating the efficacy of therapeutic interventions occurring within the ER are essential. To date, FBCI is the only standardized single-session crisis intervention for suicidal adolescents evident in the literature that has been designed for and piloted within the ER to demonstrate feasibility, acceptability, and significant reductions in inpatient hospitalization rates relative to a demographically matched, retrospectively obtained comparison sample.

Avoidance of inpatient psychiatric admission for suicidal adolescents has several benefits for the individual adolescent, the family, and the mental health system. Although the societal stigma associated with mental health problems has been reduced somewhat, the stereotypical view of adolescent inpatient psychiatric care depicted in popular literature and films continues to prevail. An inpatient admission may negatively affect an individual or family's beliefs about recovery (Hellzen & Lilja, 2008), the capacity to be safe in the world, or the family's ability to provide a safe and supportive environment for their child. Conversely, community-based supports may allow a child to refrain from developing a "dependency upon the hospital environment or from being stigmatized" (Shepperd et al., 2009, p. 3). An EIL-based crisis intervention provides the adolescent and family with the message that, despite the suicidal ideation/behavior with which they presented, there are skills that families can learn that will enable the adolescent to alleviate his or her distress and thus remain at home. The family feels empowered to be the coordinator of and participant in their child's care, comparable to the foundational empowerment model used by the community intensive therapy team in the United Kingdom (Darwish, Salmon, Ahuja, & Steed, 2006). FBCI provides psychoeducation to promote engagement in therapy and family understanding of treatment. In addition to the tangible parts of the intervention, FBCI provides hope for a family that arrived at the ER overwhelmed, anxious, and worried for a child's survival. During the study, several families expressed relief and gratitude for the care that they received in the Elk and noted during follow-ups that family communication and functioning in home and school domains had improved.

The absence of significant differences between family adaptability or cohesion (FACES II scores) and hospitalization in the intervention group was an unexpected finding. Even the most seemingly inflexible and uncommunicative families could engage with a skilled clinician to participate in psychiatric treatment of their child. Using Parad's (1965) crisis theory approach, we posit that even the most rigid family system is open to change during a crisis. FBCI allows clinicians to take advantage of this opportunity, thereby avoiding unnecessary psychiatric hospitalization.

The significant increase in referrals for intensive outpatient treatment in the pilot sample indicates that these adolescents were clearly in need of intensive mental health support; however, FBCI enabled clinicians to join with families to provide them with the tools needed to care for their children safely at home, allowing this intensive treatment to occur outside the hospital. As previously noted, FBCI incorporates cognitive therapeutic techniques to reframe negative attributions. A recent study of a 12-session cognitive-behavioral treatment for suicide prevention that also includes cognitive reframing as a key component has demonstrated feasibility in a population of suicidal adolescents (Stanley et al., 2009), providing further empirical support for cognitive-behavioral treatment techniques for suicidality specifically. FBCI could be a part of a growing number of more cost-effective alternatives to inpatient hospitalization--such as multisystemic therapy (Henggeler & Borduin, 1990; Henggeler et al., 1997; Huey et al., 2004; Schoenwald, Ward, Henggeler, & Rowland, 2000) and rapid-response outpatient models (Greenfield, Larson, Hechtman, Rousseau, & Platt, 2002)--that have been shown to be as feasible as inpatient hospitalization for treating suicidality in adolescents presenting to the Elk. The absence of significant differences in HSC and CDI scores between those receiving dispositions of an inpatient hospitalization and intensive outpatient services within the pilot study group indicates that safety can be established at home for even severely depressed adolescents.

The follow-up component of the FBCI protocol also yielded promising results. Of the 55 patients (85.9 percent) reached during the three-month follow-up period, none required an immediate inpatient hospitalization (within one week). Remarkably, only two FBCI patients (3.6 percent) reached during the three-month follow-up period required an inpatient hospitalization due to suicidal ideation or behavior.

The medical system uses a model of stabilization in the Elk whenever possible and admission only when necessary. FBCI and other crisis intervention protocols could help the mental health system move to a similar model in which inpatient admission is no longer the default position. Current trends indicate that the majority of adolescents presenting with suicidal ideation/behavior are admitted to psychiatric inpatient facilities (Brooker et al., 2007). Inpatient hospitalization is much more costly than other alternatives that have been shown to be as effective in reducing suicidal ideation/behavior in adolescents (Gould, Greenberg, Velting, & Shaffer, 2003; Henggeler et al., 2003).

This change in mindset is critical for the system to appropriately respond to and care for patients along the continuum of care. Patients who can go home with intensive outpatient follow-up do not board in the ER, where they will receive minimal psychiatric treatment. Instead, they go home with outpatient services in place, allowing them to engage in treatment more quickly than they would if they were sitting in the ER awaiting an inpatient bed.

LIMITATIONS

There were several limitations to this study. Though random assignment to FBCI or TAU conditions would have been preferable, FBCI involved changing clinicians' practice within the ER; it was not possible to randomly assign families to treatment and control groups. The closest available approximation to a control group was a retrospectively obtained sample from the most recent corresponding 18-month calendar period prior to clinician training in FBCI. The retrospective comparison component of the study also prohibited acquisition of data on the frequency of ER visits in the TAU group; thus, ER recidivism rates could not be analyzed comparatively between the two samples. The follow-up duration of three months is also a limitation. Though alternatives to inpatient hospitalization have been shown to be more effective in externalizing symptom reduction and improvement in family functioning than inpatient hospitalization (Henggeler et al., 1999; Schoenwald et al., 2000), research indicates that these gains may be relatively short-lived (Henggeler et al., 2003). We hypothesize that FBCI may reduce ER recidivism and hospitalization rates. Studies of pediatric emergency psychiatry services indicate that multiple presentations account for 19 percent to 36 percent of ER visits and that approximately 50 percent of repeat visits occur within one month of the previous presentation. Though data were unavailable on follow-up hospitalizations for the comparison group, rates of repeat ER presentations were much lower in the FBCI sample than in other samples. Currently, we are conducting a randomized clinical trial that examines the efficacy of FBCI, long-term gains, and effects of FBCI on ER recidivism rates. Although we did place follow-up phone calls to all study participants, no families required assistance in accessing additional services at any of the follow-up time points; however, other services (beyond those recommended as part of the discharge plan) were not controlled for in this study. Future studies should control for additional service use and variability.

CDI, HSC, and FACES II scores were not collected posttreatment or during follow-up and, therefore, could not be analyzed. No psychometric measures were obtained for the TAU group at any time point, as there was no practical way to proceed because of the nature of the population presenting to the ER and human subjects issues. In addition, frequency and dose of each of the four core components of FBCI were not collected as part of this study. Future studies exploring the efficacy and effectiveness of FBCI should incorporate the frequency and dose of each of these core components.

CONCLUSIONS

Patients who received FBCI were significantly less likely to be hospitalized than were their comparison cohort counterparts. Suicidal adolescents presenting in crisis to the ER were able to be sent home safely with appropriate therapeutic supports. This pilot study demonstrates that a single-visit model of crisis intervention for suicidal adolescents and their families delivered in the ER can sufficiently stabilize an adolescent and family system, regardless of cohesion and adaptability levels, to enable a safe discharge home.

It is essential to begin to use a model of crisis intervention for suicidal adolescents and their families to provide relief from their acute symptoms with the least amount of family disruption. Empirical evidence has yet to document the superiority of inpatient care in effectively reducing rates of suicidal ideation, nonlethal attempts, or completed suicides among adolescents (Gould et al., 2003). FBCI benefits the adolescent and family and simultaneously alleviates an overburdened mental health system by limiting use of scant inpatient resources, keeping them available for those who truly need them. FBCI is a standardized protocol that could be used by crisis clinicians across contexts to provide this kind of intervention, and it may be a cost-effective and advantageous alternative to inpatient hospitalization for both patients and providers.

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Elizabeth A. What, PhD, MSW, is director, Katherine M. Ginnis, MSW, MPH, is associate director, and Abigail Ross, MSW, MPH, is a research social worker, Emergency Psychiatry Service, Department of Psychiatry, Boston Children's Hospital. Funding for this pilot study was provided by the George Harrington Trust. The authors are grateful to the adolescents and their families who participated in the study and to the ER social workers who piloted family-based crisis intervention (FBCI) with them, including Ariel Botta, Elizabeth Colton Notine, Christina Feith, Lara Kay, Mary Kate Little, and Katie Naftzger. The authors also thank David DeMaso, chief of psychiatry, and the ER nursing and physician staff at Boston Children's Hospital for their support during the FBCI study period. Address correspondence to Elizabeth A. Wharff, Department of Psychiatry, Boston Children's Hospital, Fegan 8, 300 Longwood Avenue, Boston, MA 02115; e-mail: elizabeth.whatff@childrens. harvard.edu.

Original manuscript received April 12, 2010

Final revision received August 27, 2010

Accepted September 1, 2010

doi: 10.1093/sw/sw017
Table 1: Demographics of Intervention and Comparison Groups

                                  Intervention  Comparison
                                     (N-100)       (N=150)

Variable                           n     %       n     %

Gender
  Female                          76    76.0    111   74.0
  Male                            24    24.0     39   26.0
Race/ethnicity
  Asian                            2     2.0      4    2.7
  Black                           16    16.0     26   17.3
  Hispanic/Latino                 11    11.0     15   11.0
  White                           65    65.0     97   64.7
  Biracial                         3     3.0      2    1.3
  Other                            3     3.0      6    4.0
Living arrangement
  Parents                         96    96.0    139   92.7
  Other relative                   4     4.0     11    7.3
  Foster care                      0     0.0      1    0.7
Primary language
  English                         89    89.0    138   92.0
  Spanish                          7     7.0     11    7.3
  Other                            4     4.0      1    0.7
Legal custody
  Parents                         96    96.0    140   93.3
  DSS/DCF                          1     1.0      5    3.3
  Other relative                   2     2.0      1    0.7
  Other                            1     1.0      0    0.0
Primary DSM-IV axis I diagnosis
  Total depressive disorders      76    76.0    105   70.0
  Bipolar disorder                 5     5.0     10    6.7
  Other mood disorders             1     1.0      2    1.3
  Anxiety disorders/PTSD           8     8.0     10    6.6
  Other (a)                       11    11.0     23   15.3

Notes: The average age in years was 15.60 (SD=1.45) for the
intervention group and 15.50 (SD=1.47) for the comparison group.
DSS=Department of Social Services; DCF=  Department of Children
and Families; DSM-IV=Diagnostic and Statistical Manual of Mental
Disorder (4th ed.); PTSD=posttraumatic stress disorder.

(a) Includes eating disorder, psychosis, substance abuse
behavioral disorders, attention-deficit/hyperactivity disorder,
and somatoform disorders.

Table 2: Pilot Sample CDI, FACES II, and
HSC Scores

Variable           Disposition   n      M       5D       p

Total CDI          Inpatient     34   31.56    9.863   <.001
                   All others    61   23.26    9.83

Patient cohesion   Inpatient     31   47.19   12.38     .876
                   All others    59   47.63   12.925

Family cohesion    Inpatient     33   54.73    8.596    .490
                   All others    60   56.02    8.54

Patient
  adaptability     Inpatient     32   38.66    9.46     .364
                   All others    54   40.56    9.07

Family
  adaptability     Inpatient     32   44.72    7.10     .952
                   All others    58   44.81    6.32

Hopelessness       Inpatient     27   11.15    4.36     .001
                   All others    60    7.52    4.44

Notes: N=100. CDI=Children's Depression Inventory; HSC=Hopelessness
Scale for Children; FACES II = Family Adaptability and Cohesion
Evaluation Scale II.

Table 3: FBCI and Comparison Group
Disposition Outcomes, in Percentages

Disposition             FBCI     Comparison
Outcome                (N=100)    (N=150)

Inpatient              35 (a)        55
Intensive outpatient   21 (b)         5
Outpatient               43          37
Other                     0           3

Note: FBCI=family-based crisis intervention.

(a) Reduction in hospitalization rate: p<.0001.

(b) Increase in intensive outpatient referral: p<.001.
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