Adolescents who have been hospitalized for suicidal behavior are at risk for engaging in additional suicidal behavior. After hospitalization, parents or guardians are typically asked to be responsible for helping to prevent further suicidal behavior. This can include monitoring the youth, making sure the home is safe, getting the youth any needed treatment, and balancing the parents' expectations of the youth with the understanding that the youth is in a vulnerable state. Even with this effort by parents, adolescents often have additional crisis situations. The goal of this study is to develop and test an integrated electronic and care support service intervention for these caregivers of suicidal youth. It is expected that this intervention will help parents/guardians in the roles of caring for suicidal youth after discharge from the hospital. This pilot randomized controlled trial will compare the intervention to enhanced treatment as usual.
Adolescents who have been hospitalized for suicidal behavior are at high risk for engaging in additional suicidal behavior. Following hospitalization, parents or guardians are typically tasked with helping to prevent further suicidal episodes by monitoring youth, ensuring safety in the home, helping youth receive needed care, and parenting in a way that balances expectations for appropriate behavior with recognition of the vulnerable status of the adolescents. Despite parental efforts, adolescents often have additional crises, which sometimes culminate in emergency department visits and repeat hospitalizations. Findings from the principal investigators' recent longitudinal study of mothers after adolescent hospitalization for suicide attempts (Impact of Adolescent Hospitalization on Parents) suggested that the period of time following discharge from the hospital can be a very important time for providing services and supports to youth and families. Parents in that study described emotional distress (e.g., depression, anxiety) and reduced parenting self-efficacy, and indicated a need for more information about suicidal youth and the treatment needs of these youth, parenting and monitoring of suicidal youth, and support in navigating the treatment system. Given these needs, the purpose of this study is to develop, refine, and preliminarily test an integrated electronic and care support service intervention for caregivers of adolescents who have recently engaged in suicidal behavior. It is expected that such an intervention will provide needed information and supports to parents, increase parenting self-efficacy, increase parents' ability to follow safety plans in the home, reduce parents' emotional distress, and help parents access needed services in the community. As a consequence of these proximal outcomes, it is expected that the intervention will help facilitate treatment engagement and follow through for youth and caregiver, and reduce use of emergency mental health services and hospitalizations. The primary aim is to obtain, in a pilot randomized controlled trial, preliminary estimates of treatment effectiveness relative to enhanced treatment as usual. The proposed adaptive services intervention development research is intended to demonstrate the feasibility and potential utility of an intervention that will be embedded in the existing care system (psychiatric inpatient unit) for suicidal youth and the families of these youth, and ultimately, improve engagement in services and client outcomes in high-risk families.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
90
This intervention will consist of electronic and Care Support Manager (CSM) contacts with parents from the first week following their adolescent's discharge from hospitalization through the first 3 months after discharge. The electronic application content will be accessible and delivered to parents weekly. Parents will also be able to enter a keyword on their electronic device to access content and material in real time. The CSM contacts will supplement the informational content delivered electronically by providing opportunities to ask questions about the electronic application material, and by checking on progress toward treatment follow through for their youth, identifying and problem solving any difficulties and concerns, and addressing health needs of each parent.
TAU typically involves a discharge planning session by unit staff with the adolescent and their parent(s) to discuss safety monitoring and referrals for mental health services following discharge from psychiatric hospitalization. Investigators will augment this usual care by providing written materials to families outlining some of the key considerations for caring for their adolescent. These written materials will include brochures with information for parents following adolescent suicidal behavior, a listing of resources including instructions for when to call 911 or go to the emergency room, and information regarding the National Suicide Prevention Lifeline. Written materials will be provided to both the enhanced TAU participants as well as participants receiving the electronic and CSM intervention.
Wake Forest Health Sciences
Winston-Salem, North Carolina, United States
Change in parental distress as assessed with SCL-90-R
To assess severity of depression, anxiety, and hostility, parents will be administered the Symptom Checklist - 90 (SCL-90-R). The SCL-90-R yields scores along several dimensions: Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. The scale range for each dimension is a T-score of 0-100, with higher scores representing greater problem severity.
Time frame: Baseline (hospitalization), and at 3- and 6- months following discharge
Change in parental self-efficacy as assessed with PSOC
Facets of parental self-efficacy will be assessed with the Parenting Sense of Competence Scale (PSOC), which measures sense of self-efficacy and satisfaction with parenting. It has a scale range of 17-102, with higher scores indicating a greater parenting sense of competency. It has been used with parents of children and adolescents.
Time frame: Baseline (hospitalization), and at 3- and 6- months following discharge
Change in parental self-efficacy as assessed with "Me as a Parent" Parent Self-Regulation scale
Facets of parental self-efficacy will be assessed with the "Me as a Parent" Parenting Self-Regulation scale, which assesses constructs such as sense of effectiveness, sense of control as a parent, ability to manage situations with children (a central concept for the current study), and parental self-management (planful parenting activities). The scale range is 16 - 80, with higher scores representing a greater parental sense of self-regulation. It has been used with parents of children and adolescents.
Time frame: Baseline (hospitalization), and at 3- and 6- months following discharge
Change in parenting practices as assessed with Alabama Parenting Practices Questionnaire
The Alabama Parenting Practices Questionnaire will be used to assess parenting behaviors. For purposes of our study, investigators will focus on the parental involvement subscale (10 items), the positive parenting subscale (6 items), the monitoring and supervision subscale (10 items), and the inconsistent discipline scale (6 items). The scale ranges are 10-50 for the 10-item subscales, and 6-30 for the 6-item subscales. Higher scores denote better outcomes for the parental involvement and positive parenting subscales, whereas higher scores denote worse outcomes for the monitoring/supervision and inconsistent discipline subscales.
Time frame: Baseline (hospitalization), and at 3- and 6- months following discharge
Change in parent reports of adolescent suicidal behavior as assessed with C-SSRS
Parental reports of adolescent suicidal ideation and behaviors following hospitalization will be assessed with selected queries from the Columbia - Suicide Severity Rating Scale (C-SSRS). This measure does not have an overall scoring range, but it does include a suicidal ideation intensity rating with a range 0-25. In general, a greater number of endorsed items and/or a higher suicidal ideation intensity rating denote greater suicidal risk.
Time frame: Baseline (hospitalization), and at 3- and 6- months following discharge
Change in child emotional and behavioral problems as assessed with CBCL
To provide some contextual information at each assessment, parents at baseline hospitalization only will complete the Achenbach Child Behavior Checklist (CBCL). The CBCL is a widely used parent-report scale. The measure includes 20 subscales, each having a T-score range of 50-100, with higher scores denoting greater psychological and behavioral problems.
Time frame: Baseline (hospitalization), and at 3- and 6- months following discharge
Change in parent perceptions of support and safety monitoring as assessed with a series of likert rating questions
Using a series of likert rating questions, investigators also will assess the degree to which parents feel provided with information regarding their child's condition and the management of their child in the home, and the degree to which parents feel supported by the intervention and by mental health professionals. Investigators will use likert scales at formal assessment points to assess perceived success and confidence in monitoring youth and following safety plans in the first month after hospitalization, and during any other times of high risk. In addition to formal assessments, the care support manager will use ratings during regular check-ins to gauge the degree to which parents' needs are being met.
Time frame: Through study completion, up to 6 months following discharge
Adolescent service use assessed with CASA and treatment records
The semi-structured interview-based Child and Adolescent Services Assessment-Parent Interview-Version 5.0 (CASA) will be used to assess emergency department visits and repeat hospitalizations; duration and frequency of adolescent involvement with specialty mental health services (therapists, psychiatrists, etc.) following hospitalization; and attitudes about service use for adolescents. In addition, with consent/assent of parents and adolescents, investigators will obtain adolescents' treatment records to verify contacts with mental health providers. This measure does not have an overall scale range.
Time frame: Baseline (hospitalization), and at 3- and 6- months following discharge
Cost information assessed with measure of time spent
Time spent by the care support manager in patient contacts, preparation, and documentation will be tracked to estimate potential costs. These data will be preliminary due to the early phase of intervention development, but will set the stage for scalability efforts and later well-powered cost-effectiveness studies.
Time frame: Up to 6 months following discharge
Assessment of the patient satisfaction and acceptability of the intervention assessed with the Client Satisfaction Questionnaire
To assess patient satisfaction and acceptability of the intervention, investigators will administer the Client Satisfaction Questionnaire. This measure has a range of 8-32, with higher scores indicating greater satisfaction. Following Mohr et al. (2011), additional indices of the acceptability and usability of the intervention will include the degree to which parents use the mHealth application over time.
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Time frame: Through study completion, up to 6 months following discharge