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International Journal of Emergency Mental Health and Human Resilience
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The Role of Parents in Safety Planning Interventions with Suicidal Adolescents

Kimberly H. McManama O’Brien1,2,3*, Laika D. Aguinaldo2,4, Joanna Almeida1,5,6, Erina White2

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

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

3Harvard Medical School, Boston, MA, USA

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

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

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

*Corresponding Author:
Kimberly H. McManama O’Brien
E-mail: [email protected]

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


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

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

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

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

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

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

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

Funding Information

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


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