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Emergency Room Intervention for Adolescent Females

Emergency Room Intervention for Adolescent Females is a program for teenage girls 12 to 18 years old who are admitted to the emergency room after attempting suicide. The intervention, which involves the girl and one or more family members who accompany her to the emergency room, aims to increase attendance in outpatient treatment following discharge from the emergency room and to reduce future suicide attempts. A review of the literature suggests that factors related to treatment noncompliance following a suicide attempt include family discord, maternal psychopathology, attempter depression, and negative experiences with emergency room staff. The intervention consists of three components designed to improve the emergency room experience for the adolescent and family, thereby changing the family's conceptualization of the suicidal behavior and expectations about therapy. First, a 2-hour training is conducted separately with each of the six groups of staff working with adolescents who have attempted suicide. Second, the adolescents and their families watch a 20-minute videotape, filmed in Spanish and dubbed in English, that portrays the emergency room experience of two adolescents who have attempted suicide. Last, a bilingual crisis therapist delivers a brief family treatment in the emergency room.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: October 2007
1: Treatment adherence
2: Adolescent symptoms of depression
3: Adolescent suicidal ideation
4: Maternal symptoms of depression
5: Maternal attitudes toward treatment
Outcome Categories Mental health
Suicide
Treatment/recovery
Ages 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
Genders Female
Races/Ethnicities Hispanic or Latino
Race/ethnicity unspecified
Settings Other community settings
Geographic Locations Urban
Implementation History The first implementation and evaluation of the program took place from 1992 to 1994 with 65 adolescents at the Columbia Presbyterian Medical Center, an inner-city hospital in New York City serving a predominantly disadvantaged, Latina population. The program has been used in Israel and Nicaragua and is being adapted and used with American Indians in Arizona and Montana. It also has been evaluated in two emergency rooms in Los Angeles, California.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations Materials are available in both English and Spanish. The program is currently being adapted for use with American Indians.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: October 2007

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

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 attempters. Journal of Consulting and Clinical Psychology, 68(6), 1081-1093.  Pub Med icon

Rotheram-Borus, M. J., Piacentini, J., Van Rossem, R., Graae, F., Cantwell, C., Castro-Blanco, 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(5), 654-663.  Pub Med icon

Supplementary Materials

Rotheram-Borus, M. J., Piacentini, J., Miller, S., Graae, F., & Castro-Blanco, D. (1994). Brief cognitive-behavioral treatment for adolescent suicide attempters and their families. Journal of the American Academy of Child and Adolescent Psychiatry, 33(4), 508-517.  Pub Med icon

Rotheram-Borus, M. J., Piacentini, J., Miller, S., Graae, F., Dunne, E., & Cantwell, C. (1996). Toward improving treatment adherence among adolescent suicide attempters. Clinical Child Psychology and Psychiatry, 1(1), 99-108.

Outcomes

Outcome 1: Treatment adherence
Description of Measures Three measures of treatment adherence were used: attendance at a minimum of one treatment session, completion of the outpatient treatment program (i.e., attendance at six or more treatment sessions), and the total number of treatment sessions attended. Treatment adherence data were obtained from weekly logs completed by clinicians.
Key Findings In a naturalistic study conducted over 3 years, the first cohort of adolescents and their families was assigned to usual care, and the second was assigned to the intervention. Adolescents receiving the intervention were significantly more likely to visit the outpatient clinic for treatment following discharge from the emergency room compared with adolescents receiving usual care (p < .05). Receiving the intervention was significantly associated with attendance at more outpatient treatment sessions (p < .01). Adolescents in the intervention group were 3 times more likely to complete the outpatient treatment program than adolescents in the usual care group (p < .05).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.1 (0.0-4.0 scale)
Outcome 2: Adolescent symptoms of depression
Description of Measures Symptoms of depression were defined as the total score on the Beck Depression Inventory (BDI). The BDI is a 21-item self-report measure of depression with items assessing a wide range of depression symptoms, including dysphoria; anhedonia; suicidality; and disturbances in sleep, appetite, and cognitive functioning.
Key Findings In a naturalistic study conducted over 3 years, the first cohort of adolescents and their families was assigned to usual care, and the second was assigned to the intervention. Adolescents receiving the intervention showed significantly lower symptoms of depression compared with adolescents receiving usual care (p < .01). Within 1 month following the emergency room visit, 30% of the adolescents receiving usual care and 22% receiving the intervention had BDI scores in the clinical range for depression. This difference remained over the 18-month follow-up period.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 3: Adolescent suicidal ideation
Description of Measures Suicidal ideation was measured using the 12-item Suicidal Ideation Scale of the Harkavy Asnis Suicide Survey (HASS).
Key Findings In a naturalistic study conducted over 3 years, the first cohort of adolescents and their families was assigned to usual care, and the second was assigned to the intervention. Adolescents receiving the intervention reported less suicidal ideation within 1 month following the emergency room visit than did adolescents who received usual care (p < .01). Treatment differences in suicidal ideation did not persist during the study follow-up period.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 4: Maternal symptoms of depression
Description of Measures Symptoms of depression were defined as the total score on the BDI. The BDI is a 21-item self-report measure of depression with items assessing a wide range of depression symptoms, including dysphoria; anhedonia; suicidality; and disturbances in sleep, appetite, and cognitive functioning.
Key Findings In a naturalistic study conducted over 3 years, the first cohort of adolescents and their families was assigned to usual care, and the second was assigned to the intervention. Mothers receiving the intervention reported lower levels of depression within 1 month following the emergency room visit than did mothers who did not receive the intervention (p < .05). Treatment differences in maternal depression did not persist during the study follow-up period.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)
Outcome 5: Maternal attitudes toward treatment
Description of Measures Maternal attitudes toward treatment were assessed using a 25-item rating scale developed specifically for the study.
Key Findings In a naturalistic study conducted over 3 years, the first cohort of adolescents and their families was assigned to usual care, and the second was assigned to the intervention. Mothers receiving the intervention reported more positive attitudes toward treatment within 1 month following the emergency room visit than did mothers who did not receive the intervention (p < .01).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.2 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult) 		100% Female 88% Hispanic or Latino
12% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Treatment adherence 1.0 2.0 0.5 3.5 2.0 3.5 2.1
2: Adolescent symptoms of depression 4.0 4.0 0.5 3.5 2.0 4.0 3.0
3: Adolescent suicidal ideation 3.8 3.8 0.5 3.5 2.0 4.0 2.9
4: Maternal symptoms of depression 4.0 4.0 0.5 3.5 1.0 4.0 2.8
5: Maternal attitudes toward treatment 2.0 2.0 0.5 3.0 2.0 3.5 2.2

Study Strengths

The study used multiple outcome measures with practical utility. Outcomes were measured using well-known instruments with adequate reliability and validity. The intervention was implemented using a standardized training protocol and a treatment manual. Appropriate analyses were used to examine potential treatment effects.

Study Weaknesses

The study did not adequately control for potential confounding variables that may have accounted for the reported findings. The clinical logs accessed to obtain data on treatment adherence were not monitored for errors, raising concerns about the data's reliability. Fidelity to the treatment protocol was not adequately measured to ensure that the program was delivered uniformly and correctly.
Readiness for Dissemination
Review Date: October 2007

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Asarnow, J., Armm, J., & McGrath, E. (2002). Care linkage manual: A component of the Family Focused Intervention for Suicide Prevention (FISP). Los Angeles: University of California, Los Angeles, School of Medicine.

Bradley, J., & Rotheram-Borus, M. J. (1990). Evaluation of imminent danger for suicide. Tulsa, OK: National Resource Center for Youth Services.

Miller, S., Rotheram-Borus, M. J., Piacentini, J., & Graae, F. (2002). Emergency room staff training for adolescent suicide attempters. Los Angeles, CA: Center for HIV Identification, Prevention, and Treatment Services. Retrieved from http://chipts.ucla.edu/interventions/manuals/interer.html

Miller, S., Rotheram-Borus, M. J., Piacentini, J., Graae, F., & Castro-Bianco, D. (2002). Successful Negotiation Acting Positively (SNAP): A brief cognitive-behavioral family therapy manual for adolescent suicide attempters and their families. Los Angeles, CA: Center for HIV Identification, Prevention, and Treatment Services. Retrieved from http://chipts.ucla.edu/interventions/manuals/intersnap.html

University of California, Los Angeles. (2003). A new beginning [VHS tape]. Los Angeles: University of California, Los Angeles, Instructional Media.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
2.5 1.0 1.0 1.5

Dissemination Strengths

Manuals provided to support implementation are detailed and speak to a critical need for a program of this type. Training is available upon request. Scripts and worksheets included in the implementation materials could support quality assurance.

Dissemination Weaknesses

Implementation materials include outdated research and are generally difficult to navigate. No materials beyond the submitted implementation manuals are available to support formal training. The level of technical assistance available from the developer is unknown. No organized quality assurance protocol is provided to support implementation fidelity or client outcome monitoring.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Emergency Room Staff Training for Adolescent Suicide Attempters Free Yes
Successful Negotiation Acting Positively (SNAP): A Brief Cognitive-Behavioral Family Therapy Manual for Adolescent Suicide Attempters and Their Families Free Yes
Care Linkage Manual: A Component of the Family-Focused Intervention for Suicide Prevention (FISP) Free No
Evaluation of Imminent Danger for Suicide (manual) Free Yes
Training protocols Free No
Train-the-Trainer workshop in Los Angeles, CA $1,500 per day No
Consultation $350 per hour No
Quality assurance tools Free No
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation, contact:
Mary Jane Rotheram-Borus, Ph.D.
(310) 794-8278
rotheram@ucla.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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