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Evidence-Based Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in YouthCatherine R. Glenn a , Joseph C. Franklin a & Matthew K. Nock aa Department of Psychology , Harvard UniversityPublished online: 25 Sep 2014.
To cite this article: Catherine R. Glenn , Joseph C. Franklin & Matthew K. Nock (2015) Evidence-Based PsychosocialTreatments for Self-Injurious Thoughts and Behaviors in Youth, Journal of Clinical Child & Adolescent Psychology, 44:1, 1-29,DOI: 10.1080/15374416.2014.945211
To link to this article: http://dx.doi.org/10.1080/15374416.2014.945211
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EVIDENCE BASE UPDATE
Evidence-Based Psychosocial Treatments for Self-InjuriousThoughts and Behaviors in Youth
Catherine R. Glenn, Joseph C. Franklin, and Matthew K. Nock
Department of Psychology, Harvard University
The purpose of this study was to review the current evidence base of psychosocialtreatments for suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs)in youth. We reviewed major scientific databases (HealthSTAR, MEDLine, PsycINFO,PubMed) for relevant studies published prior to June 2013. The search identified 29studies examining interventions for suicidal or nonsuicidal SITBs in children oradolescents. No interventions currently meet the Journal of Clinical Child and AdolescentPsychology standards for Level 1: well-established treatments. Six treatment categorieswere classified as Level 2: probably efficacious or Level 3: possibly efficacious for reducingSITBs in youth. These treatments came from a variety of theoretical orientations, includ-ing cognitive-behavioral, family, interpersonal, and psychodynamic theories. Commonelements across efficacious treatments included family skills training (e.g., family com-munication and problem solving), parent education and training (e.g., monitoring andcontingency management), and individual skills training (e.g., emotion regulation andproblem solving). Several treatments have shown potential promise for reducing SITBsin children and adolescents. However, the probably=possibly efficacious treatmentsidentified each have evidence from only a single randomized controlled trial. Futureresearch should focus on replicating studies of promising treatments, identifying activetreatment ingredients, examining mediators and moderators of treatment effects, anddeveloping brief interventions for high-risk periods (e.g., following hospital discharge).
INTRODUCTION
Self-injurious thoughts and behaviors (SITBs) are a broadclass of cognitions and actions aimed at intentional anddirect injury to one’s own body. Although the range ofterms employed to describe SITBs (e.g., suicidality, para-suicide, deliberate self-harm, self-mutilation) traditionallyhas created confusion, the field has recently begun to focuson the distinction between suicidal and nonsuicidalself-injurious thoughts and behaviors based on key differ-ences in the prevalence, frequency, function, and severityof these behaviors (Nock, 2009, 2010). Most notably,suicidal phenomena (e.g., suicide ideation, plans, attempts)
are associated with any intent to die, whereas nonsuicidalphenomena (e.g., nonsuicidal self-injury [NSSI], suicidethreats, and gestures) are not (Nock, 2010). Although sui-cidal and nonsuicidal SITBs are distinct, growing researchindicates that NSSI is a significant risk factor for suicidalbehavior (Asarnow, Porta, et al., 2011; Wilkinson, Kelvin,Roberts, Dubicka, & Goodyer, 2011), suggesting acomplex association between these two types of behaviors.
Rates of SITBs are relatively rare in childhood butincrease drastically during the transition to adolescence(Nock et al., 2008; Nock et al., 2013). In the UnitedStates, suicide is the third leading cause of death inyouth, with approximately 4,600 suicide deaths amongadolescents each year (Centers for Disease Controland Prevention, National Center for Injury Prevention,2010). Moreover, current estimates indicate that eachyear approximately 16% of adolescents will seriously
Correspondence should be addressed to Catherine R. Glenn,
Department of Psychology, Harvard University, William James
Hall, 1280, 33 Kirkland Street, Cambridge, MA 02138. E-mail:
Journal of Clinical Child & Adolescent Psychology, 44(1), 1–29, 2015
Copyright # Taylor & Francis Group, LLC
ISSN: 1537-4416 print=1537-4424 online
DOI: 10.1080/15374416.2014.945211
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consider killing themselves, 13% will make a suicideplan, and 8% will attempt suicide (Centers for DiseaseControl and Prevention, 2012). NSSI is even morecommon among adolescents, with studies reporting anaverage lifetime prevalence of 18% in this population(Muehlenkamp, Claes, Havertape, & Plener, 2012).1
Given that suicidal and nonsuicidal self-injuriousthoughts and behaviors (which are referred to collec-tively as SITBs for the remainder of the article) usuallybegin between the ages of 12 and 14 (Nock, 2009) andmillions of adolescents engage in SITBs each year,treatments designed specifically for youth are especiallyimportant. Unfortunately, although most suicidaladolescents have received some form of mental healthtreatment (Nock et al., 2013), and the rate of treatmentfor suicidal behavior in the United States has increased(Kessler, Berglund, Borges, Nock, & Wang, 2005), therate of suicidal behavior has not shown a similardecrease (Kessler et al., 2005). Taken together, thisresearch indicates that the field is in urgent need of moreefficacious treatments for SITBs.
Over the past 10 years, there has been a sharp increasein research examining interventions specifically designedfor SITBs in youth. The purpose of the current article isto review and evaluate the evidence base of psychosocialtreatments for SITBs in children and adolescents. This isthe first review of evidence-based treatments for SITBs inyouth that has been included in the Journal of ClinicalChild and Adolescent Psychology (JCCAP), whichreflects the growing research in this area, as well as theneed for a critical examination of existing treatments’efficacy to inform both future treatment research andclinical care.
REVIEW PARAMETERS
To identify all relevant studies that examined a psycho-social intervention aimed at reducing SITBs in childrenor adolescents, we performed a comprehensive searchof four major scientific databases (HealthSTAR,MEDLine, PsycINFO, PubMed) for articles publishedprior to September 2013. Searches used a number ofdifferent terms for SITBs (e.g., self-injury, NSSI, deliber-ate self-harm, self-harm, suicide ideation, suicide attempt,suicidal behavior) and interventions (e.g., intervention,therapy, treatment). In addition, to ensure that weincluded the most current treatment research, we alsosearched ProQuest.com for dissertation abstractsrelevant to our review (although this search did notgenerate any relevant unpublished dissertations) as well
as ClinicalTrials.gov for any clinical trials currently inprogress or recently completed that examined relevanttreatments for SITBs in youth. Our initial aim was toinclude only randomized controlled trials (RCTs) ofinterventions for SITBs (see review: Brent et al., 2013).However, due to the paucity of research in this area,and in line with our goal to review all evidence-basedinterventions, we broadened our review to also includenonrandomized controlled studies (i.e., studies includinga comparison group but without randomization) andpilot studies describing promising new interventions forreducing SITBs in youth.
Inclusion and Exclusion Criteria
Studies were included if they examined an intervention(a) for children and=or adolescents younger than 19,(b) specifically designed to treat SITBs, and (c) that mea-sured a specific SITB outcome. First, we restricted ourreview to studies that examined interventions exclusivelyin youth. A number of studies were excluded becausethey examined interventions across adolescence andadulthood but did not examine treatment effects separ-ately in adolescent participants (e.g., Bateman & Fonagy,1999; Hawton et al., 1981; Hawton et al., 1987). Weincluded two studies that examined adolescents andyoung adults, ages 15 to 24 (Robinson et al., 2012; Ruddet al., 1996), because young adults are relatively close inage to older adolescents. All other studies reviewed hereincluded participants 19 years of age or younger. Ofnote, given that SITBs are relatively rare in childhood,most studies focused on treating SITBs in adolescents.A few studies included children as young as age 10(e.g., Asarnow, Baraff et al., 2011; Harrington et al.,1998; Huey et al., 2004) and one study focused onchildren ages 8 to 11 (Perepletchikova et al., 2011).Due to the limited research on treatments for SITBsin children, we did not devote a separate sectionto these studies but instead highlighted in the textthose interventions that have been examined in preado-lescent youth.
Second, given that a major goal of this review is toinform clinical care that targets SITBs, we included onlystudies that examined treatments specifically designedfor SITBs. A comprehensive review of all treatmentsfor all disorders that might include a SITB outcomewas outside the scope of this review, and we did notwant to give interventions for specific disorders (e.g.,borderline personality disorder and major depression)preferential coverage. We considered including school-based prevention programs that focused on SITBs butultimately decided to exclude these studies from ourreview: Prevention programs generally aim to screenand identify high-risk youth, whereas our review wasfocused on interventions for youth that are already
1NSSI rates include a broad range of behaviors from severe beha-
viors, such as skin-cutting, to behaviors that cause less tissue damage,
such as scratching and pinching.
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determined to be at high risk (for reviews of preventionprograms, see Katz et al., 2013; Robinson et al., 2013).
Third, we included only studies that reported one ofthe following specific SITB outcomes: (a) NSSI (self-injurious behavior performed without intent to die);(b) suicide ideation (SI: thoughts of ending one’s life);(c) suicide planning or preparations (actions taken toplan or prepare to attempt suicide); (d) suicide attempts(SAs: self-injurious behaviors performed with at leastsome intent to die); (e) suicide threats or gestures(threatening to harm oneself without intent to die);
(f) deliberate self-harm, self-harm, or parasuicide (DSH:terms used to refer collectively to self-injuriousbehaviors performed with or without intent to die),and (g) suicide events (SEs) or suicide-related behavior(terms used to refer collectively to suicidal thoughts,plans or preparatory acts, and attempts). We excludedthe following types of studies if they did not includea specific SITB outcome: treatment adherence studies(e.g., Spirito, Boergers, Donaldson, Bishop, & Lewander,2002) and studies including measures of broad suiciderisk factors, such as psychiatric symptoms (e.g., Orbach
TABLE 1
Journal of Clinical Child and Adolescent Psychology Evaluation Criteria for Evidence-Based Treatments
Methods criteria:
1. Group design: Study involved a randomized controlled design
2. Independent variable defined: Treatment manuals or logical equivalent were used for the treatment
3. Population clarified: Conducted with a population, treated for specified problems, for whom inclusion criteria have been clearly delineated
4. Outcomes assessed: Reliable and valid outcome assessment measures gauging the problems targeted (at a minimum) were used
5. Analysis adequacy: Appropriate data analyses were used and sample size was sufficient to detect expected effects
Level 1: Well-Established Treatments
Evidence criteria
1.1. Efficacy demonstrated for the treatment in at least two (2) independent research settings and by two (2) independent investigatory teams
demonstrating efficacy by showing the treatment to be either:
1.1.a. Statistically significantly superior to pill or psychological placebo or to another active treatment
OR
1.1.b. Equivalent (or not significantly different) to an already well-established treatment in experiments
AND
1.2. All five (5) of the Methods Criteria
Level 2: Probably Efficacious Treatments
Evidence criteria
2.1. There must be at least two good experiments showing the treatment is superior (statistically significantly so) to a waitlist control group
OR
2.2. One or more good experiments meeting the Well-Established Treatment level with the one exception of having been conducted in at least two
independent research settings and by independent investigatory teams
AND
2.3. All five (5) of the Methods Criteria
Level 3: Possibly Efficacious Treatments
Evidence criterion
3.1. At least one good randomized controlled trial showing the treatment to be superior to a wait list or no-treatment control group
AND
3.2. All five (5) of the Methods Criteria
OR
3.3. Two or more clinical studies showing the treatment to be efficacious, with two or more meeting the last four (of five) Methods Criteria, but none
being randomized controlled trials
Level 4: Experimental Treatments
Evidence criteria
4.1. Not yet tested in a randomized controlled trial
OR
4.2. Tested in one or more clinical studies but not sufficient to meet Level 3 criteria.
Level 5: Treatments of Questionable Efficacy
5.1. Tested in good group-design experiments and found to be inferior to other treatment group and=or wait-list control group (i.e., only evidence
available from experimental studies suggests the treatment produces no beneficial effect).
Note: Criteria adapted from Silverman and Hinshaw (2008) and Division 12 Task Force on Psychological Interventions’ reports (Chambless
et al., 1998), Chambless and Hollon (1998), and Chambless and Ollendick (2001). Criteria for methodology described in Chambless and
Hollon (1998).
PSYCHOSOCIAL TREATMENTS FOR YOUTH SITBS 3
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& Bar-Joseph, 1993). It is important to note that moststudies included in our review were designed to testinterventions for youth with a past history of SITBswho were at risk for future SITBs. Therefore, treatmentefficacy was determined by assessing the recurrenceof SITBs over the treatment period (e.g., suicidereattempts).
Evaluation Criteria
Psychosocial interventions for SITBs in youth wereassessed using the JCCAP evidence-based treatment evalu-ation criteria (see Table 1). The JCCAP five-level system(Southam-Gerow & Prinstein, 2014) was adapted fromthe evaluation criteria initially proposed by Chamblesset al. (1993) and the APA Division 12 Task Force on thePromotion and Dissemination of Psychological Proce-dures to determine intervention potency, which were laterrevised and expanded to cover a wider range of treatmentstudies (e.g., pilot studies; see Chambless et al., 1998;Chambless & Hollon, 1998; Silverman & Hinshaw,2008). Using the JCCAP criteria, treatment efficacy isdetermined by evaluating the number and quality ofstudies comparing the experimental intervention toanother active treatment=psychological placebo=medi-cation or to a waitlist=no treatment control. RCTs arethe highest quality study used to evaluate a treatment’sefficacy. Based on the level of evidence, interventions areplaced into one of five categories (see Table 1):well-established (Level 1), probably efficacious (Level 2),possibly efficacious (Level 3), experimental (Level 4), andtreatments of questionable efficacy (Level 5). For interven-tions with mixed findings, we used the guidelines providedby Chambless and Hollon (1998) to evaluate ‘‘whether thepreponderance of studies argue for the treatment’s effi-cacy’’ (p. 13). First, we examined the quality of the dispar-ate studies and weighted rigorous studies, such as RCTs,more than other types of study designs. Second, if conflict-ing results were found using comparable treatmentdesigns, we evaluated interventions conservatively anddid not classify them as well-established or probablyefficacious treatments.
It is important to note that, for JCCAP EvidenceBase Updates, interventions are classified into broadfamilies of treatments based on the target and mode oftreatment (e.g., family-based therapy: Ecological) ratherthan by ‘‘brand names’’ of treatments (e.g., MultisystemicTherapy; Huey et al., 2004); (for a rationale for thischange, see Southam-Gerow & Prinstein, 2014). In thefollowing sections, we review the existing interventionsfor SITBs in youth using the ‘‘brand names’’ and then,to be consistent with the other JCCAP Evidence BaseUpdates, we evaluate the overall families of treatments(rather than each ‘‘brand name’’ treatment individually)using the JCCAP evaluation criteria displayed in
Table 1. However, we recognize that these broad inter-vention categories may not be mutually exclusive andthat collapsing across interventions in this manner doesnot allow for consideration of differences between treat-ments that may be important.
REVIEW OF INTERVENTIONS FORSELF-INJURIOUS THOUGHTS AND
BEHAVIORS
Based on the review parameters just described, oursearch yielded 29 relevant intervention studies: 18 RCTs,five nonrandomized controlled trials, and six pilot stu-dies. Table 2 displays the descriptive information andmain findings for each study, and Table 3 summarizesthe level of evidence for each broad treatment family.It is important to note a few things about the infor-mation presented in these tables. First, many interven-tions designed for children and adolescents included afamily component, even those that were primarilydesigned as individual treatments. Based on the primarymodality and target of treatment, we categorizedinterventions as follows: (a) treatments where the familywas the primary focus of the intervention (e.g.,Attachment-Based Family Therapy: Diamond et al.,2010) were classified as family-based therapy; (b) inter-ventions that focused on individual skills training andaugmented treatment with family therapy sessions (e.g.,Integrated Cognitive-Behavioral Therapy; Esposito-Smythers, Spirito, Kahler, Hunt, & Monti, 2011) wereclassified as individual therapyþ family therapy; and(c) treatments where the adolescent was the main focusof the intervention and family sessions were optional ornot presented as integral to the treatment plan (e.g.,Skills-Based Treatment; Donaldson, Spirito, & Esposito-Smythers, 2005) were classified as individual therapy.This classification is consistent with other Evidence-Based Treatment Updates in this series (e.g., Freemanet al., 2014).
Second, when comparing interventions, it is impor-tant to consider the type of SITBs examined. Forinstance, some interventions examined treatment effectson suicidal thoughts only, whereas others examined theimpact on specific suicidal behaviors, such as suicideattempts. Table 2 displays the specific SITB outcomesand measures included in each study (if specified), andTable 3 indicates which SITB outcomes were examinedin studies of each treatment family.
Third, the majority of treatment conditions, evencontrol or comparison conditions, showed a markedreduction in SITBs over time (an issue we return to atthe conclusion of our review). For trials that includeda comparison condition, we focused our discussion onbetween-group differences (i.e., those attributable to
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TA
BLE
2
Inte
rventions
for
Self-
Inju
rious
Thoughts
and
Behavio
rsin
Youth
Auth
ors
n
Sam
ple
Chara
cter
isti
csS
etti
ng
Incl
usi
on
(In
)and
Ex
clusi
on
(E
x)
Cri
teri
a
Majo
r
Dia
gnose
s
Outc
om
es=
Mea
sure
s
Tre
atm
ent
Condit
ions,
Dose
,and
Ass
essm
ents
Stu
dy
Type
Stu
dy
Att
riti
on
Rate
(and
Tre
atm
ent
Com
ple
tion)
Main
Res
ult
s
CB
T
CB
T-I
ndiv
iduala
Do
nald
son
,
Sp
irit
o,
&
Esp
osi
to-
Sm
yth
ers
(2005)
39
12-
to17-y
ear-
old
s;82%
fem
ale
;85%
Cau
casi
an
,10%
His
pan
ic,
5%
Afr
ican
Am
eric
an
Ou
tpati
ent
In:
Pre
sen
ted
toE
D
or
inp
ati
ent
wit
h
SA
;
Ex:
Psy
cho
sis,
sever
e
inte
llec
tual
imp
air
men
t
CU
D(4
5%
),
DB
D(4
5%
),
MD
D
(29%
),A
UD
(19%
)
SA
(str
uct
ure
d
foll
ow
-up
inte
rvie
w;
Sp
irit
oet
al.
,
1992),
SI
(SIQ
)
T:
Sk
ills
-Base
dT
reatm
ent
(n¼
21),
C:
Su
pp
ort
ive
Rel
ati
on
ship
Tre
atm
ent
(n¼
18),
Do
se:
Six
acu
tein
div
idu
al
sess
ion
san
do
ne
ad
jun
ctfa
mil
yp
rob
lem
-
solv
ing
sess
ion
over
3
mo
nth
sþ
thre
em
on
thly
ind
ivid
ual
sess
ion
s;
Ass
essm
ents
:
Pre
trea
tmen
t,F=
u3
an
d6
mo
nth
s
RC
TT
:29%
;
C:
11%
;
F=
uT
ota
lsa
mp
le:
20%
Tre
atm
ent
com
ple
tion
:
�6
sess
ion
s:
77%
;fu
ll
trea
tmen
t:60%
Red
uce
dS
Ifo
rb
oth
gro
up
so
ver
trea
tmen
t,b
ut
NS
bet
wee
ngro
up
s;
NS
for
SA
Taylo
ret
al.
(2011)b
25
12-
to18-y
ear-
old
s;gen
der
an
d
eth
nic
ity
NR
Ou
tpati
ent
In:�
1ep
iso
de
of
DS
H;
Ex:
AS
D,
psy
cho
sis,
glo
bal
learn
ing
dis
ab
ilit
y,
un
wil
lin
gn
ess
to
ad
dre
ssD
SH
NR
DS
H(S
HI)
T:
Ind
ivid
ual
Man
uali
zed
CB
T(M
CB
T)
for
DS
H
(n¼
25),
Do
se:
8–12
ind
ivid
ual
sess
ion
sþ
op
tio
nal
3-s
essi
on
pare
nt
psy
cho
edu
cati
on
gro
up
(M¼
6m
on
ths)
;
C:
No
ne;
Ass
essm
ents
:
Pre
-an
dp
ost
trea
tmen
t,
F=u
3m
on
ths
Pil
ot
T:
36%
Tre
atm
ent
com
ple
tion
:64%
Red
uce
dD
SH
over
trea
tmen
tan
d
main
tain
edat
F=
u
CB
T-I
ndiv
idualþ
CB
T-F
am
ily
Bre
nt
etal.
(2009)
124
12-
to18-y
ear-
old
s;77%
fem
ale
;67%
Cau
casi
an
,19%
His
pan
ic,
13%
Afr
ican
Am
eric
an
Ou
tpati
ent
In:
SA
wit
hin
past
90
days,
UM
D,
mo
der
ate
dep
ress
ive
sym
pto
ms;
Ex:
BP
,P
DD
,
SU
D,
psy
cho
sis
UM
D
(100%
)
SE
(SS
RS
)T
1:
CB
Tfo
rS
uic
ide
Pre
ven
tio
n(C
BT
-SP
),
Do
se:
acu
te12-1
6
wee
kly
ind
ivid
ual
sess
ion
san
du
pto
6
fam
ily
sess
ion
sþ
con
tin
uati
on
6
ind
ivid
ual
sess
ion
san
d
up
to3
fam
ily
sess
ion
s
(n¼
17);
T2:
Med
icati
on
alg
ori
thm
(n¼
14);
T3:
Co
mb
ined
CB
T-S
Pþ
med
icati
on
(n¼
93);
Len
gth
for
all
Ts:
6m
on
ths;
Ass
essm
ents
:
Pre
trea
tmen
tan
dat
6,
12,
18,
an
d24
wee
ks
No
n-
ran
do
miz
ed
con
tro
lled
tria
l
To
tal
sam
ple
Wee
k12:
23%
,
Wee
k18:
30%
,
Wee
k24:
33%
Tre
atm
ent
com
ple
tion
:
T1:
65%
,T
2:
57%
,T
3:
71%
NS
for
SE
(Co
nti
nu
ed)
5
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TA
BLE
2
Continued
Auth
ors
n
Sam
ple
Chara
cter
isti
csS
etti
ng
Incl
usi
on
(In
)and
Ex
clusi
on
(E
x)
Cri
teri
a
Majo
r
Dia
gnose
s
Outc
om
es=
Mea
sure
s
Tre
atm
ent
Condit
ions,
Dose
,and
Ass
essm
ents
Stu
dy
Type
Stu
dy
Att
riti
on
Rate
(and
Tre
atm
ent
Com
ple
tion)
Main
Res
ult
s
Esp
osi
to-
Sm
yth
ers,
Sp
irit
o,
Uth
,
&L
aC
han
ce
(2006)b
614-
to16-y
ear-
old
s;83%
fem
ale
;100%
Cau
casi
an
Ou
tpati
ent
In:
Inp
ati
ent
ho
spit
ali
zati
on
for
SA
or
SI
an
d
com
orb
idA
UD
or
CU
D;
Ex:
SU
Do
ther
than
AU
Do
rC
UD
,
IQ<
70
100%
AU
D=
CU
Dan
d
MD
D
SA
(NR
),
SI
(SIQ
-Sn
)
T:
CB
Tfo
rsu
icid
ean
d
AU
D=
CU
D(n¼
6);
Do
se:
wee
kly
ind
ivid
ual
sess
ion
sfo
r6
mo
nth
sþ
biw
eek
lyin
div
idu
al
sess
ion
sfo
r3
mo
nth
sþ
mo
nth
lyin
div
idu
al
sess
ion
s3
mo
nth
sþ
con
join
tfa
mil
yse
ssio
ns
as
nee
ded
;C
:N
on
e;
Ass
essm
ents
:
Pre
trea
tmen
t,6
an
d
12
mo
nth
s
Pil
ot
T:
17%
Tre
atm
ent
com
ple
tion
:83%
Red
uce
dS
I;N
Sfo
r
SA
CB
T-I
ndiv
idualþ
CB
T-F
am
ilyþ
Pare
nt
Tra
inin
g
Esp
osi
to-
Sm
yth
ers,
Sp
irit
o,
Kah
ler,
Hu
nt,
&
Mo
nti
(2011)b
40
13-
to17-y
ear-
old
s;67%
fem
ale
;89%
Cau
casi
an
,
14%
His
pan
ic
Ou
tpati
ent
In:
SA
inp
ast
3
mo
nth
so
r
sign
ifica
nt
SI
(�41
on
SIQ
)an
d
AU
Do
rC
UD
;
Ex:
BP
,p
sych
osi
s,
curr
ent
ho
mic
idal
idea
tio
n,
SU
D
oth
erth
an
AU
Do
rC
UD
,
IQ<
70
UM
D(9
4%
),
CU
D(8
3%
),
AU
D(6
4%
),
AN
X(5
6%
),
DB
D(5
0%
)
SA
(K-S
AD
S-
PL
),S
I
(SIQ
-Sn
)
T:
Inte
gra
ted
CB
Tfo
r
AU
D=
SU
Dan
dsu
icid
e
(n¼
20);
Do
se:
Wee
kly
ind
ivid
ual
an
dw
eek
ly–
biw
eek
lyp
are
nt
sess
ion
sfo
r6
mo
nth
sþ
biw
eek
lyin
div
idu
al
an
d
biw
eek
ly-m
on
thly
pare
nt
sess
ion
sfo
r
3m
on
thsþ
mo
nth
ly
ind
ivid
ual
an
dp
are
nt
mo
nth
lyas
nee
ded
for
3m
on
thsþ
con
join
t
fam
ily
sess
ion
sas
nee
ded
;
C:
En
han
ced
TA
U–
dia
gn
ost
icev
alu
ati
onþ
com
mu
nit
y-b
ase
dT
AU
(n¼
20);
Do
se:
Vari
edfo
r
12
mo
nth
s;A
sses
smen
ts:
Pre
trea
tmen
t,3,
6,
12,
an
d18
mo
nth
s
RC
TT
:25%
,C
:15%
;
To
tal
sam
ple
3m
on
ths:
10%
;
6m
on
ths:
15%
;
12
mo
nth
s:18%
;
18
mo
nth
s:20%
;
Tre
atm
ent
com
ple
tion
(24
sess
ion
s
w=
ad
ole
scen
t
an
d12
sess
ion
s
w=
pare
nt)
:
T:
74%
ad
ole
scen
ts,
74%
fam
ilie
s,an
d
90%
pare
nts
,C
:
44%
ad
ole
scen
ts,
19%
fam
ilie
s,an
d
25%
pare
nts
Red
uce
dS
Ain
T
com
pare
dto
C
over
18
mo
nth
s;
NS
for
SI
CB
TS
kil
ls–G
roup
Ru
dd
etal.
(1996)
264
15-
to24-y
ear-
old
s;18%
fem
ale
;61%
Cau
casi
an
,
26%
Afr
ican
Am
eric
an
,
11%
His
pan
ic
Part
ial
ou
tpati
ent
In:
Pre
sen
ted
wit
h
SA
,U
MD
wit
h
SI,
alc
oh
ol
ab
use
wit
hS
I;
Ex:
SU
Do
r
chro
nic
ab
use
,
psy
cho
sis
or
tho
ugh
td
iso
rder
,
sever
eP
D
MD
(72%
),
AU
D(4
4%
)
SA
(mea
sure
NR
),S
I
(MS
SI)
T:
Tim
e-li
mit
edC
BT
gro
up
ther
ap
y
(n¼
143),
Do
se:
9h
r
dail
yfo
r2
wee
ks;
C:
Inp
ati
ent
an
d
ou
tpati
ent
TA
U
(n¼
121),
Do
se:
Vari
ed
com
bin
ati
on
of
ind
ivid
ual
an
dgro
up
RC
TF=
u:
1m
on
th:
T:
16%
,
C:
25%
,
6m
on
ths:
T:
47%
,
C:
54%
,
12
mo
nth
s:
T:
68%
,
Red
uce
dS
Ifo
rb
oth
gro
up
s,b
ut
NS
bet
wee
ngro
up
s;
no
ten
ou
gh
SA
sto
exam
ine
gro
up
dif
fere
nce
s
6
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
ther
ap
y;
Ass
essm
ents
:
Pre
trea
tmen
t,F=
u1,
6,
12,
18,
an
d24
mo
nth
s
C:
79%
Tre
atm
ent
com
ple
tion
:
T:
79%
DB
Tc
Fle
isch
hak
er
etal.
(2011)d
12
13-
to19-y
ear-
old
s;100%
fem
ale
;et
hn
icit
y
NR
Ou
tpati
ent
In:
NS
SI
or
SA
past
4m
on
ths,
an
dB
PD
or
�3
BP
Dcr
iter
ia;
Ex:
AN=
BN
,S
UD
,
psy
cho
sis,
sever
e
mo
od
epis
od
e
req
uir
ing
inp
ati
ent
trea
tmen
t,
IQ<
70,
illi
tera
cy
BP
D(8
3%
)N
SS
Ian
dS
A
(LP
C)
T:
DB
T(n¼
12),
Do
se:
Wee
kly
ind
ivid
ual
sess
ion
sþ
wee
kly
mu
ltif
am
ily
skil
lsgro
up
(þre
gu
lar
ph
on
e
con
tact
as
nee
ded
)fo
r
16–24
wee
ks;
C:
No
ne;
Ass
essm
ents
:
Pre
trea
tmen
t,F=
u
4w
eek
san
d1-y
ear
po
sttr
eatm
ent
Pil
ot
F=
uT
:0%
Tre
atm
ent
com
ple
tion
:75%
Red
uce
dN
SS
Ifr
om
pre
trea
tmen
tto
F=
u4
wee
ks
po
sttr
eatm
ent,
F=
u1
yea
ro
ver
half
stil
len
gagin
g
inN
SS
I;N
oS
As
rep
ort
edd
uri
ng
tria
l
Jam
eset
al.
(2008)
16
15-
to18-y
ear-
old
s;100%
fem
ale
;
eth
nic
ity
NR
Ou
tpati
ent
In:
DS
H>
6
mo
nth
s;
Ex:
AS
D,
BP
,
SZ
,m
od
erate
to
sever
em
enta
l
imp
air
men
t
BP
D(1
00%
)D
SH (un
spec
ified
clin
ical
inte
rvie
w)
T:
DB
T(n¼
16),
Do
se:
Wee
kly
ind
ivid
ual
sess
ion
sþ
wee
kly
skil
ls
gro
upþ
tele
ph
on
e
con
sult
ati
on
for
two
6-m
on
thb
lock
s;
C:
No
ne;
Ass
essm
ent:
Pre
-an
dp
ost
trea
tmen
t,
F=
u8
mo
nth
s
Pil
ot
T:
13%
Tre
atm
ent
com
ple
tion
:
(78%
of
sess
ion
s
com
ple
ted
,o
n
aver
age)
Red
uce
dD
SH
fro
mp
re-
to
po
sttr
eatm
ent
an
dF=
u
Jam
eset
al.
(2011)
25
13–17
yea
r-
old
s;88%
fem
ale
;
eth
nic
ity
NR
Ou
tpati
ent
In:
DS
H>
6
mo
nth
s;
Ex:
AS
D,
BP
,
SZ
,m
od
erate
to
sever
em
enta
l
imp
air
men
t
BP
D(1
00%
)D
SH (un
spec
ified
clin
ical
inte
rvie
w)
T:
DB
T(n¼
25),
Do
se:
Wee
kly
ind
ivid
ual
sess
ion
sþ
wee
kly
skil
ls
gro
upþ
tele
ph
on
e
con
sult
ati
on
for
two
6-m
on
thb
lock
s;
C:
No
ne;
Ass
essm
ents
:
Pre
-an
dp
ost
trea
tmen
t
Pil
ot
T:
28%
Tre
atm
ent
com
ple
tion
:72%
Red
uce
dD
SH
fro
mp
re-
to
po
sttr
eatm
ent
Katz
etal.
(2004)
62
14-
to17-y
ear-
old
s;84%
fem
ale
;73%
Cau
casi
an
Inp
ati
ent
In:
Ho
spit
ali
zati
on
for
SA
or
SI;
Ex:
BP
,m
enta
l
dis
ab
ilit
y,
psy
cho
sis,
sever
e
learn
ing
dif
ficu
ltie
s
NR
DS
Hd
uri
ng
trea
tmen
t
(in
cid
ent
rep
ort
sfr
om
nu
rsin
gst
aff
),
DS
Hat
F=
u
(LP
C),
SI
(SIQ
)
T:
DB
T(n¼
32),
Do
se:
10
dail
ysk
ills
gro
upþ
twic
e
wee
kly
ind
ivid
ual
sess
ion
sþ
DB
Tm
ilie
u
for
2w
eek
s;
C:
Psy
cho
dyn
am
ic
psy
cho
ther
ap
y
(n¼
30),
Do
se:
Dail
y
gro
up
sess
ion
sþ
wee
kly
ind
ivid
ual
sess
ion
sþ
psy
cho
dyn
am
icm
ilie
u;
Ass
essm
ents
:P
re-
an
d
po
sttr
eatm
ent,
F=
u1
yea
r
No
n-
ran
do
miz
ed
con
tro
lled
tria
l(t
reatm
ent
ass
ign
edb
y
un
it)
F=
uT
:17%
,
C:
10%
Tre
atm
ent
com
ple
tion
:100%
Few
erb
ehavio
ral
inci
den
ts(e
.g.,
vio
len
ceto
ward
self
or
oth
ers-
DS
H
no
tsp
ecifi
ed)
inT
gro
up
;R
edu
ced
DS
Han
dS
Iin
bo
thgro
up
sat
F=
u,
NS
dif
fere
nce
s
bet
wee
ngro
up
s
(Co
nti
nu
ed)
7
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
TA
BLE
2
Continued
Auth
ors
n
Sam
ple
Chara
cter
isti
csS
etti
ng
Incl
usi
on
(In
)and
Ex
clusi
on
(E
x)
Cri
teri
a
Majo
r
Dia
gnose
s
Outc
om
es=
Mea
sure
s
Tre
atm
ent
Condit
ions,
Dose
,and
Ass
essm
ents
Stu
dy
Type
Stu
dy
Att
riti
on
Rate
(and
Tre
atm
ent
Com
ple
tion)
Main
Res
ult
s
Rath
us
&
Mil
ler
(2002)d
111
16.1
yea
rso
ld
�1.2
(T),
15.0
yea
rso
ld�
1.7
(C);
93%
fem
ale
(T),
73%
fem
ale
(C);
68%
His
pan
ic,
17%
Afr
ican
Am
eric
an
,8%
Cau
casi
an
Ou
tpati
ent
In:
SA
inp
ast
16
wee
ks
or
curr
ent
SI,
an
dB
PD
or
�3
BP
Dfe
atu
res;
Ex:
NR
UM
D(T
:
92%
,C
:
73%
),B
PD
(T:
88%
,C
:
16%
),A
NX
(T:
40%
,C
:
21%
),S
UD
(T:
48%
,C
:
5%
)
SA
(pati
ent
self
-rep
ort
to
ther
ap
ist)
,
SI
(HA
SS
an
dS
SI)
T:
DB
T(n¼
29),
Do
se:
Tw
ice
wee
kly
ind
ivid
ual
sess
ion
sþ
mu
ltif
am
ily
skil
lsgro
up
for
12
wee
ks;
C:
Psy
cho
dyn
am
ic
or
sup
po
rtiv
e
ther
ap
y(n¼
82),
Do
se:
Tw
ice
wee
kly
ind
ivid
ualþ
fam
ily
sess
ion
sfo
r12
wee
ks;
Ass
essm
ents
:P
re-
an
d
po
sttr
eatm
ent
No
n-r
an
do
miz
ed
con
tro
lled
tria
l
(mo
rese
ver
e
pati
ents
ass
ign
ed
toD
BT
)
Vari
esfo
ran
aly
ses
(e.g
.,90%
Tan
d
50%
Cco
mp
lete
d
base
lin
eS
SI;
34%
Tco
mp
lete
dp
re-
an
dp
ost
trea
tmen
t
mea
sure
s)
Tre
atm
ent
com
ple
tio
n
(12
wee
ks)
:
T:
62%
,C
:40%
Red
uce
dS
Iin
T
gro
up
pre
-to
po
sttr
eatm
ent
(no
t
mea
sure
din
C
gro
up
;th
eref
ore
no
tab
leto
com
pare
bet
wee
n
gro
up
s);
NS
for
SA
DB
T-G
roup
Only
Per
eple
tch
i-
ko
va
etal.
(2011)
11
8-
to11-y
ear-
old
s;
55%
fem
ale
;
73%
Cau
casi
an
Sch
oo
lIn
:2n
d–6th
gra
der
s;
Ex:
NR
MD
D
sym
pto
ms
(55%
),A
NX
sym
pto
ms
(45%
)
SI
(MF
Q)
T:
DB
Tgro
up
skil
ls
(n¼
11),
Do
se:
Tw
ice
wee
kly
for
6w
eek
s;
C:
No
ne;
Ass
essm
ents
:
Pre
-an
dp
ost
trea
tmen
t
Pil
ot
NR
Red
uce
dS
Ifr
om
pre
-to
po
st
trea
tmen
t
FB
T
FB
T–A
ttach
men
t
Dia
mo
nd
etal.
(2010)
66
12-
to17-y
ear-
old
s;83%
fem
ale
;74%
Afr
ican
Am
eric
an
Ou
tpati
ent
In:
SI
(>31
on
SIQ
-Jr)
an
d
mo
der
ate
dep
ress
ion
;
Ex:
Nee
ded
psy
chia
tric
ho
spit
ali
zati
on
,
rece
nt
dis
charg
e
fro
mp
sych
iatr
ic
ho
spit
al,
psy
cho
sis,
men
tal
reta
rdati
on
or
bo
rder
lin
e
inte
llec
tual
fun
ctio
nin
g
AN
X–
no
t
spec
ified
(67%
),
AD
HD
or
DB
D(5
8%
),
MD
D(3
9%
)
SI
(SIQ
-Jr
an
dS
SI)
T:
Att
ach
men
t-B
ase
d
Fam
ily
Th
erap
y
(n¼
35),
Do
se:
Wee
kly
sess
ion
sfo
r3
mo
nth
s;
C:
En
han
ced
TA
U
(n¼
31);
Do
se:
Vari
edo
utp
ati
ent
trea
tmen
tw
ith
clin
ical
mo
nit
ori
ng;
Ass
essm
ents
:
Pre
trea
tmen
t,
6w
eek
s,12
wee
ks
(po
sttr
eatm
ent)
,
an
d24
wee
ks
RC
T6
wee
ks
T:
6%
,C
:
13%
;12
wee
ks
(po
sttr
eatm
ent)
T:
11%
,C
:6%
;
24
wee
ks
T:
11%
,
C:
16%
;
Tre
atm
ent
com
ple
tion
:
�1
sess
ion
:T
:91%
,
C:
68%
;�
6
sess
ion
s:T
:69%
,
C:
19%
;�
10
sess
ion
s:T
:63%
,
C:
6%
Red
uce
dS
Iin
T
com
pare
dto
C
an
dm
ain
tain
ed
at
F=
u
8
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
FB
T–E
colo
gic
al
Hu
eyet
al.
(2004)
160
10-
to17-y
ear-
old
s;35%
fem
ale
;65%
Afr
ican
Am
eric
an
,33%
Cau
casi
an
Ho
me
(T);
Inp
ati
ent
(C)In
:H
osp
itali
zati
on
for
SA
,S
Io
rS
P,
ho
mic
idal
idea
tio
no
r
beh
avio
r,
psy
cho
sis,
thre
at
toh
arm
self
or
oth
ers;
Med
icaid
-
fun
ded
or
wit
ho
ut
hea
lth
insu
ran
ce,
resi
din
gin
no
n-
inst
itu
tio
nal
envir
on
men
t;
Ex:
AS
D
NR
DS
Ho
rS
A
(CB
CL
);S
A
(YR
BS
);S
I(B
SI
an
dY
RB
S)
T:
Mu
ltis
yst
emic
Th
erap
y
(n¼
80),
Do
se:
Dail
y
con
tact
ifn
eed
edfo
r
3–6
mo
nth
s;
C:
Inp
ati
ent
ho
spit
ali
zati
on
(n¼
80),
Do
se:
Dail
y
beh
avio
rall
y-
base
dm
ilie
up
rogra
m;
Ass
essm
ents
:
Pre
trea
tmen
t,
4m
on
ths,
F=
u1
yea
r
po
sttr
eatm
ent
RC
TT
ota
lsa
mp
le:
2%
Tre
atm
ent
com
ple
tion
:
T:
94%
;C
:100%
Red
uce
dS
As
fro
m
pre
-to
po
sttr
eatm
ent
in
Tco
mp
are
dto
C
(YR
BS
on
ly);
NS
for
SI
FB
T–E
mer
gen
cy
Asa
rno
wet
al.
(2011)
181
10-
to18-y
ear-
old
s;69%
fem
ale
;45%
His
pan
ic,
33%
Cau
casi
an
,13%
Afr
ican
Am
eric
an
ED
In:
Pre
sen
ted
toE
D
wit
hS
Aan
d=
or
SI;
Ex:
Psy
cho
sis;
sym
pto
ms
or
oth
erfa
cto
rs
that
inte
rfer
ed
wit
hab
ilit
y
toco
nse
nt
UM
D
(40%
)
SA
(DIS
C-I
V
an
dH
AS
S),
SI
(HA
SS
)
T:
Fam
ily
Inte
rven
tio
n
for
Su
icid
eP
reven
tio
n
(n¼
89),
Do
se:
On
e
fam
ily-b
ase
dC
BT
sess
ion
inE
Dþ
ph
on
e
con
tact
48
ho
urs
po
st-c
harg
ean
dse
ver
al
oth
erti
mes
over
1m
on
th;
C:
En
han
ced
ED
TA
U(n¼
92),
Do
se:
ED
usu
al
careþ
spec
iali
zed
staff
train
ing;
Ass
essm
ents
:
Pre
trea
tmen
t,F=
u
2m
on
ths
RC
TF=
uT
:15%
;
C:
9%
Tre
atm
ent
com
ple
tion
:100%
NS
bet
wee
ngro
up
s
for
all
SIT
Bs
ou
tco
mes
Ou
gri
n,
Bo
ege,
Sta
hl,
Ban
ars
ee,
&
Taylo
r
(2013)b
70
12-
to18-y
ear-
old
s;80%
fem
ale
;53%
Cau
casi
an
,20%
Afr
ican
Am
eric
an
,11%
Asi
an
ED
In:
Rec
ent
DS
Ho
r
DS
Pb
ut
no
t
curr
entl
yre
ceiv
ing
psy
chia
tric
serv
ices
;E
x:
gro
ss
reali
tyd
isto
rtio
n,
sever
ein
tell
ectu
al
dis
ab
ilit
y;
imm
inen
tvio
len
ce
or
suic
ide
risk
EM
D
(60%
);
DB
D
(13%
)
DS
H(A
ccid
ent
an
dE
mer
gen
cy
dep
art
men
t
rep
ort
san
d
pati
ent
reco
rds)
T:
Th
erap
euti
c
Ass
essm
ent
(n¼
35);
Do
se:
30-m
inu
tese
ssio
n
usi
ng
cogn
itiv
ean
aly
tic
ther
ap
yp
ara
dig
mw
ith
fam
ilyþ
ass
essm
ent
as
usu
al
(AA
U);
C:
AA
U
(n¼
35);
Do
se
Psy
cho
soci
al
his
tory
an
dri
skass
essm
ent
over
1h
ou
r;
Ass
essm
ents
:F=
u
2yea
rs
RC
TF=
uT
:6%
,
C:
9%
Tre
atm
ent
com
ple
tion
:100%
NS
bet
wee
ngro
up
s
for
DS
Ho
ver
F=
u
(Co
nti
nu
ed)
9
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
TA
BLE
2
Continued
Auth
ors
n
Sam
ple
Chara
cter
isti
csS
etti
ng
Incl
usi
on
(In
)and
Ex
clusi
on
(E
x)
Cri
teri
a
Majo
r
Dia
gnose
s
Outc
om
es=
Mea
sure
s
Tre
atm
ent
Condit
ions,
Dose
,and
Ass
essm
ents
Stu
dy
Type
Stu
dy
Att
riti
on
Rate
(and
Tre
atm
ent
Com
ple
tion)
Main
Res
ult
s
Ro
ther
am
-
Bo
rus
etal.
(1996,
2000)
140
12-
to18-y
ear-
old
s;100%
fem
ale
;88%
His
pan
ic
ED
In:
Pre
sen
ted
toE
D
wit
hS
A,
fem
ale
gen
der
;
Ex:>
1w
eek
psy
chia
tric
ho
spit
ali
zati
on
UM
D
(44%
),
AN
X
(38%
),
DB
D
(24%
)
SA
(ED
reco
rds)
,
SI
(HA
SS
)
T:
Sp
ecia
lize
dE
D
Care
,D
ose
:
Psy
cho
edu
cati
onþ
fam
ily
sess
ionþ
staff
train
ing
(n¼
65);
C:
Sta
nd
ard
ED
Care
(n¼
75);
Do
se:
ED
evalu
ati
on
an
dre
ferr
al
too
utp
ati
ent
ther
ap
y;
Ass
essm
ents
:P
re-
an
d
po
sttr
eatm
ent,
F=
u3,
6,
12,
an
d18
mo
nth
s
No
n-
ran
do
miz
ed
con
tro
lled
tria
l
F=
uT
ota
l
sam
ple
:8%
Tre
atm
ent
com
ple
tion
:100%
Gre
ate
rre
du
ctio
nin
SI
inT
com
pare
d
toC
po
stin
terv
enti
on
;
ho
wev
er,
NS
bet
wee
ngro
up
s
for
all
SIT
Bs
ou
tco
mes
at
F=
u
FB
T–P
are
nt
Tra
inin
gO
nly
Pin
eda
&
Dad
ds
(2013)
48
12-
to17-y
ear-
old
s;fe
male
:
73%
(T);
78%
(C);
Cau
casi
an
:
64%
(T),
50%
(C);
Mix
ed
eth
nic
ity:
27%
(T)
44%
(C)
Ou
tpati
ent
In:�
1S
ITB
sp
ast
two
mo
nth
s;
pri
mary
AN
X
or
MD
D;
Ex:
PD
Do
r
psy
cho
sis
MD
D
(100%
);
AN
X
(38%
)
SIT
Bs
(co
mb
ines
all
DS
Han
dS
RB
)
(AS
Q-R
)
T:
Res
ou
rcef
ul
Ad
ole
scen
tP
are
nt
Pro
gra
m(R
AP
-P)
(n¼
24);
Do
se:
Fo
ur
2-h
ou
rse
ssio
ns,
wee
kly
or
biw
eek
lyþ
cris
is
man
agem
ent
an
d
safe
typ
lan
nin
g;
C:
Ro
uti
ne
care
(n¼
24);
Do
se:
Vari
ed
ou
tpati
ent
trea
tmen
t;
Ass
essm
ents
:P
re-
an
d
po
sttr
eatm
ent,
F=u
6m
on
ths
RC
TF=
uT
:8%
,
C:
25%
Tre
atm
ent
com
ple
tion
(all
fou
r
sess
ion
s):
Tan
dC
:
100%
Red
uce
dS
ITB
sin
T
com
pare
dto
C
fro
mp
re-
to
po
sttr
eatm
ent;
red
uct
ion
s
main
tain
edat
F=
u
FB
T–P
roble
m-F
ocu
sed
Harr
ingto
n
etal.
(1998)
162
10-
to16-y
ear-
old
s;90%
fem
ale
;et
hn
icit
y
NR
Ho
me
(T);
Ou
tpati
ent
(C)
In:
DS
P;
Ex:
DS
H(o
ther
than
DS
P),
inab
ilit
yto
engage
infa
mil
y
inte
rven
tio
n,
psy
chia
tris
t
dec
ided
part
icip
ati
on
was
con
train
dic
ate
d
(e.g
.,p
sych
osi
s)
MD
D
(67%
),
CD
(10%
)
SI
(SIQ
)T
:F
am
ily-b
ase
dp
rob
lem
solv
ing
(n¼
85),
Do
se:
Fiv
eh
om
e
sess
ion
sþ
TA
U;
C:
TA
U(n¼
77),
Do
se:
Vari
edo
utp
ati
ent
trea
tmen
t;A
sses
smen
ts:
Pre
trea
tmen
t,2
an
d6
mo
nth
s
RC
TT
ota
lsa
mp
leF=
u
2m
on
ths:
4%
,
F=
u6
mo
nth
s:
8%
Tre
atm
ent
com
ple
tion:
74%
of
T
inte
rven
tio
n
sess
ion
satt
end
ed
Red
uce
dS
Iin
T
com
pare
dto
Cin
sub
set
of
ad
ole
scen
ts
wit
ho
ut
MD
D
10
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
IPT
IPT
–In
div
idual
Tan
g,
Jou
,
Ko
,H
uan
g,
&Y
en
(2009)e
73
12-
to18-y
ear-
old
s;66%
fem
ale
;et
hn
icit
y
NR
(stu
dy
con
du
cted
in
Taiw
an
)
Sch
oo
lIn
:M
od
erate
to
sever
ed
epre
ssio
n,
SI,
or
pre
vio
us
SA
,m
od
erate
to
sever
ean
xie
ty,
or
sign
ifica
nt
ho
pel
essn
ess
in
the
past
2w
eek
s;
Ex:
Psy
cho
sis,
dru
g
ab
use
,se
rio
us
med
icati
on
con
dit
ion
,o
r
sever
e(e
.g.,
hig
h-l
eth
ali
ty)
suic
idal
beh
avio
rs
MD
D
(100%
)
SI
(BS
S)
T:
Inte
nsi
ve
Inte
rper
son
al
Psy
cho
ther
ap
yfo
r
dep
ress
edad
ole
scen
ts
wit
hsu
icid
eri
sk(I
PT
-
A-I
N)
(n¼
35),
Do
se:
Tw
ose
ssio
ns
wee
kly
þ30
min
.p
ho
ne
foll
ow
-
up
for
6w
eek
s;C
:
Psy
cho
edu
cati
onþ
sup
po
rtiv
eco
un
seli
ng
(pare
nt
incl
ud
edif
nee
ded
)(n¼
38),
Do
se:
On
eto
two
sess
ion
s
wee
kly
for
6w
eek
s;
Ass
essm
ents
:P
re-
an
d
po
sttr
eatm
ent
RC
TT
:0%
,C
:8%
Tre
atm
ent
com
ple
tion
(fu
ll6-w
eek
pro
gra
m):
T:
100%
;C
:92%
Red
uce
dS
Iin
T
com
pare
dto
C
Psy
chodynam
icT
her
apy
Psy
chodynam
icT
her
apy–In
div
idualþ
Fam
ily
Ro
sso
uw
&
Fo
nagy
(2012)
80
12-
to17-y
ears
old
;85%
fem
ale
;
75%
Cau
casi
an
,
10%
Asi
an
,
7.5
%m
ixed
race
,5%
Afr
ican
Am
eric
an
Ou
tpati
ent
In:�
1D
SH
epis
od
ep
ast
mo
nth
;
Ex:
AN
or
BN
,
PD
D,
psy
cho
sis,
sever
ele
arn
ing
dis
ab
ilit
y
(IQ<
65),
chem
ical
dep
end
ence
Dep
ress
ive
sym
pto
ms
(97%
),B
PD
(73%
)
DS
H(C
I-B
PD
an
dR
TS
HI)
T:
Men
tali
zati
on
-Base
d
Tre
atm
ent
(MB
T-A
)
for
self
-harm
(n¼
40),
Do
se:
Wee
kly
ind
ivid
ualþ
mo
nth
ly
fam
ily
ther
ap
yfo
r
1yea
r;
C:
Co
mm
un
ity-b
ase
d
TA
U-v
ari
ed(n¼
40),
Do
se:
1yea
r;
Ass
essm
ents
:
Pre
trea
tmen
t,3,
6,
an
d9
mo
nth
saft
er
ran
do
miz
ati
on
,an
d
po
sttr
eatm
ent
RC
T3
mo
nth
s
T:
13%
,
C:
8%
;
6m
on
ths
T:
3%
,
C:
10%
;
9m
on
ths
T:
13%
,
C:
15%
;
12
mo
nth
s
T:
10%
,
C:
13%
Tre
atm
ent
com
ple
tion
:
T:
50%
,
C:
43%
Red
uce
dD
SH
inT
com
pare
dto
C
po
sttr
eatm
ent
(12-m
on
th)
ass
essm
ent
on
ly
Com
bin
edS
kil
lsG
roup
Inte
rven
tion
CB
TS
kil
lsþ
DB
TS
kil
lsþ
Psy
chodynam
icT
her
apy
Sk
ills
–G
roup
Gre
enet
al.
(2011)
366
12-
to17-y
ear-
old
s;89%
fem
ale
;94%
Cau
casi
an
Ou
tpati
ent
In:�
2D
SH
epis
od
esp
ast
yea
r;
Ex:
AN
,acu
te
psy
cho
sis,
sub
stan
tial
learn
ing
dif
ficu
ltie
s
Dep
ress
ive
dis
ord
er
sym
pto
ms
(62%
),
beh
avio
ral
pro
ble
ms
(33%
)
DS
H(i
nte
rvie
w
vali
date
din
Harr
ingto
n
etal.
,1998),
SI
(SIQ
)
T:
Dev
elo
pm
enta
lgro
up
psy
cho
ther
ap
y
(n¼
183),
Do
se:
(see
Wo
od
etal.
)þ
rou
tin
e
care
;C
:R
ou
tin
eca
re
on
ly(n¼
183),
Do
se:
Vari
ed,
bu
tn
ogro
up
ther
ap
y;
Ass
essm
ents
:
Pre
trea
tmen
t,F=
u6
mo
nth
san
d1
yea
r
RC
TF=
uT
:2%
,C
2%
Tre
atm
ent
com
ple
tion
(�4
sess
ion
s):
T:
79%
,C
:63%
DS
Han
dS
I
imp
rovem
ent
for
bo
thgro
up
s,N
S
dif
fere
nce
s
bet
wee
ngro
up
s
(Co
nti
nu
ed)
11
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
TA
BLE
2
Continued
Auth
ors
n
Sam
ple
Chara
cter
isti
csS
etti
ng
Incl
usi
on
(In
)and
Ex
clusi
on
(E
x)
Cri
teri
a
Majo
r
Dia
gnose
s
Outc
om
es=
Mea
sure
s
Tre
atm
ent
Condit
ions,
Dose
,and
Ass
essm
ents
Stu
dy
Type
Stu
dy
Att
riti
on
Rate
(and
Tre
atm
ent
Com
ple
tion)
Main
Res
ult
s
Haze
llet
al.
(2009)
72
12-
to16-y
ear-
old
s;90%
fem
ale
;et
hn
icit
y
NR
Ou
tpati
ent
In:�
2D
SH
epis
od
esp
ast
yea
r,�
1D
SH
epis
od
ep
ast
3m
on
ths;
Ex:
Mo
rein
ten
sive
trea
tmen
tre
qu
ired
,
inab
ilit
yto
att
end
gro
up
s,acu
te
psy
cho
sis,
or
inte
llec
tual
dis
ab
ilit
y
MD
D(5
7%
),
DB
D(7
%),
alc
oh
ol
pro
ble
ms
(4%
)
DS
H(P
HI)
,
SI
(SIQ
)
T:
Dev
elo
pm
enta
lgro
up
psy
cho
ther
ap
y(n¼
35),
Do
se:
(see
Wo
od
etal.
)
for
up
to1
yea
r;
C:
Ro
uti
ne
care
(n¼
37),
Do
se:
Vari
edfo
r1
yea
r;
Ass
essm
ents
:
Pre
trea
tmen
t,
8w
eek
s,6
mo
nth
s,
an
d1
yea
r
RC
TT
:3%
,C
:8%
Tre
atm
ent
com
ple
tion
(�4
sess
ion
s):
T:
71%
,C
:62%
Incr
ease
dD
SH
inT
com
pare
dto
Cat
6m
on
ths
an
d1
yea
r,(h
ow
ever
,
gro
up
dif
fere
nce
s
wer
e
no
nsi
gn
ifica
nt
aft
erco
ntr
oll
ing
for
his
tory
of
med
icati
on
over
do
se);
NS
for
SI
Wo
od
,
Tra
ino
r,
Ro
thw
ell,
Mo
ore
,&
Harr
ingto
n
(2001)
63
12-
to16-y
ear-
old
s;78%
fem
ale
;
eth
nic
ity
NR
Ou
tpati
ent
In:�
1D
SH
epis
od
e
past
yea
r;
Ex:
Su
icid
eri
sk
too
sever
efo
r
am
bu
lato
ry
care
,in
ab
ilit
yto
att
end
gro
up
s,
psy
cho
sis,
sign
ifica
nt
learn
ing
pro
ble
ms
MD
D
(84%
),
DB
D
(69%
)
DS
H (in
terv
iew
—se
e
Ker
foo
t,1984),
SI
(SIQ
)
T:
Dev
elo
pm
enta
lgro
up
psy
cho
ther
ap
y
(DG
T)þ
Ro
uti
ne
care
(n¼
32),
Do
se:
Six
acu
tese
ssio
nsþ
wee
kly
lon
g-t
erm
gro
up
as
nee
ded
for
6m
on
ths
(Mdn¼
8se
ssio
ns,
ran
ge¼
0–19)þ
Ro
uti
ne
care
as
nee
ded
;
C:
Ro
uti
ne
care
(n¼
31),
Do
se:
Fam
ily
sess
ion
sþ
no
n-s
pec
ific
cou
nse
lin
gas
nee
ded
(Mdn¼
4se
ssio
ns,
ran
ge¼
0–30);
Ass
essm
ents
:
Pre
trea
tmen
t,6
wee
ks,
an
d7
mo
nth
s
RC
TF=
u7
mo
nth
s:
T:
3%
,
C:
0%
Tre
atm
ent
com
ple
tion
(�4
sess
ion
s):
T:
72%
,
C:
61%
Few
erD
SH
rep
eate
rs(i
.e.,
mu
ltip
leD
SH
epis
od
es)
inT
com
pare
dto
C
an
dlo
nger
tim
eto
rep
eat
DS
Hin
T
com
pare
dto
C;
NS
for
SI
Oth
erIn
terv
enti
on
tech
niq
ues
Res
ourc
eIn
terv
enti
ons–
Indiv
idual
Co
tgro
ve,
Zir
insk
y,
Bla
ck,
&
Wes
ton
(1995)
105
12-
to16-y
ear-
old
s;85%
fem
ale
;et
hn
icit
y
NR
ED
In:
Ad
mit
ted
for
DS
H,
DS
P,
or
SA
;
Ex:
NR
NR
SA
(un
spec
ified
psy
chia
tris
t
qu
esti
on
nair
e)
T:
Gre
enca
rdfo
r
re-a
dm
issi
on
toth
e
ho
spit
al
(n¼
47);
C:
Cli
nic
or
chil
d
psy
chia
try
dep
art
men
t
TA
U(n¼
58);
Ass
essm
ents
:
Pre
trea
tmen
t
an
dF=
u1
yea
r
RC
TT
ota
lsa
mp
le:
0%
Tre
atm
ent
com
ple
tion
:
T:
11%
use
d
gre
enca
rd
NS
bet
wee
ngro
up
dif
fere
nce
sin
SA
12
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
Dey
kin
,H
sieh
,
Josh
i,&
McN
am
arr
a
(1986)f
319
13-
to17-y
ear-
old
s;fe
male
:
68%
(Bo
sto
n),
55%
(Bro
ckto
n);
Cau
casi
an
:28%
(Bo
sto
n),
68%
(Bro
ckto
n),
Afr
ican
Am
eric
an
:57%
(Bo
sto
n),
4%
(Bro
ckto
n)
Co
mm
un
ity
In:
ED
pre
sen
tati
on
wit
hD
SH
,S
A,
or
SI;
Ex:
NR
NR
DS
H,
SI,
SA
(ph
ysi
cian
s’
rep
ort
san
d
med
ical
chart
revie
w)
T:
Dir
ect
serv
ice
(ad
vo
cacy
,fi
nan
cial
nee
ds,
soci
al
sup
po
rt)þ
edu
cati
on
al
train
ing
for
pro
vid
ers
(n¼
172),
Do
se:
NR
;C
:H
osp
ital
TA
U(n¼
147),
Do
se:
NR
;A
sses
smen
ts:
Pre
trea
tmen
t,
Co
nti
nu
ou
sF=
u2
yea
rs
No
n-
ran
do
miz
ed
con
tro
lled
tria
l
N=
A(i
nci
den
ce
of
ED
vis
its
exam
ined
;sp
ecifi
c
ad
ole
scen
tsw
ere
no
tfo
llo
wed
over
tim
e)
NS
for
all
SIT
Bs
ou
tco
mes
Ro
bin
son
etal.
(2012)
164
15-
to24-y
ear-
old
s,65%
fem
ale
;et
hn
icit
y
NR
Co
mm
un
ity
In:
His
tory
DS
H
or
SR
B;
Ex:
Kn
ow
n
org
an
icca
use
for
DS
H=
SR
B,
inte
llec
tual
dis
ab
ilit
y
AN
X(6
3%
),
MD
(67%
)
DS
H (SB
Q-1
4),
SI
(BS
S)
T:
Po
stca
rds
pro
mo
tin
g
wel
l-b
ein
gan
d
evid
ence
-base
dsk
ills
useþ
Co
mm
un
ity-
base
dT
AU
(n¼
81),
Do
se:
Mo
nth
lyfo
r
12
mo
nth
s;
C:
Co
mm
un
ity-b
ase
d
TA
Uo
nly
(n¼
83),
Do
se:
12
mo
nth
s;
Ass
essm
ents
:
Pre
trea
tmen
t,
F=
u12
an
d18
mo
nth
s
RC
TF=
u:
12
mo
nth
s:
T:
26%
,
C:
37%
;
18
mo
nth
s:
T:
38%
,
C:
55%
Red
uce
dD
SH
an
d
SI
inb
oth
gro
up
s,
bu
tN
Sb
etw
een
gro
up
s
Support
-Base
dIn
terv
enti
ons
Kin
get
al.
(2006)
289
12-
to17-y
ear-
old
s;68%
fem
ale
;82%
Cau
casi
an
Co
mm
un
ity
In:
Rec
ent
psy
chia
tric
ho
spit
ali
zati
on
,S
I
or
SA
past
mo
nth
,
an
dsc
ore
of
20
or
30
on
CA
FA
Sse
lf-h
arm
sub
scale
;
Ex:
Psy
cho
sis,
sever
em
enta
l
dis
ab
ilit
y
NR
SA
(SS
BS
),S
I
(SIQ
-Jr
an
d
SS
BS
)
T:
Yo
uth
-no
min
ate
d
Su
pp
ort
Tea
m-Iþ
TA
U-v
ari
ed(n¼
151),
Do
se:
Psy
cho
edu
cati
on
for
sup
po
rtsþ
wee
kly
con
tact
bet
wee
n
sup
po
rts
an
d
ad
ole
scen
tsþ
sup
po
rts
con
tact
edb
y
inte
rven
tio
nsp
ecia
list
s
for
6m
on
ths;
C:
TA
U-v
ari
ed(n¼
138),
Do
se:
6m
on
ths;
Ass
essm
ents
:P
re-
an
d
po
sttr
eatm
ent
RC
TT
:24%
,
C:
13%
Tre
atm
ent
com
ple
tion
:
T:
76%
,C
:87%
Red
uce
dS
Iin
T
com
pare
dto
Cin
fem
ale
so
nly
;N
S
for
SA (C
on
tin
ued
)
13
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
TA
BLE
2
Continued
Auth
ors
n
Sam
ple
Chara
cter
isti
csS
etti
ng
Incl
usi
on
(In
)and
Ex
clusi
on
(E
x)
Cri
teri
a
Majo
r
Dia
gnose
s
Outc
om
es=
Mea
sure
s
Tre
atm
ent
Condit
ions,
Dose
,and
Ass
essm
ents
Stu
dy
Type
Stu
dy
Att
riti
on
Rate
(and
Tre
atm
ent
Com
ple
tion)
Main
Res
ult
s
Kin
get
al.
(2009)
448
13-
to17-y
ear-
old
s;71%
fem
ale
;84%
Cau
casi
an
Co
mm
un
ity
In:
Rec
ent
psy
chia
tric
ho
spit
ali
zati
on
,S
I
or
SA
past
mo
nth
;
Ex:
Sev
ere
cogn
itiv
e
imp
air
men
t,
psy
cho
sis,
med
ical
inst
ab
ilit
y,
resi
den
tial
pla
cem
ent,
no
legal
gu
ard
ian
avail
ab
le
UM
D(8
8%
);
DB
D(4
2%
);
AN
X(2
9%
);
PT
SD
or
acu
test
ress
dis
ord
er
(25%
);A
UD
or
SU
D
(21%
)
SA
(DIS
C-I
V),
SI
(SIQ
-Jr)
T:
Yo
uth
-no
min
ate
d
Su
pp
ort
Tea
m-I
Iþ
TA
U-v
ari
ed(n¼
223),
Do
se:
Psy
cho
edu
cati
on
for
sup
po
rtsþ
wee
kly
con
tact
bet
wee
n
sup
po
rts
an
d
ad
ole
scen
tsfo
r
3m
on
ths;
C:
TA
U-v
ari
ed(n¼
225);
Do
se:
3m
on
ths;
Ass
essm
ents
:
Pre
trea
tmen
t;
6w
eek
s;3,
6,
an
d
12
mo
nth
s
RC
TF=
u:
6w
eek
s:25%
,
3m
on
ths:
24%
,
6m
on
ths:
30%
,
12
mo
nth
s:23%
Tre
atm
ent
com
ple
tion
(fu
llin
terv
enti
on
-
two
sup
po
rt
peo
ple
for
12
wee
ks)
:
T:
74%
Red
uce
dS
Iin
T
com
pare
dto
Cin
mu
ltip
le
att
emp
ters
on
ly
an
dat
6-w
eek
f=u
on
ly;
NS
for
SA
No
te.
ED¼
emer
gen
cyd
epa
rtm
ent;
NR¼
no
tre
po
rted
;N
S¼
no
nsi
gn
ifica
nt;
RC
T¼
ran
do
miz
edco
ntr
oll
edtr
ial.
Ma
jor
Dia
gn
ose
s:A
DH
D¼
att
enti
on
defi
cit
dis
ord
er;
AN¼
an
ore
xia
ner
vo
sa;
AN
X¼
an
xie
tyd
iso
rder
–ty
pe
no
tsp
ecifi
ed;
AS
D¼
au
tism
spec
tru
md
iso
rder
;A
UD¼
alc
oh
ol
use
dis
ord
er;
BN¼
bu
lim
ian
ervo
sa;
BP¼
bip
ola
rd
iso
rder
;B
PD¼
bo
rder
lin
ep
erso
na
lity
dis
ord
er;
CD¼
con
du
ctd
iso
rder
;C
UD¼
can
na
bis
use
dis
ord
er;
DB
D¼
dis
rup
tiv
eb
eha
vio
rd
iso
rder
;E
MD¼
emo
tio
nal
dis
ord
er;
MD¼
mo
od
dis
ord
er(b
ipo
lar
or
un
ipo
lar)
;M
DD¼
majo
rd
epre
ssiv
ed
iso
rder
;
PD¼
per
son
ali
tyd
iso
rder
;P
DD¼
per
va
siv
ed
evel
op
men
tal
dis
ord
er;
PT
SD¼
po
sttr
au
ma
tic
stre
ssd
iso
rder
;S
UD¼
sub
sta
nce
use
dis
ord
er;
SZ¼
sch
izo
ph
ren
ia;
UM
D¼
un
ipo
lar
mo
od
dis
ord
er;
Mea
sure
s:A
SQ
-R¼
Ad
ole
scen
tS
uic
ide
Qu
esti
on
na
ire
Rev
ised
;B
SI¼
Bri
efS
ym
pto
mIn
ven
tory
;B
SS¼
Bec
kS
cale
for
Su
icid
eId
eati
on
;C
AF
AS¼
Ch
ild
an
dA
do
lesc
ent
Fu
nct
ion
al
Ass
essm
ent
Sca
le;
CB
CL¼
Ch
ild
ren
Beh
avio
rC
hec
kli
st;
CI-
BP
D¼
Ch
ild
Inte
rvie
wfo
rD
SM
-IV
Per
son
ali
tyD
iso
rder
;D
ISC
-IV¼
Dia
gn
ost
icIn
terv
iew
Sch
edu
lefo
rC
hil
dre
nV
ersi
on
IV;
HA
SS¼
Ha
rkav
y-A
snis
Su
icid
e
Sca
le;
K-S
AD
S-P
L¼
Sch
edu
lefo
rA
ffec
tiv
eD
iso
rder
sa
nd
Sch
izo
ph
ren
iafo
rS
cho
ol-
Ag
eC
hil
dre
n,
Pre
sen
ta
nd
Lif
etim
eV
ersi
on
;L
PC¼
Lif
etim
eP
ara
suic
ide
Co
un
t;M
FQ¼
Mo
od
an
dF
eeli
ng
Qu
esti
on
na
ire;
MS
SI¼
Mo
difi
edS
cale
for
Su
icid
eId
eati
on
;P
HI¼
Pa
rasu
icid
eH
isto
ryIn
terv
iew
;R
TS
HI¼
Ris
kT
ak
ing
an
dS
elf
Ha
rmIn
ven
tory
;S
BQ
-14¼
Su
icid
eB
ehav
ior
Qu
esti
on
na
ire;
SH
I¼
Sel
f
Sel
fH
arm
Inv
ento
ry;
SIQ
(Jr
or
Sn
)¼
Su
icid
eId
eati
on
Qu
esti
on
nai
re(f
or
jun
ior
hig
ha
nd
sen
ior
hig
hsc
ho
ol
stu
den
ts);
SS
BS¼
Sp
ectr
um
of
Su
icid
eB
ehav
ior
Sca
le;
SS
I¼
Sca
lefo
rS
uic
ida
lId
eati
on
;S
SR
S¼
Su
icid
eS
ever
ity
Rati
ng
Sca
le;
YR
BS¼
Yo
uth
Ris
kB
eha
vio
rS
urv
ey.
Ou
tco
mes
:D
SH¼
del
iber
ate
self
-ha
rm;
DS
P¼
del
iber
ate
self
-po
iso
nin
g;
NS
SI¼
no
nsu
icid
al
suic
idal
self
-in
jury
;S
A¼
suic
ide
att
emp
t;S
E¼
suic
ide
even
t(d
efin
edb
yC
olu
mb
iaC
lass
ifica
tio
nA
lgo
rith
mo
fS
uic
ide
Ass
essm
ent
as
on
eo
rm
ore
of
the
foll
ow
ing:
com
ple
ted
suic
ide,
att
emp
ted
suic
ide,
pre
par
ato
ryact
sto
ward
sim
min
ent
suic
idal
beh
avio
r,su
icid
al
beh
avio
r,o
rsu
icid
al
idea
tio
n);
SI¼
suic
ide
idea
tio
n;
SIT
B¼
self
-in
juri
ou
sth
ou
gh
to
rb
ehav
ior
(su
icid
ala
nd
no
nsu
icid
al);
SP¼
suic
ide
pla
nn
ing
or
pre
pa
rati
on
;S
RB¼
suic
ide-
rela
ted
beh
avio
r(s
uic
ide
tho
ugh
ts,
pla
ns,
att
emp
ts).
Tre
atm
ent
Co
nd
itio
ns:
C¼
con
tro
lo
rco
mp
ari
son
gro
up
;C
BT¼
cog
nit
ive-
beh
av
iora
lth
era
py
;D
BT¼
dia
lect
icb
ehav
ior
ther
ap
y;
F=u¼
foll
ow
-up
;T¼
exp
erim
enta
ltr
eatm
ent
gro
up
;T
AU¼
trea
tmen
ta
su
sua
l.aT
he
CB
T-I
nd
ivid
ua
lin
terv
enti
on
sin
clu
ded
op
tio
na
lfa
mil
yco
mp
on
ents
(see
each
stu
dy
for
the
spec
ific
do
seo
fo
pti
on
al
fam
ily
ther
ap
yo
ffer
ed).
Ho
wev
er,
the
au
tho
rsre
po
rtth
ese
com
po
nen
tsw
ere
infr
equ
entl
yu
tili
zed
du
rin
gtr
eatm
ent.
bM
oti
vat
ion
al
inte
rvie
win
g(M
I)o
rm
oti
va
tio
nal
enh
an
cem
ent
tech
niq
ues
inco
rpo
rate
din
trea
tmen
tp
ack
ag
e.c A
lth
ou
gh
mo
tiv
ati
on
al
enh
ance
men
tte
chn
iqu
es
wer
en
ot
exp
lici
tly
dis
cuss
edin
thes
eD
BT
stu
die
s,in
crea
sin
gm
oti
va
tio
nto
cha
ng
eis
aco
reco
mp
on
ent
of
the
DB
Tp
ack
ag
e.dD
BT
gro
up
skil
lsd
eliv
ered
ina
mu
ltif
am
ily
gro
up
form
at.
e IPT
-A-I
Nw
as
pri
mari
lyan
ind
ivid
ual
-base
din
terv
enti
on
.H
ow
ever
,o
ne
pare
nt
of
ap
art
icip
an
tin
the
IPT
gro
up
rece
ived
thre
efa
mil
yth
erap
yse
ssio
ns.
Inad
dit
ion
,p
are
nts
wer
ein
clu
ded
inth
eT
AU
sup
po
rtiv
e
cou
nse
lin
gse
ssio
ns
ifn
eed
ed.
f Dey
kin
eta
l.(1
98
6)a
sses
sed
inci
den
ceo
fE
Dv
isit
so
ver
2y
ears
at
the
two
site
sw
her
eth
ein
terv
enti
on
(Bo
sto
n)
an
dco
ntr
ol
(Bro
ckto
n)
trea
tmen
tsw
ere
emp
loy
ed;
tha
t
is,
spec
ific
pa
rtic
ipa
nts
wer
en
ot
foll
ow
edo
ver
tim
e.
Dow
nloa
ded
by [
Har
vard
Lib
rary
] at
12:
18 2
0 M
ay 2
015
the experimental treatment examined). Significanttreatment mediators or moderators (when reported)are displayed in the last column of Table 2.
Finally, attrition is a major problem in treatmentresearch with youth (Kazdin, 1996), and the studiesin our review were no exception. This issue is furthercomplicated by the different evaluation methods oftreatment attrition and compliance used across studies;for instance, some studies report detailed informationabout the number of sessions completed by eachtreatment group, other studies report the number ofindividuals assessed at follow-up only, and still othersreport little to no information about dropout rates.Chambless and Hollon (1998) note that dropoutbecomes a serious concern when rates of attrition differbetween the experimental treatment and comparisontreatment groups. They suggest that, especiallyin these cases, intent-to-treat (ITT) analyses are crucialto examine treatment outcomes for all individualsrandomized to a specific intervention. However, thisdoes not address the issue that, with high dropout rates,a small percentage of individuals actually receiveda particular intervention. For the current review, wedid not want to penalize studies that did provideadequate information about treatment dropout, or moreintensive treatments that may have had greater dropoutthan briefer interventions. Therefore, we includeda column in Table 2 detailing information abouttreatment attrition and compliance in each study (whenavailable) and we discuss treatment dropout and use ofITT analyses in the text—particularly when evaluatingthe more promising interventions.
Cognitive-Behavioral Therapy
Six studies in our review examined a form of cognitive-behavioral therapy (CBT) for reducing SITBs in youth.From a CBT perspective, maladaptive behaviors, suchas SITBs, result from distorted thinking patterns anddeficits in specific skills (e.g., emotion regulation andproblem solving). CBT aims to reduce SITBs bychallenging and modifying cognitive distortions and bystrengthening skills to adaptively cope, communicate,and solve problems.
CBT–Individual. Two studies were classified asindividual CBT because they examined interventionsprimarily focused on addressing the adolescent’sskills deficits. Of note, both interventions includedsome form of optional family training or therapy, butthese components were viewed as adjuncts to theadolescent’s individual therapy; moreover, the studiesreported that these optional family trainings wereinfrequently used.
In a small RCT with adolescent suicide attempters(n¼ 39), Donaldson et al. (2005) compared a 6-monthindividual skills-based treatment (e.g., emotion regulationand problem-solving skills) to supportive relationshiptherapy. Although both were primarily individualinterventions, parents attended the initial treatmentsession and were offered one optional family problem-solving session if needed. Adolescents in both conditionsreported reductions in SI over the treatment periodand follow-up, but there were no differences betweenconditions. In addition, there were no between-group
TABLE 3
Evidence Base Update for Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth: Summary
Level 1:
Well-Established Level 2: Probably Efficacious
Level 3: Possibly
Efficacious Level 4: Experimental Level 5: Questionable Efficacy
— CBT-IndividualþCBT-FamilyþParent Training (SA)
FBT-Ecological
(SA)
CBT-Individual (DSH, SI) CBT skillsþDBT skillsþPsychodynamic therapy
skills-Group (DSH)
FBT-Attachment (SI) CBT-IndividualþCBT-Family (SE, SI)
FBT-Parent training only (SITB) CBT skills-Group (SI)
IPT-Individual (SI) DBT (DSH, NSSI, SI)
Psychodynamic therapy-IndividualþFamily (DSH)
DBT-Group only (SI)
FBT-Emergency (DSH, SA, SI)
FBT-Problem-focused (SI)
Resource interventions-Individual
(DSH, SA, SI)
Support-based interventions (SI)
Note: For each treatment family, the self-injurious outcome variable(s) examined in treatment studies is listed in parentheses. Interventions:
CBT¼ cognitive-behavioral therapy; DBT¼ dialectical behavior therapy; FBT¼ family-based therapy; IPT¼ interpersonal psychotherapy.
Self-Injurious Outcomes: DSH¼ deliberate self-harm; NSSI¼ nonsuicidal self-injury; SA¼ suicide attempt; SE¼ suicide event (defined by Columbia
Classification Algorithm of Suicide Assessment as one or more of the following: completed suicide, attempted suicide, preparatory acts toward
imminent suicidal behavior, suicidal behavior, or suicidal ideation); SI¼ suicide ideation; SITB¼ self-injurious thought or behavior (suicidal and
nonsuicidal).
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differences in SAs over the treatment follow-up. Resultsfrom this trial indicate that individual CBT is notsuperior to supportive therapy for reducing SAs or SIin youth with a history of suicide attempts.
Taylor and colleagues (2011) also examined atime-limited (8–12 sessions over 6 months) individualCBT package—Manualized CBT—for adolescentDSH, which incorporated common CBT treatmentcomponents, such as problem-solving and coping skillstraining, as well as recognizing connections betweenthoughts, feelings, and behaviors. In addition, anoptional brief (3-session) psychoeducation group wasoffered for parents, but only two parents participated.Results from the initial pilot study in 25 adolescent out-patients indicated reductions in DSH from pre- to post-treatment that were maintained at 3-month follow-up.However, it is important to note that attrition over thetreatment period was high (36% of adolescents droppedout) and DSH reductions were within-participants(because there was no control condition). RCTs inlarger samples are needed before any firm conclusionscan be drawn about the efficacy of Manualized CBTfor DSH in youth.
Individual CBT has not been shown to be more effi-cacious than another treatment for reducing SITBs inadolescents. Using the JCCAP evaluation criteria, indi-vidual CBT was classified as Level 4: experimental forDSH and SI in youth.
CBT-IndividualþCBT-Family. Two studies wereclassified as combined individual CBT and family CBTbecause the interventions included both individual andfamily sessions as integral components of the treatmentpackages. Moreover, reductions in risk factors atboth the individual and family level were identified astreatment targets. In an initial pilot study, Esposito-Smythers, Spirito, Uth, and LaChance (2006) modifiedtheir individual CBT treatment package (examined byDonaldson et al., 2005) to include family therapy andmotivational enhancement therapy. The combined indi-vidual and family CBT intervention was examined in asmall sample of adolescents (n¼ 6) with recent SI orSAs and comorbid substance use disorders. Adolescentsreported reductions in SI from pre- to posttreatment,but the intervention had little impact on SAs (33% ofthe sample attempted suicide during the treatmentperiod). Because this trial lacked a comparison group,conclusions about the efficacy of individual CBTþfamily CBT for reducing SI in youth are tentative.
A CBT-individual and family intervention was alsoexamined in the large (n¼ 124) Treatment of AdolescentSuicide Attempters (TASA) study—an open trialdesigned to examine intensive and tailored treatmentsfor adolescent suicide attempters with major depression(Brent et al., 2009). The TASA trial compared Cognitive
Behavior Therapy for Suicide Prevention (CBT-SP: seeStanley et al., 2009), a medication algorithm, and thecombination of CBT-SP and medication. CBT-SP con-sists of both individual CBT (e.g., behavioral activation,problem solving) and family skills training (e.g., familyproblem solving, family communication) over 6 months.Treatments were evaluated based on reductions inSEs—a category that included completed suicide,attempted suicide, preparatory acts toward imminentsuicidal behavior, and suicidal ideation. There were nodifferences between the treatment groups in SEs at6-month follow-up, but the authors noted that SE ratesgenerally, and SA rates specifically, were lower in theTASA trial compared to those reported in naturalisticstudies of high-risk adolescent samples following hospi-tal discharge (e.g., Goldston et al., 1999). Comparingoutcomes across treatment conditions is complicatedfor a few key reasons. First, more high-risk adolescentsreceived the combined intervention than medication ortherapy alone. RCTs demonstrating superiority ofCBT-SP compared to another active treatment areneeded. Second, individual and family treatmentstrategies were tailored to each adolescent and there-fore active treatment components varied acrossparticipants. Finally, and most importantly, the TASAtrial was not intended to compare any single inter-vention to treatment-as-usual (TAU); the lack of groupdifferences between the three treatment arms may be duein part to significant treatment effects for all conditions.
It is difficult to evaluate the efficacy of combined indi-vidual and family CBT interventions based on these twotrials. However, given the existing evidence, combinedCBT-IndividualþCBT-Family was classified as Level 4:experimental for reducing SEs and SI in youth.
CBT-IndividualþCBT-FamilyþParent Training.Building on earlier versions of their CBT packages(Donaldson et al., 2005; Esposito-Smythers et al.,2006), Esposito-Smythers et al. (2011) added a parenttraining component to create integrated CBT (I-CBT),which includes a variety of individual CBT (e.g., prob-lem solving), family CBT (e.g., behavioral contracting),and parent training (e.g., monitoring) sessions deliveredover 12 months (6 months active-weekly sessions,3 months continuation-biweekly sessions, and 3 monthsmaintenance-monthly sessions). In a small RCT ofadolescents with SAs or significant SI and comorbidsubstance use disorders (n¼ 40), the authors comparedI-CBT to enhanced treatment as usual (E-TAU:community-based TAU enhanced with a diagnosticevaluation report and case monitoring). Although bothgroups’ SI decreased over the course of treatment,adolescents receiving I-CBT had significantly fewer SAsover the 18-month study period compared to E-TAU(ITT analyses).
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I-CBT is one of the few interventions to report reduc-tions in suicidal behavior compared to TAU, and thereare some notable conclusions from this trial. First, inaddition to fewer SAs, the I-CBT group also reportedless heaving drinking and marijuana use over the courseof treatment. Given that substance use increases riskfor suicidal behavior among adolescents (Esposito-Smythers & Spirito, 2004), reductions in alcohol anddrug use in the I-CBT group may have been importantfor treatment efficacy. Second, this version of the treat-ment package, which included parent training, led to sig-nificant reductions in suicidal behavior, whereasprevious versions of the intervention (Donaldson et al.,2005; Esposito-Smythers et al., 2006) did not. We returnto these points later when we discuss common elementsof efficacious interventions. Finally, it is important tonote that, despite low attrition (10% for I-CBT and15% for E-TAU), there were differences in the treatmentdose received: in the I-CBT group, 74% of adolescents,74% of families, and 90% of parents received 24 ado-lescent and 12 parent sessions, whereas only 44% ofadolescents, 19% of families, and 25% of parents inthe comparison condition received this dose. Differencesin treatment compliance could be due to the nature ofthe intervention; that is, perhaps the protocol used inI-CBT is superior for retaining families in treatmentcompared to E-TAU. Given that few families receivedan adequate dose of E-TAU, it is somewhat unclearwhat I-CBT was compared to in this trial. Despite thislimitation, I-CBT was found to be superior to an activecontrol using ITT analyses in an RCT. Therefore, com-bined individual CBTþ family CBTþ parent trainingappears to be a promising intervention and was classi-fied as Level 2: probably efficacious for reducing SAsin youth. Of note, I-CBT has been examined only in asample of suicidal adolescents with comorbid substanceuse disorders. Replications in more clinically diversesamples are needed.
CBT skills–Group. Rudd and colleagues (1996)examined a time-limited CBT skills group treatmentdelivered to 264 adolescents and young adults (ages15–24) in a partial hospitalization setting. The experi-mental group treatment, consisting of intensive daily(9 hr per day) psychoeducation and skills training groups(e.g., communication, emotion regulation, problem solv-ing) for 2 weeks, was compared to TAU (which includedboth inpatient and outpatient treatment). Youth in bothconditions reported significant reductions in SI over thetreatment period, but there were no differences betweentreatment conditions. Because the group interventiondid not demonstrate relative efficacy over TAU, theCBT skills group intervention was evaluated as Level4: experimental for reducing SI in youth.
Dialectical Behavior Therapy
Six studies examined a form of Dialectical BehaviorTherapy (DBT) for reducing SITBs in youth. DBT(Linehan, 1993), one of the first treatments to specifi-cally target SITBs, was originally designed to treat adultfemale patients with borderline personality disorder(BPD) but has since been adapted for adolescentsregardless of BPD diagnosis (DBT-A: Miller, Rathus,Linehan, Wetzler, & Leigh, 1997; Rathus & Miller,2014). DBT includes an intensive combination of weeklyindividual therapy, weekly group skills training (i.e.,distress tolerance, emotion regulation, interpersonaleffectiveness, and mindfulness skills modules), andphone skills coaching with the therapist as needed.The goal of DBT is to help individuals regulate theiremotional and interpersonal difficulties in adaptive waysinstead of using harmful strategies such as SITBs.
DBT. Five studies (nonrandomized controlled trialsor pilot studies) have examined some variation of thestandard DBT package in youth, including individualsessions, skills groups, and telephone consultation (seeTable 2 for details about the dose and length of treat-ment examined in each trial). Three studies included astandard adolescent-only skills group (James, Taylor,Winmill, & Alfoadari, 2008; James, Winmill, Anderson,& Alfoadari, 2011; Katz, Cox, Gunasekara, & Miller,2004), whereas two trials delivered skills in a multifamilygroup format (Fleischhaker et al., 2011; Rathus &Miller, 2002). The three small pilot studies (sample sizesranged from 12 to 25 adolescents) examining DBTreported significant reductions in DSH (James et al.,2008; James et al., 2011) and NSSI (Fleischhaker et al.,2011) over the course of treatment. However, becausethese studies did not include a control or comparisongroup, it is unclear whether reductions in SITBs wereattributable to DBT. Moreover, these studies includedprimarily female patients with BPD; further researchin more diverse clinical samples is needed to examinewhether these treatment effects will generalize to non-BPD adolescents.
Two studies used a nonrandomized controlled designto compare DBT-A to psychodynamic or supportiveinterventions (Katz et al., 2004; Rathus & Miller,2002). Rathus and Miller (2002) compared 12 weeks ofoutpatient DBT (individual sessions and multifamilyskills groups) to 12 weeks of outpatient TAU (eitherpsychodynamic or supportive therapy) in a large sampleof predominantly Hispanic youth (n¼ 111). Fewer ado-lescents in the DBT group made a SA during treatmentthan the TAU group, but these group differences werenot statistically significant. Adolescents receiving DBTalso reported significant reductions in SI from pre- toposttreatment; however, SI was not measured in the
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TAU group posttreatment preventing any between-group analysis. It is important to note that this studyreported a relatively high attrition rate—38% of theDBT group and 60% of the TAU group did not com-plete the 12-week intervention. In addition, patientswere assigned to treatment based on clinical severitywith more severe patients referred to DBT.
In a more acute setting, Katz et al. (2004) compared abrief (2-week) DBT package (individual sessions, skillsgroup, and DBT milieu) to psychodynamic psycho-therapy (TAU) for 62 adolescents receiving inpatienttreatment. DBT and TAU were administered to patientson two different units. Adolescents in the DBT grouphad fewer ‘‘behavioral incidents’’ (e.g., self- or other-directed violent episodes) during treatment than thosereceiving TAU. However, it is unclear how many ofthese incidents were DSH. Over the 1-year follow-up,both groups reported reduced DSH and SI comparedto pretreatment, but there were no between-groupdifferences.
In summary, no published RCTs have examined theefficacy of DBT in youth (however, see Clinical Trialsin Progress), and no published studies to date havefound that DBT is superior to an active treatment con-trol. Of note, the two controlled trials of DBT examinedbrief intervention formats (2 and 12 weeks) that aremuch shorter than the standard 1-year DBT package,which may have decreased the potency of the inter-vention and ability to detect significant treatmenteffects. Pilot studies using longer DBT interventions(6–12 months) are promising, but RCTs are neededbefore conclusions can be made about DBT’s relativeefficacy. Based on the existing evidence, DBT was classi-fied as Level 4: experimental for SITBs (specificallyDSH, NSSI, and SI) in youth.
DBT–Group only. Perepletchikova and colleagues(2011) adapted a DBT skills group only interventionfor children ages 8 to 11. In this initial pilot study, 11children attended twice weekly skills groups for 6 weeksand reported significant reductions in SI from pre- toposttreatment. Because there was no control group, itis unclear whether SI reductions were attributable toDBT. Due to limited research on DBT-Group only, thisintervention was evaluated as Level 4: experimentalfor SI in youth.
Family-Based Therapy
Seven studies were classified as family-based therapy(FBT). These interventions all focused on the familyand targeted improvements in family functioningas a means to decrease SITBs. FBTs employed a varietyof traditional family therapy components, such as
psychoeducation, communication training, and problemsolving. Although all interventions in this categoryfocused on the family, the techniques included in thetreatment packages varied. Therefore, FBTs werefurther categorized based on the primary interventiontargets—attachment, parent training only, ecological,problem focused, or emergency.
FBT–Attachment. Diamond et al. (2010) examinedattachment-based family therapy (ABFT: Diamond,Reis, Diamond, Siqueland, & Isaacs, 2002), which aimsto reduce SITBs by improving family relationships, andespecially the parent–adolescent relationship. ABFTuses a variety of process-oriented, emotion-focused,and cognitive-behavioral techniques to enhance thequality of attachment bonds in weekly sessions over a3-month period. In an RCT with 66 adolescents (74%African American) referred from the emergency depart-ment (ED) or primary care, patients receiving ABFTreported significantly larger and more rapid reductionsin SI over the course of treatment, compared toenhanced TAU (i.e., TAU with referrals and clinicalmonitoring), and these differences were maintained 12weeks posttreatment (ITT analyses). Depressive symp-toms also declined over the course of treatment but werenot specifically examined as a treatment mediator. Thisstudy is notable as one of the few to examine, and to findpositive effects for, an SITB intervention in a predomi-nantly minority sample of adolescents.
However, several limitations of this study should benoted. First, there were low rates of treatment com-pletion, especially in the TAU group. Although themajority of adolescents attended at least one therapysession, only 69% of the ABFT group and 19% of thecontrol attended six or more therapy sessions, and evenfewer attended 10 or more therapy sessions (ABFT:63%, TAU: 6%). Second, because no behavioral outcomeswere compared in this trial, it is unclear whether ABFTis effective for reducing suicidal behavior (e.g., SAs).Despite these limitations, ABFT has shown promisingeffects compared to an active treatment control (RCTusing ITT analyses), and therefore FBT-Attachmentwas classified as Level 2: probably efficacious for SIin youth.
FBT–Parent training only. Pineda and Dadds (2013)reported promising findings for a brief (four-session)parent education program for reducing adolescentsuicide risk—Resourceful Adolescent Parent Program(RAP-P). RAP-P aims to reduce SITBs by increasingfamily education about SITBs, enhancing effectiveparenting, and decreasing family conflict and stress.Because this intervention targeted parents only in treat-ment (rather than the adolescent and family), RAP-P
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was categorized on its own as FBT–Parent training only.In a small RCT, 48 adolescents in families receivingRAP-P plus routine care reported fewer SITBs (i.e.,combined measure of DSH and suicide-related beha-vior), than adolescents in families receiving routine careonly; reductions in SITBs were maintained at 6-monthfollow-up (ITT analyses). Notably, improvements infamily functioning fully mediated the treatment effectson SITBs. In addition, treatment compliance for theRAP-P trial was extremely high: 100% of parents inboth groups completed the brief (four-session) inter-vention. Future research would benefit from examiningwhether RAP-P is efficacious for treating suicidal formsof self-injury (e.g., SA), nonsuicidal forms of self-injury(e.g., NSSI), or both. Based on the positive results fromthe initial RCT examining RAP-P, FBT-Parent trainingonly was classified as Level 2: probably efficacious forSITBs in youth.
FBT–Ecological. In contrast to brief interventionsthat focus only on the parent, more intensive and long-term FBT has also been examined for reducing SITBs inyouth: Multisystemic Therapy (MST: Henggeler,Schoenwald, Borduin, Rowland, & Cunningham, 2009)is a home-based family intervention that targets adoles-cents’ problematic behaviors within the multiple systemsthought to cause and=or maintain these behaviors. MSTwas classified as FBT–Ecological because it focuses onsystems outside of the family (e.g., peers, school, com-munity) in order to change behavior. In MST, familiesreceive daily contact (if needed) for 3 to 6 months thatfocuses on safety planning and risk management, parentskills training, and disengagement from problematicsocial systems (e.g., peer groups). In a large RCT(n¼ 156), Huey et al. (2004) compared MST to inpatienttreatment in a sample of predominantly African Amer-ican children and adolescents referred for emergencypsychiatric hospitalization. Both groups reportedreduced rates of SAs from pretreatment to 1-yeartreatment follow-up, but the MST group reported sig-nificantly fewer SAs than the hospitalization compari-son group (of note, this difference was only observedvia adolescent, but not parent, report).
This study is notable because it is one of the few toexamine an SITB intervention in minority youth, whoare underrepresented in the treatment literature, andone of two interventions found to significantly reduceSAs among adolescents (the other being I-CBT:Esposito-Smythers et al., 2011). Although these resultsappear promising, there are some important limitationsof this study. First, adolescents were included if theywere at risk of harming themselves or others, and onlyhalf the sample was identified as at risk for self-harm(due to past SAs or SI). Therefore, this study may not
accurately estimate the efficacy of MST for reducing self-injurious thoughts and behaviors specifically. Second,although participants were assigned to either MST orhospitalization, and treatment completion rates werehigh in both groups, 44% of adolescents in the MST treat-ment group had to be hospitalized during the study dueto psychiatric emergencies (but were kept separatefrom the control group). The high rate of hospitalizationsuggests that MST was not particularly effective in pre-venting acute crises. Finally, the suicide reattempt ratewas the same in both groups at the follow-up assessment.Reductions over the course of the study could have beengreater in the MST group because these adolescentsreported more SAs at baseline. Further studies are neededto rule out regression to the mean as a potential expla-nation for the positive MST findings.
In sum, results from the initial MST trial for SITBsare promising. However, given the limitations of thisparticular study, FBT–Ecological was classified as Level3: possibly efficacious for reducing SAs in youth.
FBT–Problem focused. Harrington et al. (1998)examined a family-based intervention that used beha-vioral (e.g., modeling, behavioral rehearsal) and familytherapy techniques (e.g., psychoeducation, communi-cation training) to target family problems hypothesizedto contribute to adolescents’ DSH (Kerfoot,Harrington, & Dyer, 1995). The brief (five-session)home-based family problem-solving intervention plusroutine outpatient care was compared to routine carealone in a large RCT of children and adolescents withrecent deliberate self-poisoning (n¼ 162). The FBTwas not more effective than the comparison treatmentfor reducing SI in the total sample but was somewhateffective for the subset of adolescents without majordepressive disorder (33% of the sample). However, giventhat the depressed adolescents reported more SI atbaseline, findings suggest that this brief home-basedintervention was not effective for more severely suicidalyouth. Based on the overall between-group comparisonof treatment efficacy, FBT–Problem-focused wasevaluated as Level 4: experimental for reducing SI inyouth. Of note, this intervention was much briefer thanother FBTs that were efficacious for reducing SITBs(e.g., Diamond et al., 2010; Esposito-Smythers et al.,2011). Given the limited research in this area, it iscurrently unclear whether this treatment was ineffectivedue to the target of treatment, the dose of the inter-vention, or both.
FBT–Emergency. The remaining three FBT studiesemployed even briefer (one-session) interventions in theED to enhance motivation for change and increasetreatment compliance.
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First, in a nonrandomized controlled trial, Rotheram-Borus and colleagues (Rotheram-Borus, Piacentini,Cantwell, Belin, & Song, 2000; Rotheram-Borus et al.,1996) examined a brief (one-session) specialized EDintervention, consisting of psychoeducation, a family-based therapy session (including safety planning andcontracting for follow-up treatment), and staff training,to increase outpatient treatment adherence in female sui-cide attempters (n¼ 140). Although the initial studyreported reduced SI following the specialized ED inter-vention (Rotheram-Borus et al., 1996), these differencesdid not hold at any of the follow-up assessments overthe subsequent 3 to 18 months (Rotheram-Borus et al.,2000). There were fewer SAs in the specialized ED groupover the 18-month follow-up; however, the low base rateof SAs in the total sample limited power to statisticallydetect the small between-group differences.
Asarnow, Baraff, et al. (2011) also examined a briefED intervention in 181 children and adolescents present-ing to the ED with SAs or SI. In an RCT, ED TAU plusstaff training was compared to a brief Family Inter-vention for Suicide Prevention, which included onefamily-based CBT session in the ED (including safetyplanning and contracting for follow-up treatment) plusfollow-up telephone contact 48 hr postdischarge andseveral times over the next month to improve ratesof follow-up treatment. Although the interventionincreased treatment compliance (for both psychotherapyand medication), there was not a significant reduction inSAs or SI over the subsequent 2 months compared toED TAU.
Finally, Ougrin and colleagues (Ougrin, Boege, Stahl,Banarsee, & Taylor, 2013; Ougrin et al., 2011) examinedthe utility of a one-session family-based ED intervention(i.e., therapeutic assessment), which included motiva-tional enhancement and a cognitive analytic therapyassessment of the adolescent’s DSH. The therapeuticassessment was compared to assessment as usual (i.e.,psychosocial history and risk assessment) in a sampleof 70 adolescents presenting with recent DSH. Similarto the other ED interventions, the therapeutic assess-ment increased treatment compliance but did not signifi-cantly reduce DSH over the 2-year follow-up.
Taken together, although these brief ED interven-tions seem to effectively increase compliance withfollow-up care, none of the treatments were more effi-cacious than TAU for reducing SITBs in youth. Basedon these trials, FBT-Emergency interventions wereclassified as Level 4: experimental for reducing DSH,SA, and SI in youth.
Interpersonal Psychotherapy
IPT–Individual. One study to date has examinedindividual interpersonal psychotherapy (IPT) for
adolescents (IPT-A) at risk for SITBs. IPT-A focuseson resolving developmentally appropriate interpersonalproblems (e.g., peer pressure, relationships with auth-ority figures) and improving interpersonal functioningto reduce clinical symptoms (Mufson, Moreau,Weissman, & Klerman, 1993). Tang, Jou, Ko, Huang,and Yen (2009) randomized 73 at-risk students withdepression to attend intensive IPT-A (IPT-A-IN) inschool (two sessions weekly for 6 weeks) or TAU inschool (psychoeducation and supportive counseling for6 weeks). Adolescents receiving IPT-A-IN reportedgreater reductions in SI from pre- to posttreatment com-pared to those receiving TAU. The treatment group alsoreported significant reductions in depression, anxiety,and hopelessness over the course of treatment, but it isunclear whether these changes mediated reductions in SI.
Based on positive results from this initial RCT, indi-vidual IPT was classified as Level 2: probably efficaciousfor reducing SI in youth. Although promising, it isunclear from this study whether IPT will lead to reduc-tions in suicidal behaviors as well as reductions in suici-dal thoughts. In addition, this trial was conducted in asample of adolescent students with depression; replica-tions in more diverse clinical samples are needed.
Psychodynamic Therapy
Psychodynamic therapy–Individualþ family. Onestudy in our review examined a psychodynamicintervention for reducing DSH in adolescents—Mentalization-Based Treatment for Adolescents(MBT-A: Rossouw & Fonagy, 2012). MBT-A proposesthat DSH is a reaction to interpersonal stress when indi-viduals are unable to mentalize, or understand how theirown and others behaviors are related to internal thoughtand feeling states. Originally developed as a treatmentfor BPD, the yearlong manualized intervention includesweekly individual and monthly family therapy sessionsaimed at improving mentalizing skills and self-controlto ultimately reduce DSH. In an RCT, Rossouw andFonagy (2012) compared 1 year of MBT-A to 1 yearof community-based TAU in a sample of primarilyfemale patients with BPD (n¼ 80). Adolescents in bothconditions reported significant declines in DSH overthe course of treatment; however, adolescents assignedto MBT-A reported significantly less DSH at theend of treatment compared to TAU (ITT analyses).Improvements in mentalization and reduced attachmentavoidance mediated the observed treatment effects.
Although the results of this trial appear promising,the findings should be interpreted in the context of afew limitations. First, attrition rates in both groups wererelatively high—50% of the MBT-A group and 58% ofthe TAU dropped out of treatment during the trial.Second, treatment effects did not emerge until 12
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months after treatment initiation (i.e., not during the 3-,6-, or 9-month assessments) and a significant percentageof adolescents (56% of the MBT-A group and 83% ofthe TAU group) still reported engaging in DSH at theend of treatment. Finally, although the modality andduration of treatment were relatively similar acrossgroups, more adolescents in the MBT-A group receivedfamily sessions than the TAU group. Despite somenotable limitations, Psychodynamic therapy-IndividualþFamily was found to be superior to anactive treatment control in an RCT and was classifiedas Level 2: probably efficacious for reducing DSH inadolescents. Replications in more clinically and demo-graphically diverse samples are needed.
Combined Skills Group Intervention
CBT skillsþDBT skillsþPsychodynamic therapyskills–Group. Three studies in our review examined agroup intervention—Developmental Group Therapy(DGT; Wood, Trainor, Rothwell, Moore, &Harrington, 2001)—that combines skills componentsfrom a wide range of theoretical orientations, includingCBT, DBT, and psychodynamic group therapy. DGTincludes six acute weekly sessions that focus on a rangeof themes from depression, hopelessness, and self-harmto family and peer relationships. After the acute phaseof treatment, long-term booster sessions are providedfor as long as needed. The initial RCT, conducted bythe developers of the treatment package, reportedpromising results in a sample of 63 adolescents with ahistory of DSH (Wood et al., 2001): compared to rou-tine care, adolescents receiving DGT engaged in fewerDSH episodes over the course of treatment (althoughbetween-group differences were not significant), wereless likely to be DSH ‘‘repeaters’’ (i.e., engage in mul-tiple DSH episodes), and reported that more timeelapsed before the next DSH episode. In terms of doseresponse, more sessions of DGT were related to lessDSH, whereas more sessions of routine care were relatedto more DSH (Wood et al., 2001).
However, these initially promising treatment findingshave failed to replicate in other samples of adolescents(Green et al., 2011; Hazell et al., 2009). Both studiescompared DGT to routine care in moderate to largesamples of adolescents with a history of DSH (n¼ 366,Green et al., 2011; n¼ 72, Hazell et al., 2009). Notably,Hazell et al. (2009) found that adolescents receivingDGT engaged in more DSH than those receiving routinecare; however, adolescents in the DGT group reportedmore medication overdoses prior to study initiation,which may have accounted for the higher rates ofDSH reported among this group during treatment.Given the mixed results of this group therapy and thepotential for contagion of SITBs among groups of
adolescents (Prinstein et al., 2010; Walsh & Rosen,1985), group therapy alone may be contraindicated forthis population. Therefore, the combined CBT, DBT,and Psychodynamic skills group intervention was evalu-ated as Level 5: questionable efficacy for reducing DSHin youth.
Other Intervention Techniques
Five studies in our review examined interventions thatfocused on increasing adolescents’ access to resourcesand supports. These intervention packages did not fitwell into any of the treatment families just describedand therefore were classified as ‘‘other intervention tech-niques,’’ divided into Resource interventions–Individualand Support-based interventions.
Resource interventions–Individual. Three studiesexamined different intervention strategies to increaseadolescents’ access to resources and improve treatmentcompliance. None of these interventions were signifi-cantly more efficacious than TAU for reducing SITBsin youth. Deykin, Hsieh, Joshi, and Mcnamarra (1986)examined an intervention package aimed at increasingtreatment compliance among disadvantaged (e.g.,Medicaid-eligible) youth. The intervention (employedat one site) included direct service (e.g., patient advocacyto increase access to psychiatric, financial, and socialresources) plus service provider educational trainingwas compared to TAU (used at another site). Over 2years, incidence of ED visits for DSH, SA, and SI wasexamined at the two sites in 319 adolescents; the directservice intervention was not superior to TAU for reduc-ing SITBs.
Cotgrove, Zirinsky, Black, and Weston (1995)examined a relatively simple intervention that providedadolescents with immediate access to hospital care (viaa green card). In an RCT, 105 adolescents with a historyof DSH or SAs were assigned to receive the green cardintervention or clinic TAU. Although adolescents inthe intervention group reported few suicide attemptsover the treatment period, these rates were not signifi-cantly lower than adolescents receiving standard care.Notably, only 11% of adolescents (n¼ 5) used the greencard service during the 1-year follow-up; the infrequentuse of the intervention limits the conclusions that can bedrawn about its relative efficacy.
Finally, Robinson and colleagues (2012) modified apostcard intervention that has previously been effectivefor reducing SITBs in adults (see Motto, 1976). Adoles-cents (n¼ 164) were randomly assigned to receive 12monthly postcards that promoted well-being and useof evidence-based coping skills (additions to the originalMotto, 1976, postcard intervention) plus community-based TAU, or TAU alone. SITBs decreased for all
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participants over the 18-month follow-up period, butthere were no between-group differences. It is importantto note that the original Motto (1976) study examinedthe postcard intervention in a sample of more than3,000 adults. Robinson et al.’s sample of 164 adolescentsmay have been underpowered to statistically detect anysmall effects of this intervention.
Taken together, results from these resource inter-vention studies suggest that individual-based interven-tions aimed at increasing access to clinical resourcesand enhancing treatment compliance are not more effec-tive than TAU for reducing SITBs in adolescents. Basedon existing evidence, individual-based resource interven-tions were classified as Level 4: experimental for reduc-ing DSH, SA, and SI in youth.
Support-based interventions. King and colleagues(King et al., 2006; King et al., 2009) examined asupport-based intervention for adolescents followinghospitalization—Youth-nominated Support Team(YST). YST aims to decrease SITBs by increasing ado-lescents connections with supportive others who canbuffer against stressors in their environment. Adoles-cents nominate up to four individuals (within or outsidetheir family) who complete psychoeducation sessionsabout suicide risk and safety planning and are encour-aged to maintain weekly supportive contact with theadolescent. The original YST program (YST-I) lastedfor 6 months and, in the total sample, was not moreefficacious than TAU in reducing SA or SI. Althoughthere was not a main effect of treatment, YST-I wasmore efficacious than TAU for reducing SI in girls(King et al., 2006).
In the second iteration of the intervention—YST-II—adolescents were asked to nominate adult supports only(as opposed to peers) who provided support over 3(rather than 6) months (King et al., 2009). Again therewas no main effect of treatment, but YST-II was moreefficacious than TAU for reducing SI among adoles-cents with a history of multiple SAs (King et al.,2009); however, this moderated effect was only signifi-cant 6 weeks into treatment and did not maintain forthe rest of treatment or the follow-up period. YST didnot significantly reduce the risk of SAs in either study.In addition, it is important to note that, although theseRCTs were some of the largest conducted in adolescentswith SITBs, the participation rate in the trials was verylow (i.e., 35–43% of targeted adolescents were enrolledin the trials), which could limit the effectiveness of theseinterventions outside of a controlled trial.
Taken together, these studies suggest that support-based interventions are not generally more efficaciousthan TAU for adolescents with SITBs. These interven-tions may be useful for specific subgroups of adolescents
(e.g., female or multiple attempters); however, furtherresearch is needed replicating these moderation effectsbefore firm conclusions can be drawn about the efficacyof YST in these groups. Because there was not a maineffect of the experimental treatment, and the moderationresults did not replicate across the two studies, thesupport-based intervention was classified as Level 4:experimental for reducing SI in youth.
Clinical Trials in Progress
Our search of ClinicalTrials.gov generated the followingsix relevant clinical trials currently in progress orrecently completed. Four are RCTs replicating treat-ments that have demonstrated promising results in pre-vious research. The first RCT (NCT01732601: IntensiveOutpatient Services for High-Risk Suicidal Teens, PI:Spirito) will extend the initial promising results forintensive CBT (Esposito-Smythers et al., 2011) by exam-ining the intervention in a larger sample of adolescents(n¼ 150) at high risk for suicidal thoughts and behaviors(i.e., those with a comorbid mood disorder, and eithersubstance use or self-harm). The second ongoing RCTis comparing ABFT to an active family supportivepsychological control (NCT01537419: AttachmentBased Family Therapy for Suicidal Adolescents, PI:Diamond & Kobak); this will be the second large-scaleRCT to examine this family-based therapy in suicidaladolescents. Two RCTs are evaluating the efficacy ofDBT in suicidal adolescents (NCT01528020: Collabora-tive Adolescent Research on Emotions and Suicide[CARES], PI: Linehan, McCauley, Asarnow, & Berk)or adolescents engaging in DSH (NCT00675129: Treat-ment for Adolescents With Deliberate Self Harm, PI:Mehlum); these will be the first RCTs of DBT in youth.Positive treatment effects from these RCTs wouldgreatly increase the level of evidence for theseinterventions.
The fifth trial identified is a multicenter RCT, cur-rently in progress, that is comparing Mindfulness-BasedCognitive Therapy, CBT, and TAU (NCT00694668:The [Cost-] Effectiveness of Mindfulness-training andCognitive Behavioural Therapy in Adolescents andYoung Adults with Deliberate Self Harm [DSH], PI:de Klerk & van Giezen); this will be the first study toexamine mindfulness-based CBT in suicidal adolescents.Finally, a small, nonrandomized pilot study recentlyexamined the efficacy of IPT for adolescents withcomorbid depression and NSSI (NCT00401102: IPTfor Depressed Adolescents Engaging in Non-suicidalSelf-injury, PI: Jacobson). This is the first study toexamine IPT for NSSI (Jacobson & Mufson, 2012);however, it appears that only five adolescents completedthe treatment and results of the trial have not yet beenpublished.
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SUMMARY OF EVIDENCE-BASEDTREATMENTS
Our review of the evidence-based treatment literaturefor SITBs in youth indicates that there are currentlyno Level 1: well-established treatments for any form ofSITB (nonsuicidal or suicidal) among children and ado-lescents. Level 1 classification requires evidence from atleast two independent RCTs indicating that an inter-vention is superior to an active treatment, psychologicalplacebo, or medication. Most treatments in our reviewwere only examined in a single RCT.
Probably and Possibly Efficacious Interventions
Six treatments were evaluated as Level 2: probablyefficacious or Level 3: possibly efficacious interventionsfor SITBs in youth. Level 2: probably efficacious treat-ments require evidence from at least one sound RCTindicating superiority to an active treatment, psycho-logical placebo, or medication (rather than waitlist orno treatment controls). Probably efficacious treatmentsincluded (a) CBT-IndividualþCBT-FamilyþParentTraining for SAs, (b) FBT-Parent training only forSITB (outcome measure combined suicidal and nonsui-cidal self-injurious thoughts and behaviors), (c) FBT-Attachment for SI, (d) IPT-Individual for SI, and (e)Psychodynamic therapy-IndividualþFamily for DSH.It is important to note that the interventions in ourreview meeting Level 2 criteria were each evaluated ina single RCT: Although the initial findings are promis-ing, future studies replicating positive treatment effectsare needed to increase confidence in these effects andfor the intervention to progress to a well-establishedtreatment for SITBs in youth.
In addition to the probably efficacious interventions,FBT-Ecological was evaluated as Level 3: possiblyefficacious for reducing SAs in youth. Promising resultsfrom this trial are notable because it is one of twointerventions found to significantly reduce suicidalbehavior specifically in youth. Future research in purelyself-injurious samples is needed to increase the evidencefor this intervention in SITB populations.
It may be surprising that DBT was not classified as anefficacious treatment, given its utility for reducing SITBsin adults (e.g., Linehan, Heard, & Armstrong, 1993;Linehan et al., 2006). However, there are currently nopublished RCTs examining the efficacy of DBT in youth.As previously indicated, favorable results from the RCTscurrently in progress would increase the evaluation ofDBT from experimental (Level 4) to probably efficacious(Level 2), or potentially well-established (Level 1) if bothtrials demonstrate that DBT is superior to another activepsychological treatment, for adolescent SITBs.
Efficacious Treatment Components
Our review indicates that efficacious treatments forSITBs in youth are rooted in a wide variety of theoreti-cal orientations, including CBT, FBT, IPT, and psycho-dynamic therapy. Because no single theoreticalorientation is superior, treatment efficacy is likely dueto common elements across these interventions (alsosee review: Brent et al., 2013). In general, efficacioustreatments (a) target relationship or interpersonal func-tioning, particularly within the family (and almost allinclude the family or parents in treatment); (b) involveskills training; (c) are intensive (specifically interventionsthat reduced self-injurious behavioral outcomes); and (d)address other maladaptive behaviors, or risk factors for,SITBs (specifically interventions found to reduce SAs).These components are addressed in turn next.
First, efficacious interventions all focused on improv-ing some aspect of relationship or interpersonal func-tioning. Given that family problems and interpersonaldifficulties are commonly reported reasons for suicidalbehavior among adolescents (Cotgrove et al., 1995;Wagner, Silverman, & Martin, 2003), improving familialand interpersonal functioning may be particularlyimportant for reducing further SITBs in this population.Most efficacious interventions targeted familial relation-ships specifically. Family sessions in CBT, FBT, andpsychodynamic therapy focused on improving theparent–adolescent relationship or family functioningusing psychoeducation, communication training, and=or problem-solving skills training. Moreover, two ofthe efficacious interventions found that improvementsin family functioning (Pineda & Dadds, 2013) andattachment (Rossouw & Fonagy, 2012) mediated posi-tive treatment effects. The individual IPT intervention,delivered to students in a school setting, was the onlytreatment that did not include a formal family compo-nent. However, IPT does highlight the importance ofinterpersonal effectiveness and ameliorating interperso-nal problems to improve psychological functioning(Mufson et al., 1993). Taken together, this research indi-cates that improving family functioning specifically, orinterpersonal functioning more broadly, is an importantcomponent of efficacious treatments.
Second, all efficacious treatments included at leastone skills training component, such as emotion regu-lation, problem-solving, or interpersonal effectivenessskills. The necessity of skills training for treatment suc-cess may explain why resource interventions, whichincrease access to mental health resources and socialsupport but do not include any formal skills training,have not been effective for reducing SITBs in youth.However, it is unclear from this review which skills arethe most important for effective treatment. Family-based and CBT interventions included a range of
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emotion regulation, problem-solving, and conflictmanagement skills, whereas psychodynamic andinterpersonal interventions focused primarily on skillstraining in one area (affect regulation and interpersonalproblem solving, respectively). Despite differences inskills training, a number of these interventions demon-strated some promise for reducing SITBs. The field wouldbenefit from future research identifying the individual,parent, and family skills necessary for treatment efficacy.
Notably, our review suggests that parent skillstraining may be a particularly important component ofefficacious treatments for SITBs in youth. The seriesof studies by Esposito-Smythers and colleagues providethe strongest evidence for the role of parenting skills.The initial individual CBT intervention developed bythis group (Donaldson et al., 2005) was not more effec-tive than supportive therapy for reducing SITBs. Whenfamily sessions were added to the intervention, signifi-cant reductions in SI, but not SAs, were found (althoughthis could be due to the small sample size in this pilotstudy: Esposito-Smythers et al., 2006). It was not untilparent training was added to the treatment package inI-CBT that significant reductions in SAs were observed(Esposito-Smythers et al., 2011). Other efficaciousinterventions also included parenting components, suchas a parent education and training in RAP-P and MST.The importance of parent training may help explain whysome brief family-based interventions were effective,whereas others were not: short-term (four- to five-session) parent training in the RAP-P trial reducedSITBs, but very brief (one-session) family interventionsthat focused primarily on family problem solving didnot. Further support for parent training as a mechanismof change comes from a classroom-based preventiontrial indicating that behavior management strategies inchildhood may reduce SI over adolescence and youngadulthood (Wilcox et al., 2008).
Third, the most effective interventions for reducingself-injurious behaviors (i.e., DSH or SAs) are intensive(i.e., greater number of weekly contacts and longerlength of treatment), especially in the beginning of treat-ment. Notably, none of the brief family-based orresource interventions were effective for reducing SITBs.Given that adolescents are most at risk shortly afterhospital discharge (e.g., Goldston et al., 1999), earlyintensive intervention may be necessary to providea sufficient treatment dose during this high-risk period.
Finally, it may also be important to target othermaladaptive behaviors, or risk factors for SITBs, intreatment. For instance, in the most promising inter-vention study for SITBs in youth, Esposito-Smytherset al. (2011) found that, in addition to reductions inSAs, the treatment group also reported less substanceuse over the course of treatment. (Of note, this parti-cular trial recruited participants for comorbid suicide
risk and substance use disorders, and provided treat-ment for both symptoms.) Findings from this study sug-gest that targeting risk factors for SITBs, such assubstance use, may enhance interventions. However, itis important to note that this is not true for all risk fac-tors: interventions that reduce depression do notdecrease SITBs in youth (Asarnow, Porta, et al., 2011;Gibbons, Brown, Hur, Davis, & Mann, 2012; Wilkinsonet al., 2011). In addition to general risk factors, futureresearch is needed to elucidate the specific mechanismsthat cause and maintain SITBs over time, so these fac-tors can be targeted in treatment (see Future ResearchDirections section).
Considerations When Evaluating TreatmentEfficacy
There are a number of important issues to considerwhen evaluating the treatments reviewed here, includingthe (a) SITB outcome(s), (b) comparison or control con-dition, (c) general decline in SITBs over time, (d) singletrials used to evaluate most treatment families, and (e)high attrition rates as well as low, and differential, ratesof treatment dose. Each of these issues is considered inmore detail next.
When comparing the efficacy of interventions, it isimportant to note the variety of SITB outcomes exam-ined. In this review, we identified 10 different SITB out-comes that ranged from specific behavioral outcomes,such as NSSI (rarely examined) and SAs, to broaderoutcomes, such as DSH (which includes both nonsuici-dal and suicidal behaviors) and terms that collapsedsuicidal thoughts, plans, threats, and attempts into asingle category (e.g., suicide events). Moreover, theSITB outcomes for the probably efficacious and possiblyefficacious treatments varied across studies. Someinterventions were effective for reducing SI only (FBT–Attachment, IPT–Individual), DSH (Psychodynamictherapy–IndividualþFamily), SAs (CBT–IndividualþCBT–FamilyþParent Training, FBT–Ecological), orSITBs more broadly (FBT–Parent training only). Thedifference in SITB outcomes assessed is important fora few key reasons. First, it is difficult to compare treat-ment outcomes across studies because different SITBswere examined using a variety of measures. Second,for studies that included more vague outcomes, suchas DSH or SITBs (which includes both suicidal and non-suicidal thoughts and behaviors), it is unclear whetherthese interventions are efficacious for reducing nonsuici-dal forms of self-injury, suicidal forms of self-injury, orboth. Researchers often collapse multiple SITB out-comes into a single category because these behaviorsare relatively infrequent in the population, and thereforelarge sample sizes are necessary to examine a single formof SITB. Although combining different forms of SITB
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makes sense for practical reasons, these broad categorieslimit our understanding of treatment effects. Finally,many studies examined, and found positive treatmenteffects for, suicidal thoughts. Although SI is concerning,not all adolescents with suicidal thoughts will engage insuicidal behaviors (Nock et al., 2008; Nock et al., 2013).Moreover, given that a history of SAs (rather than otherSITBs) is currently the most robust risk factor forcompleted suicide (Goldsmith, Pellmar, Kleinman, &Bunney, 2002), it will be important for future researchto examine interventions that specifically target suicidalbehavior.
Second, a range of control or comparison conditionswere also used across trials, making it difficult to inter-pret the consistency of treatment effects across studies.Although TAU is the most frequently employed com-parison condition, the nature of the usual care providedranges and is often not described in great detail. Ina sample of 63 adolescents receiving TAU, Spirito,Stanton, Donaldson, and Boergers (2002) found thattreatments varied widely in theoretical orientation (cog-nitive, behavioral, psychodynamic) and frequency ofsessions (range¼ 0–22). Consistent with Spirito, Stan-ton, et al. (2002), TAU in the current review varied fromsupportive counseling (Tang et al., 2009) to inpatienthospitalization (Huey et al., 2004). Of course, the appro-priate comparison treatment will depend on the severityof the sample, with more severe patient samples requir-ing more intensive control treatments than less severegroups. However, as Spirito, Stanton, et al. noted, theincreased monitoring and resources available in RCTsmay make less intensive interventions clinically appro-priate for even severe samples of adolescents. We returnto this issue in our discussion of future research.
Third, in most studies reviewed, SITBs tended todecrease markedly over time, even without intervention.Given this natural decline, or regression to the mean,pilot studies, which lack a control or comparison group,are of limited utility for evaluating an intervention’sefficacy. In the current review, RCTs were weightedmore heavily than pilot studies, which resulted in a lessfavorable evaluation of interventions that have primarilybeen examined in noncontrolled studies.
Fourth, most treatments, and particularly the moreefficacious treatments, were examined only in a singletrial, and therefore evaluations are based on the efficacyof an intervention in one specific sample. For instance,both IPT–Individual and FBT–Parent training onlyinterventions were examined in adolescents withdepression, and I–CBT (CBT–IndividualþCBT–FamilyþParent Training) was examined in adolescents withsubstance use disorders. Replications of promisingtreatments in more diverse samples are needed beforeconclusions can be made about the generalizability oftreatment findings.
Finally, high attrition rates and poor treatmentattendance were major problems in many of the trialsreviewed. These issues made it difficult to evaluate theefficacy of some experimental interventions: If a largepercentage of the treatment and=or control groupdropped out of the trial, or there were differences inthe dose of treatment between conditions, this limitedthe inferences that could be drawn about a specific treat-ment approach. Moreover, low rates of treatment com-pletion are important when considering how theseinterventions will work in naturalistic settings (i.e.,moving from efficacy to effectiveness studies).
FUTURE RESEARCH DIRECTIONS
Improvement in Study Design and Measurement
A major shortcoming of the treatment literature in thisarea is the lack of experiments or RCTs. As previouslydiscussed, RCTs are essential for establishing the effi-cacy of an intervention, and multiple independent RCTsare necessary for a treatment to be considered well-established. Moreover, our review indicates that pilotstudies are of limited utility given the episodic natureof SITBs. Future research also would benefit from stu-dies that include specific SITB outcomes, more detailabout the intervention components included in boththe experimental and comparison treatment packages,and greater standardization of usual care conditionsacross trials.
Replication and Dismantling Studies of PromisingTreatments
Replication is vital to confirm the efficacy of an inter-vention. For instance, although Wood et al. (2001)initially reported promising results of DGT, attemptsto replicate these findings by other research groups wereunsuccessful (Green et al., 2011; Hazell et al., 2009).Given that well-established treatments require at leasttwo independent RCTs, one straightforward but vitallyimportant future direction is for independent researchteams to examine the efficacy of the probably efficacioustreatments identified in this review. In addition, it will beimportant for future studies to examine the efficacy ofthese treatments in various sociodemographic and clini-cal groups (as most have only been examined in one spe-cific sample of adolescents). Although obtaining grantfunding for replication studies can be difficult, research-ers can enhance the incremental utility of replications bybuilding in tests of additional factors, such as testingmediators or moderators of change.
In addition, the field would benefit from futureresearch examining whether some or all intervention
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components included in potentially efficacious treatmentsare necessary to produce significant treatment effects.The current interventions demonstrating the most prom-ise for reducing SAs in youth are intensive and include avariety of treatment elements. Dismantling studies couldbe helpful for identifying the components essential fortreatment efficacy. For instance, Esposito-Smytherset al. (2011) found that parent training enhancedtheir CBT package. Relatedly, Pineda and Dadds(2013) reported positive effects for a parent educationintervention that did not include the adolescent intreatment. Future research is needed to examine thetreatment efficacy of parent training and educationalone for reducing suicidal behavior in youth.
Examination of Treatment Mediators andModerators
It will also be important for future studies to examinehow (mediation) these interventions work and for whom(moderation). A few family-based treatment studieshave identified significant mediators of treatment out-come. For instance, increased family functioningmediated positive treatment effects in the RAP-P trial(Pineda & Dadds, 2013), and improvements in mentali-zation and attachment mediated positive outcomes forMBT-A (Rossouw & Fonagy, 2012). These findingsprovide support for the proposed mechanisms of changein these trials.
In addition, it will be important for future researchto highlight potential moderators of treatment effects,as not all interventions will work for all individuals(Kraemer, Wilson, Fairburn, & Agras, 2002). Somestudies in our review reported that their interventiononly worked for some participants (e.g., Harringtonet al., 1998). However, because there was no main effectof treatment, it is unclear whether these findings reflecttrue moderation.
Development of Effective Brief Interventions
Treatments demonstrating the most promising resultsfor reducing self-injurious behaviors (e.g., SAs) inadolescents are intensive and long term. However, giventhat adolescents (and adults) are at greatest risk forattempting suicide in the 6 months following hospitaldischarge (Brent et al., 1993; Goldston et al., 1999;Prinstein et al., 2008), long-term interventions may beinadequate for helping adolescents during these high-risk periods. For instance, in the TASA trial, 40% ofSE occurred within the first month of the study beforea sufficient dose of treatment could be delivered (Brentet al., 2009). Unfortunately, the brief (resource) inter-ventions examined to date, including crisis management
and increasing hospital access, have not proven effectivefor reducing SITBs in adolescents.
Safety planning is one potential brief treatment thatis being used increasingly in a variety of clinical settings,and specifically within the United States Department ofVeterans Affairs Healthcare System (Stanley & Brown,2012). Through a series of six steps, safety planninghelps patients identify warning signs for distress, copingskills, social supports, clinical resources, and waysto restrict access to lethal means. The safety planningintervention is designed to be unique as a single-session,stand-alone treatment for individuals at risk for suicide(Stanley & Brown, 2012). Although safety planning ispotentially promising as a brief intervention, there iscurrently no empirical evidence documenting its efficacyfor reducing SITBs in adults or adolescents. However,there are data indicating that restricting access to lethalmeans, such as firearms, can decrease SAs usingthat particular method (Brent & Bridge, 2003). Futureresearch should focus on examining other brief interven-tions that may be useful for reducing risk for SITBsduring early high-risk periods.
Utilization of Single-Case Experimental Designs
Although large-scale RCTs are necessary to ultimatelyevaluate an intervention as well-established, they arenot the only designs useful for treatment research. In fact,large trials that require hundreds of participants (to haveenough power to detect effects) may actually be inappro-priate for testing novel treatments with unknown effi-cacy. Single-case experimental designs (SCEDs: Barlow,Nock, & Hersen, 2009) are one alternative to RCTs thatmay be particularly ideal for developing new treatmentsfor SITBs. In contrast to RCTs that examine treatmenteffects on target outcomes between individuals, SCEDsexamine the impact of treatment on targets within indivi-duals (e.g., Wallenstein & Nock, 2007). SCEDs may beparticularly useful for developing new interventions thatcan later be examined in standard RCTs.
CONCLUDING COMMENTS
Although research on interventions for SITBs hasincreased over the past 10 years, there are currently nowell-established treatments for suicidal or nonsuicidalSITBs in youth. Several treatments have shown potentialpromise: Interventions identified as efficacious includetreatment components that foster familial and otherinterpersonal relationships, improve parenting skills,and strengthen individual coping skills. Most of theseinterventions are intensive and focus on treating boththe family as well as the adolescent. However, theseconclusions are based on a single RCT per treatment,
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and it is unclear which intervention components arenecessary and sufficient for reducing SITBs. Futureresearch is needed to replicate promising treatments, toisolate essential treatment components, to determinehow these treatments work (i.e., mediators), and to ident-ify which adolescents will benefit most from these inter-ventions (i.e., moderators). In addition, giventhat adolescents are at heightened suicide risk shortlyafter discharge from the hospital, the field needs briefinterventions that can be administered within the monthpostdischarge.
Due to the paucity of established treatments forSITBs, treatment providers may find it useful to referto evidence-based clinical guidelines for working withsuicidal youth, such as those provided by the Councilof the American Academy of Child and AdolescentPsychiatry (AACAP Official Action, 2001). These guide-lines provide information regarding clinical assessment,crisis management, and hospitalization for suicidalyouth. Given the increasing treatment research in thisarea, it is our hope that the next edition of this reviewwill be able to discuss well-established treatments foreffectively reducing SITBs in children and adolescents.
FUNDING
The research was supported, in part, by a grant from theNational Institute of Mental Health (F32 MH097354)awarded to Catherine R. Glenn and a MacArthurFellowship awarded to Matthew K. Nock. We thankDaniel Coppersmith, Sima Shabaneh, and SuzanneShdo for their assistance reviewing the relevant litera-ture for this manuscript.
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