research

Family-based Crisis Intervention with Suicidal Adolescents in the Emergency Room: A Pilot

Study Elizabeth A. Wharff, Katherine M. Ginnis, and Abigail M. Ross

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

KEYWORDS; crisis intervention;family intervention; suicidal adolescents; suicide

As the adolescent suicide rate has been in- creasing over the last several decades (Centén for Disease Control and Preven-

tion, 1998, 2007a, 2007b, 2008; Office of Disease Prevention and Health Promotion, 2000), there has been a parallel increase (as high as 59 percent) in pédiatrie emergency room (ER) usage rates by adolescents in need of mental health evaluations in the United States (Breslow, Erickson, & Cava- naugh, 2000; EUison, Hughes, & White, 1989; Hughes, 1993; Page, 2000; Sills & Bland, 2002; Stewart, Spicer, & Babl, 2006). Suicidality in ado- lescents has been the most significant factor in the majority of ER visits for behavioral health con- cerns (Stewart et al., 2006) and the most common presenting problem for adolescents subsequently admitted to an inpatient psychiatric unit (Brooker, Ricketts, Bennett, & Lemme, 2007).

Although the number of psychiatric ER visits has increased substantiaUy (Bruffaerts, Sabbe, & Demyttenaere, 2004; Hughes, 1993; Larkin, Claassen, Emond, PeUetier, & Camargo, 2005), child mental health service avaUabUity has not

kept pace, resulting in longer ER wait times and stays for patients (American CoUege of Emergency Physicians, 2008), Ekely contributing to a phe- nomenon termed psychiatric "boarding" (Man- sbach, Wharff, Austin, Ginnis, & Woods, 2003) that has gained notoriety in the popular press (Holmberg, 2007; Katz, 2006; Kowalczyk, 2007; Trafford, 2000). Boarding describes a patient who is in psychiatric crisis and requires inpatient hospi- talization but for whom there is no available inpa- tient psychiatric bed (Mansbach et al., 2003). In a recent survey of ER medical directon, over 70 percent reported boarding psychiatric patients as a routine practice, with nearly 40 percent doing so a minimum of once a week (American CoUege of Emergency Physicians, 2008).

In current practice, the standard of care in emergency psychiatry is evaluation and disposition with little or no treatment provided at the time of presentation (Bruffaerts, Sabbe, & Demyttenaere, 2008). Psychiatric ER protocol is a noteworthy deviation from triage practice in standard emer- gency care, in which the most acute patients are

doi: 10.1093/SW/SWS017 O 2012 National Association of Social Wo-kers 133

prioritized and receive the most rapid and inten- sive care. Historically, there has been little focus on psychiatric treatment within the emergency setting, often due to time pressures to move pa- tients through the ER and the prevailing treat- ment philosophy that psychiatric treatment of suicidal patients requires admission to a locked in- patient facility.

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

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

FBCI is based on the assumptions that an inpa- tient hospitalization is not necessarily the most helpful level of psychiatric care for adolescents with suicidal ideation/behavior, that families and caregivers are able to provide support to an adoles- cent fanuly member if given both an opportunity and effecdve tools to use, and that a family that learns to support an adolescent while he or she is in crisis wül be empowered to provide ongoing support once the acute psychiatric crisis subsides. Based on an integradon of cognidve-behavioral skill building, psychoeducadon, therapeudc readiness.

and safety planning, FBCI uses nonjudgmental collaboradon (Madsen, 1999) to stabilize padents and provide psychiatric intervention in the ER for both the adolescent and the family, thereby de- creasing a patient's level of risk and increasing the capacity of the family to maintain the patient at home with appropriate therapeutic supports.

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

METHOD

Study Design This puot study was conducted in the Boston Children's Hospital ER, in which approximately 1,000 patients in psychiatric crisis are seen annually. Nearly 40 percent of these patients present •with chief complaints of depression or suicidal ideation/behavior. During an 18-month period (January 1, 2001, through June 30, 2002), 100 suicidal adolescents and their families were re- cruited to participate in the pilot study of FBCI when presenting to the ER. The sample was ob- tained consecutively. Padents were excluded when they met at least one of the following five criteria: (1) not currently living with a fanuly, (2) presenting to the ER unaccompanied by a family member, (3) intoxicated/sedated at the time of ER presentation, (4) presenting with cog- nitive limitations that prohibited FBCI participa- tion (that is, severe psychosis or significant developmental delay), and (5) presenting during an overnight shift (11:00 P.M. through 8:00 A.M., Monday through Friday) or during weekend hours (5:00 P.M. Friday through 8:00 A.M. Monday), because FBCI-trained staff were not available to administer the intervention during these ER shifts. Informed consent and assent were obtained from all patients and families prior to patients receiving both a standard psychiatric

134 Social Work VOLUME 57, NUMBER 2 APRIL 2012

evaluation and FBCI. After finishing the standard psychiatric evaluation with the chUd and famUy, the social worker used her best chnical judgment to make the decision about whether the patient could benefit from FBCI. If the evaluating social worker had any uncertainty about whether the patient was appropriate for FBCI, a supervisor was avaUable for consultation.

A pUot design was selected because the entire ER psychiatry staff was trained in the interven- tion protocol, rendering random assignment of famihes to standard or specialized ER care im- possible. Prior to commencing the study, aU ER psychiatry social work staff members were trained in FBCI protocol by the creators of the inter- vention. FBCI staff were required to attend weekly meetings to review cases with the crea- tors of the intervention. Fidelity to the interven- tion was measured using a checklist requiring completion of each of the four core essential components of FBCI. Interrater rehabUity was established prior to study start. FBCI staff met weekly during the 18-month pUot study period to maintain interrater reHabUity. The safety of FBCI was measured by the number of FBCI patients who reported incidence of a suicide attempt or completion during the three-month foUow-up period. FeasibUity was measured by our abUity to adequately train ER staff in FBCI protocol and implement the single-session inter- vention within the context of a busy ER. Fideh- ty to the intervention was measured using a checklist requiring completion of each of the four core essential components of FBCI. Demo- graphic and clinical characteristics and disposition data from the pUot sample were then compared with data obtained retrospectively from a cohort of suicidal adolescents presenting consecutively to the ER during the previous 18-month calen- dar period (fanuary 1, 1999, through June 30, 2000). The Boston ChUdren's Hospital institu- tional review board approved the pUot study.

Recruitment and Consent for the Pilot Study AU patients and famUies presenting to the ER during the study period received standard emer- gency care, or treatment as usual (TAU). This process began with a medical examination by an ER physician. Once medical clearance was ob- tained and a psychiatric consultation was

requested, participants were approached by a psy- chiatry research assistant to obtain informed consent/assent. Once consent was obtained, the patient and famUy were asked to complete some brief psychometric measures—the ChUdren's Depression Inventory (CDI) (Kovacs, 1982), the Hopelessness Scale for ChUdren (HSC) (Spirito, WUhams, Stark, & Hart, 1988) and the FamUy Adaptability and Cohesion Evaluation Scale II (FACES II) (Olson, Portner, & Lavee, 1982)—to assess depression, hopelessness, and flexibUity of famUy system, respectively. AU psychometric mea- sures used have demonstrated strong reliabUity and vahdity (Kazdin, Rogers, Sc Colbus, 1986; Kovacs, 1992; Olson et al., 1983). Famihes were also asked to complete a comprehensive famUy self-report form, which coUected demographic and historical information. Patients and families were not excluded if the famUy or adolescent did not complete the assessment forms. AU forms were avaUable in Spanish and English. Interpreters were avaUable for famUies whose first language was other than English or Spanish. The Study Flow is depicted in Figure 1.

Determination of Inclusion for FBCI On completion of the standard emergency psy- chiatry evaluation with the adolescent and family, the evaluating chnician, either a licensed master's- or doctoral-level social worker, reviewed the case with the attending psychiatrist to determine the appropriate level of psychiatric care. FamUies were offered FBCI only if the evaluating social worker, attending psychiatrist, and famUy were in agree- ment that FBCI might enable the adolescent to return home safely. The decision to offer FBCI was based on both the acuity of the adolescent's suicidality and the capacity for galvanizing envi- ronmental supports avaUable to and within the famUy system. If the evaluating social worker, at- tending psychiatrist, and famUy concurred that FBCI might help the adolescent return home safely with his or her famUy, the social worker then proceeded with FBCI. Adolescents who were not offered FBCI were hospitalized at an in- patient psychiatric facUity.

FBCI The thoretical underpinnings of this single-session ER intervention come from cognitive-behavioral, narrative, and family systems therapies, with an

WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 135

Figure 1: Study Flow Chart

Patient presents to ER with suicidality and is medically cleared

Exclusion Criteria: Acuity of suicidality

• Study team obtains informed consent and administers CDI, HSC,

and FACES II • Clinician performs standard

psychiatric evaluation and determines FBCI eligibility

Patient is ::iot FBCI eligible: Disposition of inpatient tospitalization (« = 33)

Exclusion Critetia: • Not currently living

with a family • Presenting to ER

unaccompanied by a family member • Intoxicated/

sedated at the time of ER presentation • Severe cognitive

limitations that prohibited FBCI participation • Presenting during an

ovemight/ weekend shift

Patient is FBCI eligible (n = 67)

Clinician does FBCI in ER: Meets with patient and family both individually and together

Clinician consults with attending psychiatrist, adolescent, and family to determine whether the patient can retum home safely

Patient is hospitalized (n =

2) Patient returns home safely (« = 65)

Note: ER = emergency room; CDI = ChildreiTs Depressio • Inventory; HSC = Hopelessness Scale for Children; FACES II = family Adaptability and Cohesion Evaluation Scale II; FBCI = family.based crisis intervention.

overaU approach of nonjudgmental collaboration, as described by Madsen (1999;. First, the social worker holds separate meetings with the adoles- cent and family to assess the sequence of events and differing perceptions leading to the suicidal problem. During these meetings, the social worker uses a narrative approach to help each party tell his or her story. The social worker also explores what each party feels would be necessary for the adolescent to retum home safely with his or her family. Next, the social worker meets with

the whole family together, attempting to con- struct a single, unified perception of the problem using the same narrative approach. We refer to unified perception of the problem as the "joint crisis narrative." During the meeting, the social worker assesses family roles and the potential flex- ibUity and adaptabiUty of the family system, using cUnical interventions to both facilitate and improve communication among family members. The social worker uses cognitive—behavioral ther- apeutic approaches, including relaxation.

136 Social Work VOLUME 57, NUMBER 2 APRIL 2012

problem-solving, and cognitive reframing tech- niques to shift negative atttibutions. The social worker also works with the chud and family to problem solve around any specific dilemmas as needed. In the family meeting, the social worker tties to help the family and adolescent work to- gether to improve intrafamilial communication, to safety plan, and to effect additional changes that will enable the adolescent to feel safe at home. The goal of FBCI is to effect changes that wOl reduce the acute symptoms that brought the ado- lescent to the ER and increase the family's aware- ness of the problem and sense of efficacy to help their chud, thereby avoiding inpatient admissions and further disruptions of the adolescent's hfe. After completing FBCI, the social worker again consults with the supervising psychiattist to review the case and obtain consensus that the patient is able to return home safely. Patients are discharged home only when the patient, family, attending psychiattist, and assessing social worker agree that this is the best disposition for the adolescent.

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

Retrospective Comparison Group Demographic and clinical charactetistics and dis- position outcomes of patients in the pilot sample were compared retrospectively with adolescents {N= 150) who presented consecutively to the same ER with complaints of suicidal behavior/ ideation duting the corresponding 18-month cal- endar petiod immediately preceding the puot study petiod Qanuary 1, 1999, through June 30, 2000). Retrospective cohort patients met the same inclusion and exclusion ctitetia as those in

the pilot sample. Standard psychiattic assessment information—including demographic informa- tion. Diagnostic and Statistical Manual of Mental Dis- orders (4th ed.) {DSM-IV) (Ametican Psychiattic Association, 1994) diagnoses, and disposition de- tennination—that pertained to each patient in the retrospective compatison group was obtained through a medical record review.

Statistical Analyses Frequency disttibutions and means were calculat- ed for demographic data in both the puot and retrospective cohort compatison samples (see Table 1). Mean CDI, HSC, and FACES II adapt- ability and cohesion scores were computed for the sample using a dichotomous disposition outcome (inpatient hospitahzation/aU others) as the depen- dent vatiable (see Table 2). Between-groups dif- ferences in mean CDI, HSC, and FACES II scores were examined using independent sample Í tests (see Table 2).

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

RESULTS

Demographics The pilot sample included 100 adolescents ages 13 to 18 years presenting to a large urban ER with symptoms of suicidality. A total of 144 suici- dal adolescents presented to the ER duting the FBCI study petiod, 44 of whom were excluded from participating in the study due to aforemen- tioned exclusion ctitetia, lack of available research assistants, or lack of available FBCI-trained staff.

Among the 100 adolescents participating in the pilot study, 76.0 percent were female. Mean patient age was 15.6 {SD= 1.5) years. Sixty-five percent of patients self-identified as white, 16 percent self-identified as black, 11 percent self- identified as Hispanic/Latino, 3 percent self- identified as biracial, 2 percent self-identified as Asian, and 3 percent self-identified as being of another race. Demographic data obtained

WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 137

Table 1: Demographics of Intervention and Comparison Groups

iiteryention'(/V= 100)

Variable Comparison (/V={150) ¡

Gender Female Male

Race/ethnicity

Asian Black Hispanic/Latino White Biracial Other

Living arrangement

Parents Other relative Foster care

Primary language English

Spanish Other

Legal custody

Parents DSS/DCF Other relative Other

Primary DSM-IVxás I diagnosis

Total depressive disorders Bipolar disorder

Other mood disorders Anxiety disorders/PTSD Other'

76

24

2

16

11

65

3

3

96

4

0

89

7

4

96

1

2

1

76

5

1

8

II

76.0

24.0

2.0

16.0

11.0

65.0

3.0

3.0

96.0

4.0

0.0

89.0

7.0

4.0

96.0

1.0

2.0

1.0

76.0

5.0

1.0

8.0

11.0

111

39

4

26

15

97

2

6

139

11

1

138

11

1

140

5

1

0

105

10

2

10

23

74.0

26.0

2.7

17.3

11.0

64.7

1.3

4.0

92.7

7.3

0.7

92.0

7.3

0.7

93.3

3.3

0.7

0.0

70.0

6.7

1.3

6.6

15.3 Notes: The average age in years was 15.60 (SD=1.4S) for the intervention group and 15.50 {SD=1.47) for the comparison group. DSS = Department of Social Sen/ices; DCF = Department of Children and Families; DSM-IV= Diagnostic and Statistical Manual of Mental Disorder (4th ed.); PTSD = posttraumatic stress disorder. 'Includes eating disorder, psychosis, substance abuse behavioral disorders, attention-deficit/hyperactivity disorder, and somatoform disorders.

Table 2: Pilot Sample CDI, FACES II, and

HSC Scores

Total CDI

Patient cohesion

Family cohesion

Patient adaptability

Family adaptability

Hopelessness

Inpatient All others Inpatient All others Inpatient

All others

Inpatienc All others

Inpatient All others Inpatient

All others

34 61 31

59 33 60

32 54

32 58 27 60

31.56 23.26

47.19 47.63 54.73 56.02

38.66 40.56

44.72 44.81

11.15 7.52

9.863 9.83

12.38

12.925 8.596 8.54

9.46

9.07

7.10 6.32 4.36 4.44

<.OO1

.876

.490

.364

.952

.001

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

Table 3: FBCI and Comparison Group

Disposition Outcomes, in Percentages

Disposition Outcome Inpatient Intensive outpatient Outpatient Other

FBCI (/V=100)

35" 21"

43 0

Comparison (W=150)

55 5

37 3

Note: FBCI = family.based crisis intervention. "Reduction in hospitaiization rate: p<.0001. ''increase in intensive outpatient referrai: p < .001.

retrospectively from the comparison sample (150

suicidal adolescents presenting consecutively to

the ER during the corresponding previous

18-month calendar period) are presented in

Table 1. Patients in the comparison sample did

not differ significantly in age, race and ethnicity,

138 Social Work VOLUME 57, NUMBER 2 APRJL 2012

living arrangements, primary language, legal custody status, caregiver relationship status, primary DSM-IV diagnosis, or reported family history of depression from their counterparts in the pilot study. Exclusionary criteria were matched between samples.

On compledon of the initial psychiatric evalua- tion, 67 percent of adolescents (n = 67) were eligi- ble to receive FBCI. The remaining 33 percent (n = 33) who did not receive FBCI were hospital- ized due to the acuity of their suicidality. Of the 67 patients who received FBCI, 97.0 percent {n = 65) were not hospitalized. Only two padents who received FBCI were hospitalized after their ER visit. These patients were unable to engage in safety planning during FBCI and thus required hospitalization. Statistically significant differences in depressive symptom severity occurred between patients who were admitted to an inpatient unit and those who were not. Mean CDI scores for 34 patients with an inpatient disposition (31.50 [SD = 69.86]) were significantly greater than the mean CDI scores for 60 patients who did not (23.26 [5D = 9.83]). CDI scores were not avail- able for two patients who were ineligible for FBCI and for three who received the intervention and were discharged home. Similarly, mean HSC scores were higher among patients who were hos- pitalized (n = 27 [p = .001]). HSC scores v/ere not available for eight patients deemed ineligible for FBCI and for five patients who received FBCI and were discharged home.

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

Suicidal adolescents and families who presented to the ER during the FBCI pilot period v/ere sig- nificantly less likely to be admitted to an inpatient psychiatry unit than were members of the matched sample who presented during the com- parison period. Sixty-five percent of suicidal pa- tients presenting during the study period were discharged home, whereas only 44.7 percent of the comparison cohort (n = 67) were discharged home. Adolescents and their families presenting to the ER during the pilot study period v/ere sig- nificandy more likely to receive a referral to

intensive outpatient services (acute day treatment programs and intensive home-based therapies) at discharge fi'om the ER (21.0 percent [n = 21] venus 5.3 percent [n = 8], p<.001) than were their TAU counterparts in the retrospective cohort (see Table 3).

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

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

DISCUSSION Considering the increasing rates and high costs of adolescent psychiatric hospitalization and an in- creasingly overburdened health-care system, inves- tigations evaluating the efficacy of therapeutic interventions occurring within the ER are essen- tial. To date, FBCI is the only standardized single- session crisis intervention for suicidal adolescents evident in the literature that has been designed for and pUoted within the ER to demonstrate feasi- bility, acceptabUity, and significant reductions in inpatient hospitalization rates relative to a demo- graphicaUy matched, retrospectively obtained comparison sample.

WHARPF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 139

Avoidance of inpatient psychiatric admission for suicidal adolescents has several benefits for the in- dividual adolescent, the familŷ and the mental health system. Although the sodetal stigma associ- ated with mental health problems has been reduced somewhat, the stereotypical view of ado- lescent inpatient psychiatric care depicted in popular literature and films continues to prevail. An inpatient admission may negatively affect an individual or family's beliefs about recovery (Hellzen & Lilja, 2008), the capacity to be safe in the world, or the family's ability to provide a safe and supportive environment for their chud. Con- venely, community-based supports may allow a chud to refrain from developir.g a "dependency upon the hospital environment or from being stigmatized" (Shepperd et al, 2009, p. 3). An ER-based crisis intervention provides the adoles- cent and family with the message that, despite the suicidal ideation/behavior with, which they pre- sented, there are skills that famlies can learn that will enable the adolescent to alleviate his or her distress and thus remain at home. The family feels empowered to be the coordinator of and partici- pant in their child's care, comparable to the foun- dational empowerment model used by the community intensive therapy team in the United Kingdom (Darwish, Salmon, Ahi^a, & Steed, 2006). roCI provides psychoeducation to promote en- gagement in therapy and (¡mraiy understanding of treatment. In addition to the tangible parts of the in- tervention, FBCI provides hope for a family that arrived at the ER overwheln^ed, anxious, and worried for a child's survival. During the study, sev- eral families expressed relief and gmdtude for the care that they received in the ER and noted during follow-ups that family communication and function- ing in home and school domains had improved.

The absence of significant differences between family adaptability or cohesion TACES II scores) and hospitalization in the intervention group was an unexpected finding. Even the most seemingly inflexible and uncommunicati'^e families could engage with a skilled clinician to participate in psychiatric treatment of their child. Using Parad's (1965) crisis theory approach, ve posit that even the most rigid family system is open to change during a crisis. FBCI allows cHricians to take ad- vantage of this opportunity, thereby avoiding un- necessary psychiatric hospitalization.

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

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

The medical system uses a model of stabihza- tion in the ER whenever possible and admission only when necessary. FBCI and other crisis inter- vention protocols could help the mental health system move to a similar model in which inpatient admission is no longer the default position. Current trends indicate that the majority of ado- lescents presenting with suicidal ideation/behavior

140 Social Work VOLUME 57, NUMBER 2 APRIL 2012

are admitted to psychiatric inpatient facilities (Brooker et al., 2007). Inpatient hospitaUzation is much more costly than other alternatives that have been shô wn to be as effective in reducing suicidal ideation/behavior in adolescents (Gould, Greenberg, Velting, & Shaffer, 2003; Henggeler et al., 2003).

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

LIMITATIONS There were several limitations to this study. Though random assignment to FBCI or TAU conditions would have been preferable, FBCI involved changing clinicians' practice within the ER; it was not possible to randomly assign famiUes to treatment and control groups. The closest avail- able approximation to a control group was a retro- spectively obtained sample from the most recent corresponding 18-month calendar period prior to cUnician training in FBCI. The retrospective com- parison component of the study also prohibited acquisition of data on the frequency of ER visits in the TAU group; thus, ER recidivism rates could not be analyzed comparatively between the two samples. The foUô w-up duration of three months is also a Umitation. Though alternatives to inpa- tient hospitalization have been shown to be more effective in extemaUzing symptom reduction and improvement in family functioning than inpatient hospitalization (Henggeler et al., 1999; Schoen- wald et al., 2000), research indicates that these gains may be relatively short-lived (Henggeler et al., 2003). We hypothesize that FBCI may reduce ER recidivism and hospitaUzation rates. Studies of pédiatrie emergency psychiatry services indicate that multiple presentations account for 19 percent to 36 percent of ER visits and that ap- proximately 50 percent of repeat •visits occur within one month of the prê vious presentation. Though data were unavailable on foUow-up hos- pitalizations for the comparison group, rates of repeat ER presentations were much lower in the FBCI sample than in other samples. Currently, we

are conducting a randomized cUnical trial that ex- amines the efficacy of FBCI, long-term gains, and effects of FBCI on ER recidî vism rates. Although we did place foUow-up phone caUs to aU study participants, no famiUes required assistance in ac- cessing additional services at any of the foUow-up time points; however, other services (beyond those recommended as part of the discharge plan) were not controUed for in this study. Future studies should control for additional service use and variability.

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

CONCLUSIONS

Patients who received FBCI were significantly less Ukely to be hospitaUzed than were their compari- son cohort counterparts. Suicidal adolescents pre- senting in crisis to the ER were able to be sent home safely with appropriate therapeutic supports. This puot study demonstrates that a single-visit model of crisis intervention for suicidal adoles- cents and their famiUes deUvered in the ER can sufficiently stabilize an adolescent and family system, regardless of cohesion and adaptabiUty levels, to enable a safe discharge home.

It is essential to begin to use a model of crisis intervention for suicidal adolescents and their families to provide reUef from their acute symp- toms with the least amount of family disruption. Empirical ê vidence has yet to document the supe- riority of inpatient care in effectively reducing rates of suicidal ideation, nonlethal attempts, or completed suicides among adolescents (Gould et al, 2003). FBCI benefits the adolescent and family and simultaneously alleviates an overbur- dened mental health system by limiting use of scant inpatient resources, keeping them available for those who truly need them. FBCI is a stan- dardized protocol that could be used by crisis

WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 141

clinicians across contexts to provide this kind of intervention, and it may be a cost-effective and advantageous alternative to inpatient hospitaliza- tion for both patients and providers.

REFERENCES American College of Emergency Phyäcians. (2008).

ACEP Psychiatric and Substance Aiiuse Survey 2008. Retrieved firom http://www.acep.org/uploadedFiles/ ACEP/Advocacy/federal_issues/PsychiatricBoarding Summary.pdf

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washing- ton, DC: Author.

Breslow, R. E., Erickson, B. J., & Cavanaugh, K. C. (2000). The psychiatric emergency service: Where we've heen and where we're going. Psychiatric Quar- terly, 71, 101-121.

Brooker, C , Ricketts, T , Bennett, S., & Lemme, F. (2007). Admission decisions following contact with an emergency mental health assessment and interven- tion service. joHma/ of Clinical Nursing, 6, 1313-1322.

Bruffaerts, R., Sabbe, M., & Demytteaaere, K. (2004). At- tenders of a university hospital psychiatric emergency service in Belgium—General chaacteristics and gender differences. Social Psychiatry and Psychiatric Epi- demiology, 39, 146-153.

Bruffaerts, R., Sabbe, M., & DemytteBaere, K. (2008). Emergency psychiatry in the 21s! century: Critical issues for the future. European Journal of Emergency Medicine, 15, 276-278.

Centers for Disease Control and Prevention. (1998, August 14). Youth risk behavior surveillixice—United States, 1997. Morbidity and Mortality WeMy Report, 43(SS-3), 1-18.

Centers for Disease Control and Prevention. (2007a, Sep- tember 7). Suicide trends among youths and young adults aged 10-24 years—United States, 1990-2004. Morbidity and Mortality Weekly Report, 56, 905-908.

Centers for Disease Control and Prevention. (2007b). Web-based injury statistics query and reporting system. Atlanta, GA: U.S. Deparanent of Health and Human Services.

Centers for Disease Control and Prevention. (2008, June 6). Youth risk behavior surveillance—United States, 2007. Morbidity and Mortality Weekly Report, 57(SS04), 1-131.

Darwish, A., Salmon, G., Ahuja, A., &: Steed, L. (2006). The community intensive therapy team: Develop- ment and philosophy of a new service. Clinical Child Psychology and Psychiatry, 11, 591-605.

ElHson, J. M., Hughes, D. H., & White, K. A. (1989). An emergency psychiatry update. Hospital & Community Psychiatry, 40, 250-260.

Gould, M. S., Greenberg, T., Velting,D. M., & Shaffer, D. (2003). Youth suicide risk and preventive inter- ventions: A review of the past 10 years. Jowma/ of the American Academy of Child and Adolescent Psychiatry, 42, 386-405.

Greenfield, B., Larson, C , Hechtman,. L., Rousseau, C , & Platt, R. (2002). A rapid-response outpatient model for reducing hospitalization rates imong suicidal ado- lescents. Psychiatric Services, 53, 1574-1579.

Hellzen, O., & Lilja, L. (2008). Former patients' experi- ences of psychiatric care: A qualitative investigation. International Journal of Mental Health Nursing, 17, 279-286.

Henggeler, S. W., & Borduin, C. M. (1990). Family therapy and beyond: A multisystemic approach to treating the behavior problems of children and adolescents. Pacific Grove, CA: Brooks/Cole.

Henggeler, S. W., Rowland, M. D., Halliday-Boykins, C , Sheidow, A. J., Ward, D. M., Randall, J., et al. (2003). One-year follow-up of multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis. _/oHma/ of the American Academy of Child and Adolescent Psychiatry, 42, 543-551.

Henggeler, S. W., Rowland, M. D., Pickrel, S. G., Miller, S. L., Cunningham, P. B., Santos, A. B., et al. (1997). Investigating family-based alternatives to institution- based mental health services for youth: Lessons learned fi:om the pilot study of a randomized field trial. Jowma/ of Clinical Child Psychology, 26, 226-233.

Henggeler, S. W., Rowland, M. D., Randall, J., Ward, D. M., Pickrel, S. G., Cunningham, P. B., et al. (1999). Home-based multisystemic therapy as an al- ternative to the hospitalization of youths in psychiatric crisis: Chnical outcomes. JoMma/ of the American Academy of Child and Adolescent Psychiatry, 38, 1331-1339.

Holmberg, D. (2007, June 10). The patients in the hall- ways. New York Times. Retrieved from http://w^vw. nytimes.com/2007/06/10/nyregion/nyregion special2/10Rhospitals.html

Huey, S. J. Jr., Henggeler, S. W., Rowland, M. D., Halhday-Boykins, C. A., Cunningham, P. B., Pickrel, S. G., et al. (2004). Multisystemic therapy effects on attempted suicide by youths presenting psy- chiatric emergencies. Jouma/ of the American Academy of Child and Adolescent Psychiatry, 43, 183-190.

Hughes, D. H. (1993). Trends and treatment models in emergency psychiatry. Hospital & Community Psychia- try, 44, 927-928.

Katz, A. (2006, April 16). Patients wait for hours in hall- ways: Strain felt throughout state. New Haven Register, pp. 15-17.

Kazdin, A., Rogers, A., & Colbus, D. (1986). The Hope- lessness Scale for Children: Psychometric characteris- tics and concurrent validity. Journal of Consulting and Clinical Psychology, 51, 241-245.

Kovacs, M. (1982). Children's Depression Inventory (CDI) short form. Toronto: Multi-Health Systems Inc.

Kovacs, M. (1992). Children's Depression Inventory (CDI) short form. Toronto, Canada: Multi-Health Systems Inc.

Kowalczyk, L. (2007, February 3, 2005). Romney's Med- icaid cuts hit hard, hospitals say. Boston Globe, pp. Al, C5.

Lamb, C. E. (2009). Alternatives to admission for children and adolescents: Providing intensive mental health- care services at home and in communities: What works? Current Opinion in Psychiatry, 22, 345-350.

Larkin, G. L., Claassen, C. A., Emond, j . A., Pelletier, A. J., & Camargo, C. A. (2005). Trends in U.S. emer- gency department visits for mental health conditions, 1992 to 2001. Psychiatric Services, 56, 671-677.

Madsen, W. C. (1999). Collaborative therapy with multi- stressed families: From old problems to new futures. New York: Guilford Press.

Mansbach,J. M., Wharff, E., Austin, S. B., Ginnis, K., & Woods, E. R. (2003). Which psychiatric patients board on the medical service? Pediatrics, 11 í(6, Pt. 1), e693-e698.

Office of Disease Prevention and Health Promotion. (2000). Healthy People 2010. Rockville, MD: U.S. department of Health and Human Services.

Olson, D. H., McCubbin, H. I., Bames, H. L., Larsen, A. S., Muxen, J. J., & Wilson, M. A. (1983). Families:

142 Sociat Work VOLUME 57, NUMBER 2 APRIL 2012

What makes them work. Beverly Hills, CA: Sage Publications.

Olson, D. H., Portner, J., & Lavee, Y. (1982). Family Adaptability and Cohesion Evaluation Scales II. St. Paul: University of Minnesota.

Page, D. (2000). Pédiatrie psychiatry: More blues in ED? Hospital & Health Networks, 74(8), 24.

Parad, H. J. (1965). Crisis intervention: Selected readings. New York: Fatnily Service Association of America.

Rotberam-Borus, M. J., Piacentini, J., Canrwell, C , Belin, T. R., & Song, J. (2000). Tbe 18-month impact of an emergency room intervention for adolescent female suicide attempters. Jowma/ of Consulting and Clinical Psychology, 68, 1081-1093.

Rotberam-Borus, M. J., Piacentini, J., Van Rossem, R., Graae, E, Cantwell, C , Castro-Bianco, D., et al. (1996). Enbancing treatment adberence witb a spe- cialized emergency room program for adolescent suicide attempters. Joumu/ ofthe American Academy of Child and Adolescent Psychiatry, 35, 654-663.

Scboenwald, S. K., Ward, D. M., Henggeler, S. W., & Rowland, M. D. (2000). Multisystemic tberapy versus bospitalization for crisis stabilization of youtb: Place- ment outcomes 4 montbs postreferral. Mental Health Services Research, 2, 3—12.

Sbepperd, S., Doll, H., Gowers, S., James, A., Fazel, M., Fitzpatrick, R., et al. (2009, April 15). Alternatives to inpatient mental bealtb care for children and young people. Cochrane Database of Systematic Reviews(2), CD006410. doi: 10.1002/14651858.CD006410. pub2

Sills, M. R., & Bland, S. D. (2002). Summary statistics for pédiatrie psychiatric visits to US emergency depart- ments, 1993-1999. Pediatrics, 110, pe40.

Spirito, A., Williams, C. A., Stark, L. J., & Hart, K.J. (1988). Tbe Hopelessness Scale for Cbildren: Psycho- metric properties witb normal and emotionally dis- turbed adolescents. Jouma/ of Abnormal Child Psychology, 16, 445-458.

Spooren, D., Van Heeringen, C , &Jannes, C. (1998). Strategies to increase compliance witb out-patient af- tercare among patients referred to a psycbiatric emer- gency department: A multi-centre controlled intervention study. Psychological Medicine, 28, 949-956.

Stanley, B., Brown, G., Brent, D., Wells, K., Poling, K., Curry, J., et al. (2009). Cognitive-bebavioral tberapy for suicide prevention (CBT-SP): Treatment model, feasibility, and acceptability. Jouma/ ofthe American Academy of Child and Adolescent Psychiatry, 48, 1005-1013.

Stewart, C , Spicer, M., & Babl, F. E. (2006). Caring for adolescents witb mental health problems: Cballenges in tbe emergency department. Jouma/ of Paediatrics and Child Health, 42, 726-730.

Trafford, A. (2000, June 27). Boarder kids, on tbe edge. Washington Post, pp. 5—6.

Elizabeth A. Wharff, PhD, MSW, is director, Katherine M. Ginnis, MSW, MPH, is associate director, and Abigail Ross, MSW, MPH, is a research social worker, Emergency Psychiatry Service, Department of Psychiatry, Boston Children's Hospital. Funding for this pilot study was provided by the George Harrington Trust. The authors are grateful to the adolescents and their families who participated in the study and to the ER social workers who piloted family- based crisis intervention (FBCI) with them, including Ariel Botta, Elizabeth Colton Notine, Christina Feith, Lara Kay,

Mary Kate Little, and Katie Naftzger. The authors also thank David DeMaso, chief of psychiatry, and the ER nursing and physician staff at Boston Children's Hospital for their support during the FBCI study period. Address corre- spondence to Elizabeth A. Wharff, Department of Psychiatry, Boston Children's Hospital, Fegan 8, 300 Longwood Avenue, Boston, MA 02115; e-mail: elizabeth.wharf@childrens. harvard.edu.

Original manuscript received Aprii 12, 2010 Final revision received August 27, 2010 Accepted September 1, 2010

PRACTICE UPDATES

Are you involved in a program, research project, practice innovation, or other

effort that may interest readers? Send your article (six double-spaced pages or fewer) as a Word document through the online portal at http://swj.msubmit.net (initial, one-time registration is required).

WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the FR 143

Copyright of Social Work is the property of National Association of Social Workers and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.