24-Hour warning signs for adolescent suicide attempts.

BACKGROUND: Little is known about when youth may be at greatest risk for attempting suicide, which is critically important information for the parents, caregivers, and professionals who care for youth at risk. This study used adolescent and parent reports, and a case-crossover, within-subject design to identify 24-hour warning signs (WS) for suicide attempts. METHODS: Adolescents (N = 1094, ages 13 to 18) with one or more suicide risk factors were enrolled and invited to complete bi-weekly, 8-10 item text message surveys for 18 months. Adolescents who reported a suicide attempt (survey item) were invited to participate in an interview regarding their thoughts, feelings/emotions, and behaviors/events during the 24-hours prior to their attempt (case period) and a prior 24-hour period (control period). Their parents participated in an interview regarding the adolescents' behaviors/events during these same periods. Adolescent or adolescent and parent interviews were completed for 105 adolescents (81.9% female; 66.7% White, 19.0% Black, 14.3% other). RESULTS: Both parent and adolescent reports of suicidal communications and withdrawal from social and other activities differentiated case and control periods. Adolescent reports also identified feelings (self-hate, emotional pain, rush of feelings, lower levels of rage toward others), cognitions (suicidal rumination, perceived burdensomeness, anger/hostility), and serious conflict with parents as WS in multi-variable models. CONCLUSIONS: This study identified 24-hour WS in the domains of cognitions, feelings, and behaviors/events, providing an evidence base for the dissemination of information about signs of proximal risk for adolescent suicide attempts.

Lifetime non-fatal overdose experiences among at-risk adolescents and young adults in the emergency department with past-year opioid use in the USA.

BACKGROUND: Adolescents and young adults with risk factors for opioid misuse and opioid use disorder are at elevated risk for overdose. We examined prior non-fatal overdose experiences among at-risk adolescents/young adults to inform prevention efforts. METHODS: Adolescents/young adults (ages 16-30) in two US emergency departments self-reporting past year opioid misuse or opioid use plus a misuse risk factor completed a baseline survey as part of an ongoing randomised controlled trial. We describe baseline factors associated with (a) overall non-fatal overdose experiences and (b) groups based on substance(s) used during the worst overdose experience. RESULTS: Among 771 participants (27.9% male), 40.7% reported a non-fatal overdose experience. Compared with those without a prior overdose experience, those with prior overdose experience(s) were less likely to be heterosexual, and more likely to report a prior suicide attempt and greater peer substance misuse. Regarding the worst overdose experience, substance(s) included: 36.6% alcohol only, 28.0% alcohol and cannabis, 22.6% alcohol with other substance(s) and 12.7% other substance(s) only (eg, opioids). Compared with the alcohol only group, the alcohol and cannabis group were younger and less likely to be heterosexual; the alcohol with other substance(s) group were older and had greater peer substance misuse; and the other substance(s) only group were more likely to be male, receive public assistance, screen positive for anxiety and less likely to be heterosexual. CONCLUSIONS: Among at-risk adolescents/young adults, findings support the need for tailored overdose prevention efforts based on substance(s) used, with consideration of sexuality, mental health and peer substance use. TRIAL REGISTRATION NUMBER: NCT04550715.

A Prospective Examination of the Interpersonal-Psychological Theory of Suicidal Behavior in Adolescents.

OBJECTIVE: Given the large and complex array of suicide risk factors, theoretical frameworks are critical to furthering our understanding of risk. This study prospectively examined several key constructs of the interpersonal-psychological theory of suicidal behavior (IPTS) in a large, geographically diverse sample of U.S. adolescents. METHOD: Conducted in collaboration with the Pediatric Emergency Care Applied Research Network, adolescents, ages 12 to 17, were recruited from emergency departments. Baseline and 6-month follow-up samples were comprised of 6,448 (59% female sex) and 2,009 (64% female sex) adolescents, with self-identified race/ethnicity as follows (baseline/follow-up): White (52%/54%), Black (22%/23%), Multiracial (6%/6%), American Indian (3%/3%), other/unknown race (15%/14%), and Latinx (25%/23%). Youth and parents completed adolescent suicide risk surveys at baseline and 6-month follow-up (retention, 69%). Latent class analysis was used to identify classes of painful and provocative events (PPE), considered a precursor to acquired capability. RESULTS: In keeping with IPTS tenets, thwarted belongingness (TB), perceived burdensomeness (PB), and the interaction between TB and PB were each significant predictors of suicidal ideation at baseline and follow-up. However, only PB and PPE were significant predictors of cross-sectional suicide attempts and only TB and PPE were significant predictors of prospective suicide attempts in models that adjusted for baseline suicidal ideation. The three-way interaction among PB, TB and PPE was nonsignificant. CONCLUSIONS: Results from this large-scale prospective study suggest the importance of TB, PB, and PPE to our understanding of suicidal thoughts and suicide attempts among adolescents, pointing to promising prevention and intervention targets.

Firearm Safe Storage in Rural Families: Community Perspectives About Ownership and Safety Messaging.

Firearm-related injuries are the leading cause of death among youth in the United States, and rates of firearm-related suicide in rural youth are more than double those in urban youth. Although safe firearm storage has been shown to reduce firearm injuries, little is known about how to culturally tailor such interventions for rural families in the United States. Informed by community-based participatory methods, focus groups and key informant interviews were conducted to design a safe storage prevention strategy for rural families. Participants included a broad array of community stakeholders (n = 40; 60% male, 40% female; age 15-72, M = 36.9, SD = 18.9) who were asked to identify acceptable messengers, message content, and delivery mechanisms that were perceived as respectful to the strengths of rural culture. Independent coders analyzed qualitative data using an open coding technique. Emerging themes included (1) community norms, values, and beliefs about firearms; (2) reasons for ownership; (3) firearm safety; (4) storage practices; (5) barriers to safe storage; and (6) suggested intervention components. Firearms were described as a "way of life" and family tradition in rural areas. Owning firearms for hunting and protection influenced family storage decisions. Intervention strategies that use respected firearm experts as messengers, refer to locally derived data, and that reflect community pride in firearm safety and responsible ownership may improve the acceptability of prevention messages in rural areas.

Behavioral health services in Urban American Indian Health Programs: Results from six site visits.

This study explores behavioral health services for American Indians and Alaska Natives (AIANs) at six Urban Indian Health Programs (UIHPs). Interviews and focus groups with clinicians and staff inquired about behavioral health treatment available, service needs, client population, and financial and staffing challenges. Resulting site profiles were created based on focused coding and integrative memoing of site visit field notes and respondent transcripts. These six UIHPs evidenced diversity across multiple facets of service delivery even as they were united in their missions to provide accessible and effective behavioral health treatment to urban AIAN clients. Primary challenges to service provision included heterogenous client populations, low insurance coverage, limited provider knowledge, lack of resources, and incorporation of traditional healing. Collaborative research with UIHPs harbors the potential to recognize challenges, identify solutions, and share best practices across this crucial network of health care sites for improving urban AIAN well-being.

National trends in non-fatal suicidal behaviors among adults in the USA from 2009 to 2017.

BACKGROUND: The age-adjusted rate of suicide death in the USA has increased significantly since 2000 and little is known about national trends in non-fatal suicidal behaviors (ideation, plan, and attempt) among adults and their associated sociodemographic and clinical characteristics. This study examined trends in non-fatal suicidal behaviors among adults in the USA. METHODS: Data were obtained from adults 18-65 years of age who participated in the National Survey on Drug Use and Health (NSDUH), including mental health assessment, from 2009 to 2017 (n = 335 359). Examinations of data involved trend analysis methods with the use of logistic regressions and interaction terms. RESULTS: Suicidal ideation showed fluctuation from 2009 to 2017, whereas suicide plan and attempt showed significantly positive linear trends with the odds increasing by an average of 3% and 4%, respectively. Suicide plan increased the most for females and adults ages 18-34, and attempt increased the most for adults with drug dependence. Both plan and attempt increased the most among adults who either had mental illness but were not in treatment or had no mental illness. CONCLUSIONS: Given attempted suicide is the strongest known risk factor for suicide death, reducing non-fatal suicidal behaviors including attempt are important public health and clinical goals. The interactional findings of age, sex, mental health status, and drug dependence point toward the importance of tailoring prevention efforts to various sociodemographic and clinical factors.

Understanding adolescent responses to differently worded suicide attempt questions: results from a large US pediatric sample.

BACKGROUND: Clinical assessments are a primary method for ascertaining suicide risk, yet the language used across measures is inconsistent. The implications of these discrepancies for adolescent responding are unknown, which is troubling as multiple research areas (i.e. on culture, mental health language, and suicide communication) indicate individuals from varying sociodemographic backgrounds may communicate differently regarding mental health concerns. The aims of the current study are to investigate whether a geographically diverse sample of adolescents respond differently to directly and indirectly phrased suicide attempt questions (i.e. directly phrased includes the term 'suicide' and indirectly asks about suicidal behavior without using 'suicide'), and to examine whether sociodemographic factors and history of mental health service usage relate to endorsement differences. METHODS: Participants were N = 5909 adolescents drawn from the Emergency Department Screening for Teens at Risk for Suicide multi-site study. The lifetime suicide attempt was assessed with two items from an adapted version of the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008): (1) a directly phrased question asking about 'suicide attempts' and (2) an indirectly phrased question providing the definition of an attempt. RESULTS: An adolescent majority (83.7%) consistently reported no lifetime suicide attempt across items, 10.1% consistently reported one or more lifetime attempts across items, and 6.2% of adolescents responded discordantly to the items. CONCLUSIONS: Multivariable models indicated multiple demographic and mental health service variables significantly predicted discordant responding, with a notable finding being that father/stepfather education level at or below high school education predicted endorsing only the direct question.

Predicting the severity of peer victimization and bullying perpetration among youth with interpersonal problems: A 6-month prospective study.

INTRODUCTION: Peer victimization is prevalent and associated with adverse outcomes. In this prospective study of youth who self-reported interpersonal problems, we examined school connectedness, school behavioral difficulties, academic difficulties, and internalizing problems (social anxiety, self-esteem, depression) as predictors of peer victimization and bullying perpetration severity. We also examined the moderating effects of gender. METHODS: Participants were 218 youth (66.5% female), ages 12-15 years (M = 13.5, SD = 1.1), who screened positive for peer victimization, bullying perpetration, and/or low social connectedness using self-report measures. Youth were recruited from an emergency department in the United States as part of an intervention trial. Youth identified primarily as African American (53.7%) and Caucasian (31.7%). Youth completed a 6-month follow-up assessment (75% retention). Separate Bayesian regression models were used to examine the effects of baseline school connectedness, school behavioral difficulties, academic difficulties, and internalizing problems on the severity of 6-month peer victimization and bullying perpetration. RESULTS: Baseline depression was positively related to both peer victimization and bullying perpetration severity. Baseline behavioral problems were positively related to bullying perpetration severity. Interactions indicated that gender moderated the relationship between school connectedness and peer victimization. CONCLUSIONS: Given the adverse outcomes linked with peer victimization and bullying perpetration, an improved understanding of factors that predict victimization and perpetration severity may be helpful in defining intervention targets.

Adaptive intervention for prevention of adolescent suicidal behavior after hospitalization: a pilot sequential multiple assignment randomized trial.

BACKGROUND: The need for effective interventions for psychiatrically hospitalized adolescents who have varying levels of postdischarge suicide risk calls for personalized approaches, such as adaptive interventions (AIs). We conducted a nonrestricted pilot Sequential, Multiple Assignment, Randomized Trial (SMART) to guide the development of an AI targeting suicide risk after hospitalization. METHODS: Adolescent inpatients (N = 80; ages 13-17; 67.5% female) were randomized in Phase 1 to a Motivational Interview-Enhanced Safety Plan (MI-SP), delivered during hospitalization, alone or in combination with postdischarge text-based support (Texts). Two weeks after discharge, participants were re-randomized in Phase 2 to added telephone booster calls or to no calls. Mechanisms of change were assessed with daily diaries for four weeks and over a 1- and 3-month follow-up. This trial is registered with clinicaltrials.gov (identifier: NCT03838198). RESULTS: Procedures were feasible and acceptable. Mixed effects models indicate that adolescents randomized to MI-SP + Texts (Phase 1) and those randomized to booster calls (Phase 2) experienced significant improvement in daily-level mechanisms, including safety plan use, self-efficacy to refrain from suicidal action, and coping by support seeking. Those randomized to MI-SP + Texts also reported significantly higher coping self-efficacy at 1 and 3 months. Although exploratory, results were in the expected direction for MI-SP + Texts, versus MI-SP alone, in terms of lower risk of suicide attempts (Hazard ratio = 0.30; 95% CI = 0.06, 1.48) and suicidal behavior (Hazard ratio = 0.36; 95% CI = 0.10, 1.37) three months after discharge. Moreover, augmentation with booster calls did not have an overall meaningful impact on suicide attempts (Hazard ratio = 0.65; 95% CI = 0.17, 3.05) or suicidal behavior (Hazard ratio = 0.78; 95% CI = 0.23, 2.67); however, boosters benefited most those initially assigned to MI-SP + Texts. CONCLUSIONS: The current SMART was feasible and acceptable for the purpose of informing an AI for suicidal adolescents, warranting additional study. Findings also indicate that postdischarge text-based support offers a promising augmentation to safety planning delivered during hospitalization.

Saving Lives: Recognizing and Intervening with Youth at Risk for Suicide.

Suicide is the second leading cause of death for youth in the United States. Fortunately, substantial advances have been achieved in identifying and intervening with youth at risk. In this review, we first focus on advances in proactive suicide risk screening and psychoeducation aimed at improving the recognition of suicide risk. These strategies have the potential to improve our ability to recognize and triage youth at risk who may otherwise be missed. We then review recent research on interventions for youth at risk. We consider a broad range of psychotherapeutic interventions, including crisis interventions in emergency care settings. Though empirical support remains limited for interventions targeting suicide risk in youth, effective and promising approaches continue to be identified. We highlight evidence-based screening and intervention approaches as well as challenges in these areas and recommendations for further investigation.

LET's CONNECT Community Mentorship Program for Adolescents with Peer Social Problems: A Randomized Intervention Trial.

This study examined the effectiveness of LET's CONNECT (LC), a community mentorship program based on the positive youth development model. Participants were 218 youth (66.5% girls), ages 12 to 15, who reported peer victimization, bullying perpetration, and/or low social connectedness. These youth were randomized to LC or the control group (community resource information). The LC program linked youth to community mentors who connected with youth and facilitated their involvement in social growth activities across a 16-month period. Outcomes were assessed at 6 and 16 months with self-report measures of social and community connectedness, thwarted belongingness, depression, self-esteem, and suicidal ideation and behavior. In intent-to-treat analyses, LC was associated with modest positive effects for social connectedness, self-esteem, and depression. It had no effects on suicidal ideation or behavior. Results suggest that LC has the potential to positively impact the developmental trajectories of youth dealing with the interpersonal challenges of victimization, bullying perpetration, or low social connectedness. LC implementation challenges and directions for further research are also discussed.

Evidence-Based Interventions for Youth Suicide Risk.

PURPOSE OF REVIEW: To review and discuss recent advances in evidence-based interventions (EBIs) for youth suicide risk. RECENT FINDINGS: There is a growing body of research on the effectiveness of interventions targeting suicidal ideation and behavior among adolescents. Dialectical Behavioral Therapy-Adolescent has shown effectiveness across two independent randomized controlled trials (RCTs). Several other interventions have shown effectiveness in only one trial and are in need of replication. New interventions are also being developed that incorporate developments in technology and adaptive intervention designs. It is recommended that future research focus on strategies for engaging underserved youth with interventions, consider the broader needs of youth living in poverty, and further tailor interventions to subgroups with distinct risk profiles. Limited EBIs exist for preadolescents, despite evidence for an increasing rate of suicidal behavior for these youth. Several interventions for youth suicide risk are highly promising, but further investigation is necessary. EBIs that are effective for preadolescents are needed, and greater efforts to tailor interventions for distinct subgroups of youth at risk are recommended.

Telepsychotherapy with Youth at Clinical High Risk for Psychosis: Clinical Issues and Best Practices during the COVID-19 Pandemic.

Early detection and prevention of psychosis has become an international priority. Much of this work has focused on youth presenting with attenuated symptoms of psychosis-those at Clinical High Risk for psychosis (CHR)-given their elevated probability of developing the full disorder in subsequent years. Individuals at CHR may be prone to exacerbated psychological distress during the COVID-19 pandemic and its subsequent physical isolation measures, due to heightened stress sensitivity and comorbid mental health problems. Telepsychotherapy holds promise for reaching this population, especially during the current COVID-19 outbreak. However, there are limited evidence-based guidelines or interventions for use of telepsychotherapy with this population. In this paper, we review common clinical issues for individuals at CHR and how they might be exacerbated by the COVID-19 pandemic; best practices for treatment and adaptations for telepsychotherapy for individuals at CHR; and highlight real clinical issues that we are currently experiencing in a United States-based specialized CHR clinic as we conduct telepsychotherapy via videoconferencing. We conclude with questions for those in the field to contemplate, as well as potential challenges and benefits in using telepsychotherapy with individuals at CHR and their families.

Short-term change and prediction of suicidal ideation among adolescents: a daily diary study following psychiatric hospitalization.

BACKGROUND: Our understanding of suicidal ideation (SI) and its risk precursors is largely informed by studies spanning over wide time intervals (weeks, months, years). Little is known about SI as it occurs in daily lives of individuals at risk for suicide, the extent to which suicidal thoughts are dynamic over short periods of time, and the degree to which theoretically informed risk factors predict near-term SI. METHODS: Thirty-four adolescents hospitalized due to last-month suicide attempt and/or last-week SI (76% female; ages 13-17) responded to daily surveys sent to their cell phones for four consecutive weeks after discharge (n = 652 observations). RESULTS: There was notable variability in day-to-day SI, with half of ideation ratings changing at least one within-person standard deviation from one day to the next. Results of mixed effects models revealed concurrent (same-day), but not short-term prospective (next-day), associations between SI (frequency, duration, urge) and well-established predictors (connectedness, burdensomeness, hopelessness). However, synergistic effects of low connectedness with either high burdensomeness or high hopelessness were reliably associated with more severe same- and next-day suicidal ideation. CONCLUSIONS: This study adds to emerging literature indicating that suicidal thoughts fluctuate considerably among individuals at risk for suicide, further extending it by focusing on adolescents in the critical posthospitalization period. Fostering high-risk adolescents' sense of connectedness to others may be an especially promising intervention target. Frequent assessment of SI and its predictors, independently and in combination, could help identify promising predictors of short-term risk and meaningful intervention targets in high-risk teens.

Predicting 3-month risk for adolescent suicide attempts among pediatric emergency department patients.

BACKGROUND: The incidence of adolescent suicide is rising in the United States, yet we have limited information regarding short-term prediction of suicide attempts. Our aim was to identify predictors of suicide attempts within 3-months of an emergency department (ED) visit. METHODS: Adolescents, ages 12-17, seeking health care at 13 pediatric EDs (Pediatric Emergency Care Applied Research Network) and one Indian Health Service Hospital in the United States were consecutively recruited. Among 10,664 approached patients, 6,448 (60%) were enrolled and completed a suicide risk survey. A subset of participants (n = 2,897) was assigned to a 3-month telephone follow-up, and 2,104 participants completed this follow-up (73% retention). Our primary outcome was a suicide attempt between the ED visit and 3-month follow-up. RESULTS: One hundred four adolescents (4.9%) made a suicide attempt between enrollment and 3-month follow-up. A large number of baseline predictors of suicide attempt were identified in bivariate analyses. The final multivariable model for the full sample included the presence of suicidal ideation during the past week, lifetime severity of suicidal ideation, lifetime history of suicidal behavior, and school connectedness. For the subgroup of adolescents who did not report recent suicidal ideation at baseline, the final model included only lifetime severity of suicidal ideation and social connectedness. Among males, the final model included only lifetime severity of suicidal ideation and past week suicidal ideation. For females, the final model included past week suicidal ideation, lifetime severity of suicidal ideation, number of past-year nonsuicidal self-injury (NSSI) incidents, and social connectedness. CONCLUSIONS: Results indicate that the key risk factors for adolescent suicide attempts differ for subgroups of adolescents defined by sex and whether or not they report recent suicidal thoughts. Results also point to the importance of school and social connectedness as protective factors against suicide attempts.

Parental Self-Efficacy to Support Teens During a Suicidal Crisis and Future Adolescent Emergency Department Visits and Suicide Attempts.

This study of adolescents seeking emergency department (ED) services and their parents examined parents' self-efficacy beliefs to engage in suicide prevention activities, whether these beliefs varied based on teens' characteristics, and the extent to which they were associated with adolescents' suicide-related outcomes. Participants included 162 adolescents (57% female, 81.5% Caucasian), ages 13-17, and their parents. At index visit, parents rated their self-efficacy to engage in suicide prevention activities and their expectations regarding their teen's future suicide risk. Adolescents' ED visits for suicide-related concerns and suicide attempts were assessed 4 months later. Parents endorsed high self-efficacy to engage in most suicide prevention activities. At the same time, they endorsed considerable doubt in being able to keep their child safe if the teen has thoughts of suicide and in their child not attempting suicide in the future. Parents whose teens experienced follow-up suicide-related outcomes endorsed, at clinically meaningful effect sizes, lower self-efficacy for recognizing suicide warning signs, for obtaining the teen's commitment to refrain from suicide, and for encouraging their teen to cope, as well as lower confidence that their teen will not attempt suicide; self-efficacy to recognize warning signs was at trend level. Despite endorsing high self-efficacy for the majority of suicide prevention activities, parents of high-risk teens expressed less confidence in their capacity to influence their teen's suicidal behavior, which could undermine parents' effort to implement these strategies. The relationship between parental self-efficacy and youth suicide-related outcomes points to its potential value in guiding clinical decision making and interventions.

LET's CONNECT community mentorship program for youths with peer social problems: Preliminary findings from a randomized effectiveness trial.

This study examined the effectiveness of LET's CONNECT (LC), a community mentorship program for youths who report peer social problems, which is based on a positive youth development framework. Participants were 218 youths (66.5% girls), aged 12 to 15 years, who were recruited from an urban medical emergency department and screened positive for bullying victimization, bullying perpetration, and/or low social connectedness. Youths were randomized to LC (n = 106) or the control condition (n = 112). Six-month outcomes were assessed with self-report measures of youth social connectedness, community connectedness, thwarted belongingness, depression, self-esteem, and suicidal ideation. LC was associated with a significant increase in only one of these outcomes, social connectedness (effect size = 0.4). It was associated consistently with trend-level positive changes for thwarted belongingness (decreased), depression (decreased), community connectedness, and self-esteem (effect sizes = 0.2). There was no effect on suicidal ideation (effect size = 0.0), and although not a primary outcome, eight youths in the LC condition and seven youths in the control condition engaged in suicidal behavior between baseline and follow-up. Although LC effect sizes are consistent with those from previous studies of community mentorship, there were multiple challenges to LC implementation that affected dosage and intervention fidelity, and that may account for the lack of stronger positive effects.

Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk.

Suicide is the tenth leading cause of death in the United States, accounting for more than 42,000 deaths in 2014. Although this tragedy cuts across groups defined by age, gender, race/ethnicity, and geographic location, it is striking that nearly four times as many males as females die by suicide in the U.S. We describe the current regulations and recommendations for suicide risk screening in healthcare systems and also describe the aspirational goal of "Zero Suicide," put forth by the National Action Alliance for Suicide Prevention. We then provide information about suicide risk screening tools and steps to take when a patient screens positive for suicide risk. Given the substantially higher suicide rate among males than females, we argue that it is important to consider how we could optimize suicide risk screening strategies to identify males at risk and females at risk. Further research is needed to accomplish this goal. It is recommended that we consider multi-factorial suicide risk screens that incorporate risk factors known to be particularly important for males as well as computerized, adaptive screens that are tailored for the specific risk considerations of the individual patient, male or female. These strategies are not mutually exclusive. Finally, universal suicide risk screening in healthcare settings, especially primary care, specialty medical care, and emergency department settings, is recommended.

Connectedness to family, school, peers, and community in socially vulnerable adolescents.

Youth who feel connected to people and institutions in their communities may be buffered from other risk factors in their lives. As a result, increasing connectedness has been recommended as a prevention strategy. In this study, we examined connectedness among 224 youth (ages 12-15), recruited from an urban medical emergency department, who were at elevated risk due to bullying perpetration or victimization, or low social connectedness. Regression analyses examined multiple domains of connectedness (family, school, peer, community) in relation to adjustment. Youth who felt more connected to parents reported lower levels of depressive symptoms, suicidal ideation, non-suicidal self-injury, and conduct problems, higher self-esteem and more adaptive use of free time. Youth who felt more connected to their school reported lower levels of depressive symptoms, suicidal ideation, social anxiety, and sexual activity, as well as higher levels of self-esteem and more adaptive use of free time. Community connectedness was associated with less social anxiety but more sexual activity, and peer connectedness was not related to youth adjustment in this unique sample. Findings suggest that family and school connectedness may buffer youth on a trajectory of risk, and may therefore be important potential targets for early intervention services.

SELF-RATED EXPECTATIONS OF SUICIDAL BEHAVIOR PREDICT FUTURE SUICIDE ATTEMPTS AMONG ADOLESCENT AND YOUNG ADULT PSYCHIATRIC EMERGENCY PATIENTS.

BACKGROUND: This study's purpose was to examine the predictive validity and clinical utility of a brief measure assessing youths' own expectations of their future risk of suicidal behavior, administered in a psychiatric emergency (PE) department; and determine if youths' ratings improve upon a clinician-administered assessment of suicidal ideation severity. The outcome was suicide attempts up to 18 months later. METHODS: In this medical record review study, 340 consecutively presenting youths (ages 13-24) seeking PE services over a 7-month period were included. Subsequent PE visits and suicide attempts were retrospectively tracked for up to 18 months. The 3-item scale assessing patients' perception of their own suicidal behavior risk and the clinician-administered ideation severity scale were used routinely at the study site. RESULTS: Cox regression results showed that youths' expectations of suicidal behavior were independently associated with increased risk of suicide attempts, even after adjusting for key covariates. Results were not moderated by sex, suicide attempt history, or age. Receiver-operating characteristic (ROC) analyses indicated that self-assessed expectations of risk improved the predictive accuracy of the clinician-administered suicidal ideation measure. CONCLUSIONS: Youths' ratings indicative of lower confidence in maintaining safety uniquely predicted follow-up attempts and provided incremental validity over and above the clinician-administered assessment and improved its accuracy, suggesting their potential for augmenting suicide risk formulation. Assessing youths' own perceptions of suicide risk appears to be clinically useful, feasible to implement in PE settings, and, if replicated, promising for improving identification of youth at risk for suicidal behavior.