Correlates of Menarcheal Age in a Psychiatric Sample of Adolescents.

ABSTRACT: Early pubertal timing is associated with more adverse childhood experiences (ACEs) and increased risk for psychopathology during adolescence. However, most work to date has used community or epidemiological samples, and it remains unclear whether these associations persist in acute clinical samples. The present study examined associations between age at menarche and ACEs, psychiatric symptoms, and emotion regulation difficulties in a sample of N = 140 adolescents on a psychiatric inpatient unit. Youth with early menarche reported higher levels of depressive symptoms, more severe suicidal ideation, and greater difficulty with emotion regulation than youth with normative age at menarche. There was a marginal effect of youth with early menarche reporting more ACEs and more anxiety symptoms. These results suggest menarcheal age, and ACEs may be useful risk factors to assess in inpatient settings to predict risk for more severe outcomes, and future research on pubertal timing in high acuity settings is warranted.

Investigating Substance Use as a Coping Strategy Among Adolescent Psychiatric Inpatients: A Comparative Analysis Before and During the COVID-19 Pandemic.

The COVID-19 pandemic resulted in significant changes in daily life, potentially impacting mental health and substance use behavior. Research on COVID-related changes in adolescent substance use have yielded mixed findings. The current cross-sectional chart review study compared rates of past-year substance use before and during COVID-19 among adolescent psychiatric inpatients, and investigated how motives for coping with COVID-19 changes were related to psychiatric acuity, and past-year substance use. Count models assessed if the number of past-year days of alcohol and cannabis use was higher among adolescents (n = 491, 11-18 years, 61% female) hospitalized during COVID-19 (3/14/20 to 4/5/21) versus adolescents hospitalized before COVID-19 (8/30/2019 to 3/13/20). For a subsample of COVID-19 inpatients (n = 124; 75% female), we evaluated psychiatric correlates of endorsing substances to cope with COVID-19 changes/rules. Results indicated adolescents admitted during COVID-19 reported significantly more past-year alcohol and cannabis use days than adolescents admitted before COVID-19. Adolescents endorsed using alcohol (19%), cannabis (33%), and e-cigarettes/vaping (25%) to cope with COVID-19. E-cigarette/vaping to cope with COVID-19 was significantly related to lifetime suicide attempt. Endorsing alcohol or cannabis to cope with COVID-19 was associated with a significantly greater number of past-year use days for each respective substance. Adolescent psychiatric inpatients admitted during COVID-19 reported more substance use days than adolescents admitted before COVID-19. Using substances to cope was linked to psychiatric correlates (e.g., suicidality). Assessing the presence and function of substance use in this population may be important to identify, treat, and prevent compounding negative outcomes during times of community stress.

Sleep disturbance and suicidality in psychiatrically hospitalized adolescents: The role of specific emotion regulation domains.

BACKGROUND: Sleep disturbance is associated with broadband measurements of emotion regulation (ER). The linkage between ER, a multidimensional process, and suicidal ideation and suicide attempt is also documented in theoretical and empirical work. Recent research indicates that distinct profiles of ER are associated with psychiatric outcomes, including adolescent suicidal ideation and attempt. The present study examined whether specific domains of ER would explain the association between sleep disturbance, and ideation and attempt among psychiatrically hospitalized adolescents. METHOD: The sample included 284 adolescents who completed self-report measures on sleep disturbance, ER, suicidal ideation, suicide attempt, and psychiatric symptoms upon inpatient hospitalization. RESULTS: Findings indicated that sleep disturbance was associated with suicidal ideation. Further, a single ER domain (perceived limited access to ER strategies) fully accounted for the significant association between sleep disturbance and suicidal ideation. A reported suicide attempt in the past week was correlated with the nonacceptance of emotional responses, perceived limited access to ER strategies, and emotional clarity, but was not associated with sleep disturbance. DISCUSSION: The current findings highlight the importance of examining narrowband ER and indicate the presence of differential associations between sleep disturbance, ER, and suicide-related outcomes. Findings further elucidate the possible role of impaired cognitive responses to emotional experiences in the co-occurrence of sleep disturbance and youth psychiatric outcomes.

Experiences of Child and Adolescent Psychiatric Patients Boarding in the Emergency Department from Staff Perspectives: Patient Journey Mapping.

Over the past decade, healthcare providers nationwide have contended with a growing boarding crisis as pediatric patients await psychiatric treatment in emergency departments (EDs). COVID-19 has exacerbated this urgent youth mental health crisis, driving EDs to act as crisis units. Journey mapping is a robust methodology with which to examine strengths and challenges in patient care workflows such as boarding and emergency psychiatric care. Psychiatric, emergency medicine, and hospitalist providers serving patients boarding at a northeastern children's hospital participated in semi-structured qualitative interviews. Investigators conducted directed content analysis with an inductive approach to identify facilitators, barriers, and persistent needs of boarding patients, which were summarized in a patient journey map. Findings were presented to participants for feedback and further refinement. Quantitative data showed a three-fold increase in the number of patients who boarded over the past three years and a 60% increase in the average time spent boarding in the ED. Emergent qualitative data indicated three stages in the boarding process: Initial Evaluation, Admitted to Board, and Discharge. Data highlighted positive and negative factors affecting patient safety, availability of beds in pediatric hospital and psychiatric inpatient settings, high patient-provider ratios that limited staffing support, and roadblocks in care coordination and disposition planning. Patient journey mapping provided insight into providers' experiences serving patients boarding for psychiatric reasons. Findings described bright points and pain points at each stage of the boarding process with implications for psychiatric care and systemic changes to reduce boarding volume and length of stay.

Non-suicidal Self-Injury, Suicidal Behaviors, and Mental Health Symptoms among Sexual Minority Youth with Juvenile Justice System Involvement.

Sexual minority youth have long remained an understudied population within the juvenile justice system, despite emerging evidence suggesting that sexual minority youth are overrepresented. Recent literature indicates that system-involved sexual minority youth may have more behavioral health concerns than their heterosexual counterparts. Even so, more work is needed to elucidate the unique needs of sexual minority youth who become involved in the system, especially as it pertains to suicidal behaviors and non-suicidal self-injury (NSSI). The present study provided a descriptive evaluation of the prevalence of sexual minority youth making early system contact and their mental health concerns. Of the 218 justice-involved youth from a Northeastern family court in the sample, over a quarter identified as a sexual minority (n = 58). Our findings indicated that these youth evidenced significantly higher scores on a mental health screener compared to their heterosexual counterparts, evidencing greater symptomology on scales indicative of depression/anxiety, thought disturbance, etc. Further, sexual minority youth reported higher rates of lifetime, past year, and past month NSSI as well as lifetime and past year suicide attempts. These findings highlight the need to support the well-being of sexual minority youth in the juvenile justice system by screening for and addressing their mental health needs in this unique setting.

COVID-19-Specific Suicidal Thoughts and Behaviors in Psychiatrically Hospitalized Adolescents.

This study examined the presence and correlates of COVID-specific suicidal thoughts and behaviors (i.e., thoughts of or engaging in intentional COVID-19 exposure with associated suicidal intent) among psychiatrically hospitalized adolescents. Adolescents (N = 143) completed study measures as part of the standard intake process between March 13th and August 14th, 2020. Participants answered questionnaires assessing COVID-specific passive and active suicidal ideation (SI) and suicidal behavior, as well as COVID-related stressors and emotions, and public health guidance compliance. Findings highlights that COVID-specific SI is common in high-risk youth. COVID-specific SI was associated with COVID-19-related negative emotions, elevated stress, and decreased public health guidance compliance. Results suggest that COVID-specific suicidal thoughts and behaviors, and risk correlates, should be assessed within high-risk populations to facilitate prevention of risky behavior associated with intentional COVID-19 exposure.

Adolescent depressed mood and difficulties with emotion regulation: Concurrent trajectories of change.

INTRODUCTION: Adolescent depression is a significant mental health concern. Emotion regulation difficulties have been associated with subsequent depressive symptoms, though different facets of emotion regulation are rarely compared. This study examined the degree to which trajectories of change in different facets of emotion regulation (goal-directed behavior, impulse control, and regulation strategies) and depressive symptoms were associated across twelve months in a clinical adolescent sample. METHODS: Participants included 110 adolescents from the US who were enrolled in a randomized trial that tested a cognitive-behavioral treatment for youth with co-occurring mental health and substance use concerns (Mage = 15.71 years; 57.3% male). Assessments were conducted at baseline, 3-, 6-, and 12-month follow-ups. Three separate bivariate latent basis growth curve analyses were conducted. Correlations between latent intercepts and latent slopes, as well as overall model fit, were examined. RESULTS: Impulse control and goal-directed behavior were each associated with depressive symptoms at baseline. Additionally, change in impulse control over time was significantly associated with change in depressive symptoms. However, the same was not true for goal-directed behavior. Overall fit indices for models of emotion regulation strategies were below acceptable levels and thus could not be interpreted. CONCLUSIONS: Findings from the present study indicate that adolescents' depressive symptoms appear to improve as their perceived ability to control impulses improves. These results suggest that addressing impulse control difficulties may be an important step in treating adolescent depression and co-occurring disorders.

Parent-adolescent relationship characteristics and adolescent cannabis use: A growth curve analysis.

Background: Adolescent cannabis misuse may be associated with serious academic, conduct, and health problems. Identifying factors associated with adolescent cannabis misuse over time may provide insight to address these factors in interventions. Parent-adolescent relationship characteristics (i.e., attachment, discipline) have been linked to adolescent cannabis misuse and may be important factors to study. Objectives: We investigated time-varying associations between parent-adolescent relationship domains and weekly adolescent-reported cannabis misuse. We hypothesized that during times when parents reported less positive aspects of their relationship with their adolescents, adolescents would report higher levels of cannabis misuse. Methods: Data were drawn from a community clinic treatment study for adolescents with substance use and co-occurring psychiatric disorders (n=110; average age=15.71; 57.3% male). Latent growth modeling with time-varying predictors (parent-adolescent relationship characteristics) was used to examine if the associations between adolescent cannabis misuse and relational frustration, discipline, and attachment varied across the study period (baseline, 3-, 6-, and 12-months). Results: Weekly cannabis misuse significantly increased over time, even after accounting for parental relationship characteristics. When parents rated higher levels of relational frustration relative to their average level of frustration, adolescents reported higher cannabis misuse at all study periods except 12-month follow-up. Conclusion: Results support the importance of considering how specific aspects of the parentadolescent relationship, in this case elevated parental frustration, are associated with adolescent cannabis misuse during treatment and after its completion. Findings suggest parental relationship frustration is a key factor to assess and address within individually tailored interventions for co-occurring cannabis misuse and psychiatric disorders.

Family-focused cognitive behavioral treatment for depressed adolescents in suicidal crisis with co-occurring risk factors: a randomized trial.

BACKGROUND: Suicide is the second leading cause of death among adolescents. The purpose of this study was to test a family-focused outpatient cognitive behavioral treatment (F-CBT) protocol for depressed adolescents following psychiatric hospitalization for a suicide attempt or suicidal ideation, and who had a co-occurring risk factor (suicidal behavior prior to the index admission, nonsuicidal self-injury, and/or a substance use disorder), in a randomized Phase 2 efficacy trial. METHOD: One hundred forty-seven adolescents (mean age = 14.91 years; 76.2% female, 85.5% White) and their families, recruited primarily from an inpatient psychiatric hospitalization program, were randomly assigned to F-CBT or enhanced treatment-as-usual (E-TAU). A suicide attempt was the primary outcome variable. Depression, suicidal ideation, and nonsuicidal self-injury are also reported here. Assessments were completed at pretreatment as well as 6, 12, and 18-months postrandomization (Trial Registration ClinicalTrials.gov Identifier: NCT01732601). RESULTS: In the sample as a whole, rates of attempts decreased from 20% at 6 months to 9% at 12 months to 7% at 18 months. There was no evidence of a significant difference between treatment arms in rates of suicide attempts, major depressive disorder, suicidal ideation, or nonsuicidal self-injury at any of the postrandomization assessment points. CONCLUSIONS: Though F-CBT was associated with reductions in suicidality, depression, and nonsuicidal self-injury, E-TAU showed an equally strong effect. Greater frequency of F-CBT treatment sessions, particularly at the start of care, and alternative approaches to transitioning to care at 12 months, may be necessary when using F-CBT with this population.

Cognitive-Behavioral Therapy Plus Healthy Lifestyle Enhancement for Depressed, Overweight/Obese Adolescents: Results of a Pilot Trial.

The objective of this article was to conduct a treatment development study to examine the feasibility, acceptability, and preliminary efficacy of treating depressed, overweight/obese adolescents using both an exercise regimen and a Cognitive Behavioral Therapy (CBT) protocol modified to address aspects of healthy living and nutrition (CBT plus healthy lifestyle; CBT-HL). A randomized controlled repeated measures design was used to test the hypothesis that CBT-HL would lead to greater reductions in depressed mood and weight compared to CBT for Depression Only (CBT). Participants (n=33; 24 in CBT-HL condition) included 33 adolescents (median age 15, 73% female, 61% white, 36% Hispanic) who met DSM-IV criteria for Current Major Depressive Episode (MDE) and had BMI ≥ 85th percentile. CBT-HL was found to be feasible to implement with most adolescents. Both conditions resulted in improvement in depressed mood. The CBT-HL protocol was more effective in stabilizing weight status as assessed by BMI. Percent time spent in MVPA was increased at 12 weeks for adolescents in CBT-HL compared to those in CBT. The CBT-HL protocol was acceptable to most, but not all, adolescents, and resulted in an improvement in depressed mood as well as stabilization of weight status. A larger study to test efficacy and moderators of treatment outcome is necessary to better understand which adolescents would benefit most from the increased demands of exercise and adhering to nutrition recommendations in addition to standard CBT for depression. Revisions to the treatment protocol to support weight loss, not just stabilization, are also suggested.

Interactive Effect of Parent and Adolescent Psychiatric Symptoms on Substance Use among Adolescents in Community Treatment.

Both adolescent and parent psychiatric symptoms are well-established risk factors for adolescent substance use (SU), but the ways that these symptoms interact are not well understood. This study examined the interactive effects of parent and adolescent psychiatric symptoms on adolescent frequency of alcohol and marijuana use, over and above the effects of parental SU. Seventy adolescents presenting to a community mental health center (CMHC) participated. Parent and adolescent psychiatric symptoms were measured with the brief symptom inventory (BSI) and child behavior checklist (CBCL), respectively. Hierarchical regressions revealed different patterns for adolescent alcohol and marijuana use. For alcohol, the BSI parent phobic anxiety subscale predicted increased adolescent use while the parent interpersonal sensitivity subscale predicted decreased use: the effects of these parental symptoms were strongest among adolescents with higher levels of externalizing problems on the CBCL. For marijuana, the BSI parent psychoticism subscale predicted increased adolescent use, whereas paranoid ideation predicted decreased use. Results suggest that adolescent SU treatment and assessment should attend to both adolescent and parent psychiatric symptoms.

Concurrent Treatment of Depression in Parents and Adolescents: A Case Example.

The detrimental influence of parent psychopathology-and depression, in particular-on adolescent mental health has been well documented. Routes of transmission include both direct and indirect factors, such as poor parent-adolescent communication, ineffective parenting practices, modeling ineffective coping skills, increased family discord and stress, inadvertent reinforcement of adolescent depressed mood and suicidal ideation and behavior, and decreased treatment adherence. This paper introduces a novel treatment to concurrently treat both a depressed adolescent as well as a depressed parent. This approach improves upon traditional cognitive-behavioral therapy by targeting relational factors of each adolescent-parent dyad while simultaneously addressing each individual's depression. Principles of case conceptualization and treatment planning using this novel approach are illustrated using a case example.

Parent Management Training and Collaborative & Proactive Solutions: A Randomized Control Trial for Oppositional Youth.

This study examined the efficacy of Collaborative & Proactive Solutions (CPS) in treating oppositional defiant disorder (ODD) in youth by comparing this novel treatment to Parent Management Training (PMT), a well-established treatment, and a waitlist control (WLC) group. One hundred thirty-four youth (ages 7-14, 61.9% male, 83.6% White) who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for ODD were randomized to CPS, PMT, or WLC groups. ODD was assessed with semistructured diagnostic interviews, clinical global severity and improvement ratings, and parent report measures. Assessments were completed pretreatment, posttreatment, and at 6 months following treatment. Responder and remitter analyses were undertaken using intent-to-treat mixed-models analyses. Chronological age, gender, and socioeconomic status as well as the presence of comorbid attention deficit/hyperactivity and anxiety disorders were examined as predictors of treatment outcome. Both treatment conditions were superior to the WLC condition but did not differ from one another in either our responder or remitter analyses. Approximately 50% of youth in both active treatments were diagnosis free and were judged to be much or very much improved at posttreatment, compared to 0% in the waitlist condition. Younger age and presence of an anxiety disorder predicted better treatment outcomes for both PMT and CPS. Treatment gains were maintained at 6-month follow-up. CPS proved to be equivalent to PMT and can be considered an evidence-based, alternative treatment for youth with ODD and their families.

Negative cognitive style and perceived social support mediate the relationship between aggression and NSSI in hospitalized adolescents.

Despite the well-documented association between aggression and NSSI among adolescents, relatively little research has been conducted on the mechanisms underlying this relationship. The purpose of this study was to investigate potential socio-cognitive mechanisms through which aggression and NSSI are related. Participants were 186 adolescents (ages 13-18) recruited from a psychiatric inpatient facility in the northeastern United States. According to teen report, 57.5% of the sample endorsed NSSI in the previous year. Mediation was tested using the modern bootstrapping technique described by Hayes, using 5000 resamples with replacement, including sex and depression diagnosis as covariates. Results demonstrated that greater negative self-talk, a more negative cognitive style, and lower perceived family support were all significant mediators of the relationship between aggression and greater frequency of NSSI, whereas perceived social support from friends was not a significant mediator. Limitations, clinical implications, and future research directions of the current research are discussed.

Evaluation of Reliability Between Race and Ethnicity Data Obtained from Self-report Versus Electronic Health Record.

INTRODUCTION: Disparities based on perceived race and ethnicity exist in all fields of medicine. Accurate data collection is crucial to addressing these disparities, yet few studies have evaluated the validity of data gathered. This study compares self-reported race and ethnicity data, considered the gold standard, with data documented in the electronic health record (EHR), to assess the validity of that data. METHODS: Data from self-reported questionnaires was collected from adolescents admitted to a psychiatric inpatient unit from February 2019 to July 2022. Demographic questionnaires were self-administered as part of a larger battery completed during the admission process. Data was compared to demographic information collected from the hospital's EHR for the same patients and time. RESULTS: In a sample of 1191 patients (ages 11-18, 61.9% female, 89% response rate), substantial agreement was observed for Hispanic ethnicity (κ = 0.64), while agreement for specific racial groups ranged from slight to substantial (κ = 0.10-0.63). In addition, it was noted that there was discrepancy between multiracial identification, with 17.1% of patients identifying as more than one race in self-reported data compared to 3.1% in EHR data. CONCLUSIONS: The findings from this data set highlight the need for caution when using EHR data to draw conclusions about health disparities. It also suggests that the method of data collection meaningfully influences the responses patients provide. Addressing these challenges is essential for advancing equitable healthcare and mitigating disparities among patients.

Application of the Three-Step Ideation-to-Action Theory to Passive and Active Suicidal Ideation in College Students.

Background: Few studies have tested the three-step theory of suicide (3ST), particularly in college students, who have unique developmental experiences of connectedness and high rates of suicidal ideation (SI). This study tested if factors purported in the 3ST distinguish undergraduate students with no SI, passive SI, and active SI using two conceptualizations of connectedness: social connection and meaning in life. Methods: A sample of undergraduate students aged 18-26 from an urban university completed an online survey (n=265). Results: Results showed some support for the 3ST. Greater psychological pain increased likelihood of passive SI (OR=3.74, p<.001); the model accurately identified 36% of students with passive SI. Greater pain (OR=2.74, p=.01) and hopelessness (OR=17.17, p<.05) differentiated students with active SI from those without SI in social connection models. In meaning models, greater pain relative to meaning in life differentiated students with passive SI (OR=2.29, p<.01) and active SI (OR=1.81, p<.05) relative to no SI. Each model accurately identified 68% of students with active SI. No 3ST factors differentiated students with passive SI from those with active SI. Conclusions: There was limited applicability for 3ST in differentiating college students with passive SI from those with no SI or active SI, with better differentiation of students with active SI relative to no SI. Interventions for college students with passive and active SI could target psychological pain, foster hope, and cultivate meaning.

An examination of theory-based suicidal ideation risk factors in college students with multiple marginalized identities.

Social marginalization increases the risk of suicidal ideation (SI) among individuals with diverse identities, yet research examining the effects of marginalization has focused on one identity. Emerging adulthood is a critical period of identity development and the age group with the highest rates of SI. Considering the challenges of living in potentially heterosexist, cissexist, racist, and sizeist environments, we tested whether possessing multiple marginalized identities was associated with severity of SI through factors proposed in the interpersonal-psychological theory (IPT) and the three-step theory (3ST) of suicide and if mediation paths were moderated by sex. A sample of 265 college students completed a cross-sectional online survey assessing SI and constructs related to IPT and 3ST. The number of marginalized identities was generated by adding minoritized sexual orientation, race/ethnicity other than non-Hispanic White, body mass index >25 kg/m2, sexual attraction to same sex but identified as heterosexual, and gender-fluid identity. In IPT multiple mediation analyses, possessing more marginalized identities was associated with SI severity through burdensomeness and hopelessness, but not belonging. Indirect paths through burdensomeness and belonging were moderated by sex. For 3ST, possessing more marginalized identities was associated with SI severity through hopelessness and psychological pain, but not social connection or meaning in life. Future research should consider intersecting social identities and test mechanisms by which multiply marginalized college students develop resilience to SI risk factors, such as support within their marginalized groups, to inform suicide assessment and intervention efforts on college campuses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations of Restraint and Seclusion With Race and Ethnicity on an Adolescent Inpatient Psychiatry Service.

There is limited work examining the association of race and ethnicity with restraint and seclusion (R/S) in pediatric inpatient psychiatric units. The present study assessed risk of R/S by race and ethnicity based on a retrospective review of electronic medical records (EMRs) from an adolescent inpatient psychiatric service. Demographic, diagnostic, and R/S data were analyzed for all 1,865 admissions of 1,327 patients from an adolescent unit at a child and adolescent psychiatric hospital from June 2018 to June 2021. R/S occurred in 459 of the admissions. For the purpose of patient privacy and statistical analysis, race was grouped into the following: Black or African American, other (American Indian or Alaskan Native, Asian, multiracial, other), and White. Patients identified as unknown were not included in the analysis. A binary logistic regression with a repeated subject effect regressed R/S onto race and adjusted for age, gender, and length of stay (LOS). There was an overall significant association of R/S and race (χ22 = 16.81, p < .001), but not ethnicity. In a regression model adjusted for age, gender, and LOS, patients identified as Black or African American were at significantly higher risk of R/S compared with patients identified as White (odds ratio = 1.66, p = .036). There was no significant difference in risk of R/S between patients identified as White vs other. Younger age and longer LOS were also significantly associated with R/S. These findings highlight a critical health care disparity related to race on an inpatient adolescent psychiatry service. There is likely a combination of individual and systemic factors leading to discriminatory practices in the use of R/S. Future work will assess potential associations with diagnosis and child welfare involvement and will examine additional characteristics of R/S. Focus groups held with hospital and community stakeholders will guide next steps to address these findings.

Assessing feasibility and acceptability of yoga and group CBT for adolescents with depression: A pilot randomized clinical trial.

PURPOSE: Given increasing rates of depression in adolescents, there is a clear need for innovative treatments. In this pilot randomized clinical trial, we assessed acceptability and feasibility of two group-based interventions: yoga and cognitive-behavioral therapy (CBT). The goal of this work is to prepare for a future fully powered randomized trial to test the hypothesis that yoga is not inferior to an established adolescent depression treatment, namely, group CBT. METHODS: We enrolled 42 adolescents with elevated depression symptoms. Participants were randomly assigned to a 12-week group-based intervention, yoga or CBT. We had a priori feasibility and acceptability targets, including for recruitment rate, retention rate, expectancy, credibility, program satisfaction, class attendance, engagement in home practice, and instructor/leader manual adherence. We assessed adverse events, and within-subject changes in outcomes (depression, anxiety, impairment, sleep disturbance) and possible mediators (mindfulness, self-compassion). RESULTS: Both interventions met most acceptability and feasibility targets. The only target not met related to low engagement in home practice. Participants within each study arm showed decreased depression symptoms over time and increased self-compassion. CONCLUSIONS: A yoga intervention appears to be acceptable and feasible to adolescents with depression. However, it may be challenging for this group to engage in unstructured home practice.

Skills to Enhance Positivity in adolescents at risk for suicide: Protocol for a randomized controlled trial.

BACKGROUND: Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention. OBJECTIVE: To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life. METHODS: Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873). RESULTS: The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress. DISCUSSION: The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone.