Multisystemic Therapy Effects on Attempted Suicide by Youths Presenting Psychiatric Emergencies STANLEY J. HUEY, JR, PH.D., SCOTT W. HENGGELER, P#.D., MELISA D. ROWLAND, M.D., COLLEEN A, HALLIDAY-BOYKINS, P.D., PHILLIPPE B. CUNNINGHAM, Px.D., SUSAN G. PICKREL, M.D. AND JAMES EDWARDS, M.D. ABSTRACT ‘Objective: To evaluate the efficacy of mulisystemie therapy (MST) in reducing attempted suicide among predominantly ‘African American youths referred for emergency psychiatric hospitalization. Method: Youths presenting psychiatric ‘emergencies were randomly assigned to MST or hospitalization Indies of attempted suicide, suicidal ideation, depres Sie alfect, and parental contol were assessed before teatment, at 4 months after recruitment, and at the 1-year posttreatment folow-up. Results: Basod on youth report, MST was signiicanty more effective than emergency hos Pitalizaion at decreasing rates of attempted sulcde at t-year follow-up; also, the rate of symptom reduction over time ‘was greater for youths rocolving MST. Also, treatment ciferences in pattems of change in attempted suicide (caregiver report) varied as a function of ethnicity, gender, and age. Moreover, treatment effects were found for caregiver-rated parental contol but not for youth depressive affect, hopelessness, or suicidal ideation, Conclusions: Results generally ‘support MST’ effectiveness at reducing attempted suicide in psychiatrically cisturbed youngsters, whereas the effects ‘of hospitalization varied based on informant and youth demographic characteristics, J. Am. Acad, Child Adolesc. Psyehiatry, 2004;49(2):188~190. Key Words: attempted suicide, mutsystemic therapy, hospitalization, treatment mod- Attempted suicide is a significant mental health prob- lem that affects nearly 9% of adolescents in the United States each year (Grunbaum et al., 2002). Although the vast majority of youth suicide attempts are nonlethal (King, 1997), attention to self-harm behavior is impor- tant for at least wo primary reasons. First, suicidal individuals place enormous demands on the mental Accipied September 29, 2003. Dr Hug i withthe Deparomone of Pychoogy ond Program in American Studies and Esc, Unive of Souther Calf; Dr angele, Re and Halliday-Boyins, Cunningham, and Edward are with the Family Se vices Rwarch Center, Department of Pychiatry and Behavioral Sciences ‘Medea! Univer of South Carolin: and Dr, Pike swith Mergy Medi! (Coner,Bebsvoral Health Uni, Recebrg, OR The racer reported in this article was supported by NIMH gran: [ROIMI51952 and ROIMH51852, end AHRQ grant PO! HSIO87. Specish ‘honk goto Sonja Schoenuald fr er comments on a eal dai of this manure CConpondnce to Dr Huey, Department of Pycholgy, Univer of South ere California, SCM 501, 3620 8. McClintock Avenue, Lor Angle, CA 90089-1061: emai: bey ud (0890-8567/04/4302-018302004 by the American Academy of Child and Adolescene Psyche. DO: 10.1097/01chi.0000101700.13857.13 J. AM. ACAD. CHILD ADOLESC health system in terms of staff resources and financial costs, particularly within inpatient hospital settings ers for Disease Control and Prevention, 2002). Second, an episode of attempted suicide poses a sig- nificant risk for persistent psychosocial problems (e.g., criminal behavior, druglalcohol problems, divorce) and future suicide completion (Brent et al., 1993b). Thus, interventions that reduce the frequency of attempted suicide could produce collateral benefits in terms of decreased suicide morbidity, increased quality of life, and mental health cost savings. Although significane advances have been made in understanding the precursors to youth suicidality (Wagner, 1997), litle is known about effective means for treating attempted suicide in youths. Whereas cog- nitive-behavioral and family-focused interventions show efficacy in ameliorating depressive symptoms (Rotheram-Borus et al. 2001), decreasing suicidal ide- ation (Rotheram-Borus et al., 1996, 2001), and creasing treatment satisfaction (Harrington et al., 1998) among suicidal adolescents, these approaches have not been more effective than control conditions in reducing the frequency of attempted suicide, PSYCHIATRY, 43:2, FEBRUARY 2004 183HUEY EF At. There ate several possible reasons why these treat- ment approaches have been of limited effectiveness. First, whereas a host of interpersonal (c.g. family con- flict, life stress) and intrapersonal (e.g., hopelessness, depression, poor problem-solving ability) factors are implicated as precursors co suicidal behavior (e.g. Lewinsohn et al, 1996), many extant interventions for suicidal youths focus on cognitive factors (Shaffer and Piacentini, 1994), and while involving other family members (e.g., Piacentini et al., 1995), they usually fail to address the larger set of factors in the youth’s social ecology suggested as contributors to suicidal behavior (4g. school problems, interpersonal conflict, caregiver ‘mental health problems). Second, many interventions are conducted in hospitals or mental health settings rather than in the nacural ecology (i.e, home or com: munity), thus creating substantial barriers to service access that may contribute to high rates of noncompli- ance and treatment nonattendance among suicidal youths (Spirito et al., 1992; Swedo, 1989). Finally, standard interventions for suicidal youths are typically brief by design (e.g,, most involve 10 or fewer concact hours) and may be of insufficient intensity and dura. tion to affect the long-term trajectory of attempted suicide (Brent et al, 1993a). Thus, there appears to be a considerable gap berween the complex needs of sui cidal youths and the comprehensiveness of existing ser- vives for treating diese youths. In light ofthis gap, the present scudy was designed to determine whether an intensive family- and commu nity-based treatment (multisystemic therapy [MST]) (Henggeler er al., 2002) could serve as a safe and ef- fective alternative to the inpatient hospitalization of youths presenting psychiatric emergencies. MST is an evidence-based treatment that has a strong track record in treating the complex needs of serious juvenile of- fenders (e.g., U.S. Public Health Service, 2001) and shows promise in the treatment of serious emotional disturbance (eg, Kazdin and Weise, 1998). Such promise is evidenced by the high fimily engagement and treatment completion rates demonstrated in MST programs (Henggeler et al, 1998); the ability of MST to modify risk factors (eg. substance usc, family dif- ficulties, bebavior problems, caregiver and youth psy- chiatric distress) across the youth and family’s social ecology (Henggeler et al., 2002); and the capacity of MST to deliver intensive services (lasting 3-5 months) due to the use of a home-based model of service deliv- exy by therapists with low caseloads. Thus, given the multiple needs of suicidal youths, MST was examined 184 JoaM a8 a viable alternative to acute hospitalization with af- cercare, ‘The present manuscripe is a critical part of the re~ search emanating from a randomized trial comparing MST with inpatient psychiatric hospitalization for youths presenting mental health emergencies. The ini- tial and follow-up evaluations focused on broad clinical (Henggeler et al., 1999, 2003) and service level (Schoenwald et al, 2000) outcomes. In light of the nature of the sample, this study focuses on outcomes pertaining to attempted suicide and symptoms closely associated with this life-chreatening problem. Based on data from youths and primary caregivers collected through 16 months after recruitment, «wo primary hy- potheses were considered with regard to the role of MST in reducing attempted suicides in youths. First, MST was hypothesized to be more effective than hos- pitalization ar decreasing attempted suicide and suicidal ideation, improving the youth’s affective state (.c., de- pressive affect, hopelessness), and improving parental functioning (ie., parental control). Second, given chat age and developmental status (Wichstrom, 2000), eth- nicity (Brent et al, 1988), and gender (Hollis, 1996; Spirito et al., 1991) have been found to interact with other precipitating factors to alter the risk of suicidal ideation and behavior, these factors were assessed as potential moderators influencing the effectiveness of MST on attempted suicide. METHOD Participants Parccipanes weie 156 youths who were approved for emergency paychiaric hospitalization ar che Medical Unversity of South Caro- Tina because of suicidal ideation/planning ot atempred suicide, homicidal ideation or behavior, psychosis, or other threat of harm to self or others. Youths were inchided if they were (1) aged 10 10 17, 2) Medicaid funded or without health insurance, and (3) re- siding in 2 noninsttuional environment such a8 the home of 3 family member or relative, foster home. oF shelter. Although youths ‘were excluded if they recived a diagnosis of autism, no additional caclusionary itera were wied based on osher precssting mental healt, physical healh, or inellecualdificulis ‘The youths were predominantly male (65%) and had an avenge age of 12.9 years (SD = 21). Sincy-five percen were Afi Ameri- can, 33% European American, and 19 other. At time of entry into the seudy, 3196 percent of the youths lived in «wo-parent house- holds chat included a least one biological ar adoptive parent, 519% lived in single-parent households thar included a east one bioogi- cal or adoptive parent, and 1896 fived with someone other than & biologleal or adoptive paren. Youths were pedominandy from low sociozconomic backgrounds, with 69% of families receiving Aid 0 Families wih Dependent Childeen, food stamps, Supplemental Se cirity Income, of some other form of government aid, and with 79% receiving Media. ACAD, CHILD ADOLESC. PSYCHIATRY, 43.2, FEBRUARY 2004Hospital refer for suicidal ideation, suicide planning, and at- tempted suicide ax preseatment was derived from hospital eds. sion intake records. Records were coded for the fllawing referral problems: (1) suicidal ideation, (2) suicide plan, (3) suide at- tempt, (4) homicidal ideation, (5) homicidal plan, (6) homicide acempt, (7) psychosis, and (8) other threat of harm 10 self or others. Based on these records, 5196 of the youths were classified a5 suicidal Guide ideation, pla, eratemp) at intake and 49% were clasified ar nonsvicidl Procedures: Families were recruited for inclusion a che hospital's emergency department or inpatient admision office and then randomly as- signed co either the MST or hospitalization condition (see Henggeler et al., 1999, for detils on recruitment and treatment assignment), Data fiom three evaluation periods ate included in this seudy: within 24 hours of acceptance into the project a the ‘completion of MST home-based services (an average of & months ier secruitmends and approximately 1 year Following tzeatment termination, with the yoked comparison case astsed atthe same time. Families were pad $50 for each completed assessment, Treatment Conditions Muligytemie Therapy. The MST clinical pots is specified in ‘manual designed forthe teatment of antisocial youths (Henggeler eta, 1998) and has been adapted for the weatment of psychiac cally disused youths (Henggeler etal, 2002). MST isa family. ‘centered, home-based ineerrention tha args the multiple systems in which the youth and family are embedded. MST adopts Bron- Fenbrenner’s (1979) socialcological model of human develop- _ment, which suggests tha problem behaviors are ofien maintained by problematic transactions within and across the multiple systems ofthe youth's social ecology. MST therapists intervene primarily 2¢ the family level, (1) empowering caregivers with the skills and sesoures they need to communicate with, monitor, and discipline ‘he children effectveys (2) assisting cateivers in engaging thei children in prosocal activites while disengaging the youth From deviant poets: and (3) addressing individual snd systemic bariers ro fective parenting, To achieve these ends, MST is delivered in the Family's natural environment (¢g, bore, school, community) by therapists wained in the use ofa variety of evidence-based inter ventions (eg, contingency contacting, communication training, ‘behavioral patent taining). MST is intensive (contact is daly when needed) yet timelimited (sernce! range from 3 to 6 months, re- auiting that therapist caseloads be iy low compared with tad ional services (caeloade of 4-6 families), In addition, MST therapists ate guided by a set of nine treatment prncipes chat offer general guidelines chat direc ease conceptuaization, treatment specification, and prioritisation of interventions, and ongoing qual iry assurance o support treatment fidelity is intensive (Henggeler et al, 2002), In accordance with the MST treatment principles adapted forthe sreitment of youths in poychatic criss, MST therapists adope a Ihandfl of core strategies £0 minimize the vsk ofsel-harmn among, Suicidal youths. These suategis include (1) development of asafery plan with the family requiring thar potentially lethal suicidal meth fod (eg. gun, lethal medications, knives, sheets) be secured ot liminated (2) containment and monitoring of youth by eteyvers, parcicularly when negative influences are perent in the community, (3) disengagement from deviant peers who may precipitate a su. ‘dal episodes and (4) helping responsible adults in the natural ‘cology provide monitoring and structure to diminish suicide rik (Henggeer eal, 2002). Paricular attention wat given to targeting the methods used by the youth in previous suicidal episodes. MST EFFECT ON ATTEMPTED SUICIDE Hospitalization. Youths asigned to the hospitalization condition were admitted 10 the Youth Division Inpatiene Peychateic Unit at the Medical Universgy of South Carolina. The primary goals were to provide acute stabltzation and peychiatic evaluation and esab- lish an aftercare plan, eypically with the local community mental brerlth center. Youths were served by 2 multiisiplinary team in- luding 2 child psyehiaes, child psychiatry resident, general psy chiatey tesident, social worker, special education teacher, and. ‘nursing staff. The urit has a behaviorally based miliew program witha point system that is individualized to each youth, targeting the behaviors chat precipitated admissicn. Fer youths with a mod- erate to high risk of suicidal behavior, hospital staff were instructed to implement additional procedures that maximized the youth's safety while on the unit (eg, checks by autsing staff every 15 minutes, mouth checks following administration of oral medica- ‘ions, prohibition of potenilly lethal ier such as belts and shoe- laces) After discharge, the team attempted f0 match the youth's needs with avilable mental health providers inthe community. Ik is important to note that 449 of MST youths were also ‘admitted for psychiatic hospitalization during the course of teat- ‘ment due to emergencies that could not be handled in community settings. To mainain treatment integrity, when an MST youth quired hospitalization, care was taken t Separate the youth fi the regular inpatient population (Henggeler etal, 1999). Rega less the MST condition included both those who did and did not receive psychiatric hospitalization during the treatment period. Moasures Parental Control. Patent contol was evaluated using youth and caregiver reports on the Family, Friends, and Self Scale (FES) (Gimpson and McBride, 1992}, 60-icem questionnaire designed co asst a youth's social relationships aod psychological adjustment Items are rated on a scale froma 0 Cnever" 0 4 (Palmas always) For thie study che contol subscale was used as an index of parenal control (eg, "Do your parents let you go anywhere you please swithour asking”). Alpha coefiients for caregiver (@ = 63) and youth (0 = 63) reports on the control subscale wete only modest for this sample; However, previous research suggest thatthe youth vetsion of this scale has good reliability and predictive validity ‘Simpson and MeBride, 1992). Depresive Affer. Measures of youth depressive affect were de- rived from three sources. Fist, youths completed the depression subscale of the Brie Symptom Inventory (BSI) (Derogatis, 1992), ‘which included six items indicating dysphoric mood and affect ove the past 7 days. Keme were rated on aseae from O ("noe at all”) t0 4 (Ceatremely”). Becase one item on tht sale wat indicative of Suicidal ehinkng, aad we were also creating an index of depression independent of suicidality, + strategy wsed by other investigators was Followed (eg, Brent etal, 1986) and this item was deleted frou the depression sale. Thus, the final sale incaded five items (eg. “How often have you experienced feelings of worthlessnes") with = 85, “The anieryldepression subscale ofthe Child Behavior Checklist (CBCL) (Achenbach, 1991) served asa second index of depresive affece, The CBCL requites caregivers to tae 118 child behavior problems on a scale fom 0 (not true”) 0 2 ("very often ewe") ovee the pase 6 months. Sample tems include "unhappy, sad, depressed” and "underactve.” The 14 items chat formed the anxiety depres fion scale showed good internal consistency (0 = 87). Hopelessnes, defined as negative expectations toward the futuee, constituted 3 final index of depression. According to cognitive mod «sof depression, hopelesness represents a core cognitive feature of| ‘depression in adule snd childeen (Kashani etal 1992). Hopeless- hese was measured by youth selreport on the I7-item Hopeless J. AM. ACAD, CHILD ADOLESC. PSYCHIATRY, 43:2, FEBRUARY 2004 185HUEY ET AL, ness Seale for Children (Kazdin etal, 1986), with cach item rated 1 tue oF flue forthe past 2 weeks. Sample items inched “AIL an sce ahead of me ae bad things not good things” and "I will hhave more good times than bad ines” The internal consistency of this sale was accepabe (0 = 79). ‘Shida deation The presence of sii idetion was evaluated ting items from youth selfceport on both the BSI (se above) and the Youth Ris Behavior Survey (YRBS) (Kolbe et i, 1993). From the BS, rwo items (How often did you have thoughts of ending your life” and “How often did you have thoughts of deuth oF dying") wete used ro construct the first index of suicidal ideation Swicidalideators were considered those who gave a positive rating for either ofthese tems (ie, provided ating between "T” and "#) From the YRES, the itn “Did you stouly consider attempt ing sicide during the pas 12 months?” was used a a second index of youth suicidal ideation. The YRBS is 53-item survey developed by the Centers for Disease Control and Prevention (CDC) co eval ste rsk bchatiors among school-based Youngsters across the United Scaes, The YRBS was used in 1991 with a national sample of 12.273 youths ro eb national prevalence rats for health rk be havior among sens in grades 9 though 12 (Breer ex al, 1995) Evidence suggests god test-retest reliability on this item among idles and high-school students (X = 0.76; Beene et al, 1995) “Auempied Suicide, Two independent sources were used to eva ae avempted suicide. First, single item epresenting the frequency cof sl hazm behavior fom the eategive’ perspective (Deliberate harms self of attempts suicide”) was selected from the CBCL, Responses ranged fem 0 (rot tue) to 2 (very tre oF often tee). A second index of atempred Suicide was single ter taken from youth self-report on the YRBS that represented the number of Cimes the youth astempred slide in the past 12 months (.. “How many cimes did you actualy atempr suicide”). Responses ranged from 0 (0 times") co 4 ("6 of more times). Because ofthe cxtemely skewed cesponse dstibution (ie, the vast majtity of respondents in both treatment conditions reported no suicide a- temp at postretment ad follow-up, the two avemped suicide variables were dichotomized into “yes” (indicating that suicidal behavior occured) or “no” Gindicating that suicidal behavior did Data Analysis, Mixed-ffecs groweh modeling was usod to examine the effects of teatment on indices of depresive affect and parental contol GBryk and Raudenbush, 1992), However, because the attempted suicide and suicidal ideation dependent variables were essentially binomial (.., youths were either suicidal or not suicida), sandard mixed-model assumptions (eg.. normality and homogeneity of variance) were volaed. Thus, forthe svicidality indies, generalized Tineat mined model analysis (GLM) was used (Liell eal, 1996). GLMs ae extensions of Fixed linac model to cates where standard Tinear-model sumptions ate vielated. For each analysis, we evaluated whether the two treatment con dion differed in terms of ther linae (Le, no change of dieection versus continuous symptom decline) or quadratic (curvilinear with 4 ingle change in diection versissympeom decline followed by maintenance of reatment gins effec. Subsequently, we evaluated ‘whether dhe youth's age, gene, a ethnicity movers hese fe RESULTS Outcomes Table 1 presents the percentage of youths who were suicide attempuers or ideators before treatment, alter treatment, and at the 1-year follow-up for both the MST and hospital conditions. Also included are means and standard deviations for continuous variables, as ‘well as significance tests for time and treatment effects Significant linear time effects were found for categiver- and youth-rated attempted suicide, youth-rated sui- cidal ideation, caregiver-rated anxious/depressed, youth-rated depressive affect, and youth-rated hope- lessness, suggesting that MST and hospitalization were both associated with decreased sympromatology over time. Significant linear and quadratic ceatment effects were found for youth-rated attempted suicide. These results indicate that MST was significantly more effec- tive than psychiatric hospitalization at reducing at- tempted suicide over the course of 16 months following recruitment. Furthermore, the groups dif- fered in their symptom wajectory. Before treatment, MST youths reported a higher frequency of attempted suicide, but over the course of treatment and follow-up the frequency declined sharply relative to hospitalized youths. No significant treatment effects were found for caregiver-rated atvempred suicide. However, significant quadratic treatment effects were found for caregiver-rated parental control. Whereas caregivers of hospitalized youths reported constant levels of parental control over time, caregivers of MST youths reported an increase in parental control from before to after treatment, but the levels returned. to baseline by the 1-year follow-up. MST appeared to have no long-term, differential effects on suicidal ide- ation, youth depressive affect, or youth-rated parental control Moderator Etfects Further rests were conducted to determine whether certain characteristics of the youth (ie, age, gender, ethnicity) influenced the ditection or strength of treat- ment effects. Thus, condition x time x moderator analyses were conducted to evaluate whether these vari- ables moderated the effects of treatment on subsequent suicide attempts. ‘With respect to linear effects, no significant mod- erator effects were found for caregiver-rated attempted suicide. However, regarding quadratic effects, results indicated that age (tay9 = 3.47, p <.05; Fig. 1,aand b), gender (Fo99 = 6.49, p < 01; Fig. 1, ¢ and d), and ethnicity (lg = 481, p < 01; Fig. 1, € and 1) exch moderated the effects of MST on caregiver-rated at- tempted suicide. An analysis of quadratic effects within 186 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:2, FEBRUARY 2004MST EFFECT ON ATTEMPTED SUICIDE TABLE 1 Group Proportions or Means (and Standard Deviations) for Suicidality, Depressive Affect, and Parental Conteh Time Effect Treatment Ecce. ‘Treatment Elece Pretreatment _Postweatment Lye Follow-up ¢(Lineae) + (Linea) # (Quadratic) % * % YRBS Auempted Suicide MST 3 “i 4 sore 261" 3.60%" Hospital 19 9 4 BCL Attempted Suicide MST 46 2 ° 5.25 1s? 031 Hospital 0 30 7 [BSI Suicidal Ideation MsT 60 3 19 sore 135 -0.40 Hospi 38 4” 8 YRBS Suicidal Ideation MsT 7 2 15 337 029 os Hospital 2 2 16 Mean(SD)__-Mean(SD)_—_Mean (SD) CBCL Anxious/Depressed MsT 66,76(1239) 60.43(11.82) 57731976) 049 oar Hospital G68 (L110) $8.14 G59) 5681868) BSI Depresion ‘MST 1.07 (1.10) 0.68 (093) 0.60(0.84) —-3.47" -0.23 -031 Hospital 121 (115) 0.83 (0.97) 0.70(087) ‘Wopelesness MST 532 355) 453 G38) 385029) 2.65 082 0.94 Hospital 609 (414 447 (323) 3.93,2.99) FFRS Conzrl Scale, Caregiver ‘MST 285 (0.58) 3.06 (0.54) —2.87(059) 0.33 043, 2.08" Hospital 292 62} 295 @51) 292054) FFF5 Control Scale, Youth ‘MST 248 (0.73) 253 (0.75) -239(080) 1.13 14 0.85 Hospical 258 (075) 246 (0.73) 2330.79) ‘Nove BSL = Brief Symprom lnvemory; CBOL = Ohild Gchavior Checks; FFS = Family, Friends, and Self Sealy MST = mulsysemie ‘therapy: YRBS = Youth Risk Behavior Survey. *p<.05:"p <.01; p< O01. cach age, gender, and ethnic group revealed differential trends by treatment condition. As evidenced in Fi 1, regardless of demogeaphic category, youths in the MST condition tended to exhibit a substantial decline in suicidal behavior rom before treatmaem t0 after treatment; it leveled off at the L-year follow-up. How- ever, the trajectory for youths in the hospital condition tended to vary considerably as a function of age, gen- der, and ethnicity. For example, attempted suicide in hospitalized. preadolescents actually increased slightly from before to after treatment but dropped substan- tially in che year following treatment; conversely, at- tempted suicide in hospitalized adolescents dropped substantially from before to after treatmenc and stayed fairly constant in the year following treatment. Because J. AM, ACAD. CHILD ADOLESC, PSY PRY, 48:2, FEBRUARY 2004 all youths in some demographic categories reported no attempred suicide during certain assessment periods (eg. at the I-year follow-up, no females in either treat- ment condition self-reported any episode of attempted suicide), moderacor analyses based on youth selF-teport of attempted suicide could not be eatried out Discussion This report presents the first examination of MST for suicidal behavior in children and adolescents. Im- portantly, the results support the efficacy of MST rela- tive to inpatient paychizttic hospitalization i the frequency of attempted suicide. In addit sis of quadratic effects suggests thar MST may contrib- x87HUEY ET AL, 2. Pre-Adolescents (Ages 9-12) (CBCL) b. Adolescents (Ages 12-17) (CBCL) gs g = a w a w B » Fw i Q clu Waonar hawt nea Rs «Females ent) d.aes (e8et) om g- Ee B ow B at B » wet z zy bs 5 volta owtccneSharanip semana” pa et ‘¢. African-Americans (CBCL) {. Euro-Americans (CBCL) 3 gi tonal 3 Bw 3 By E go z z 5 a Pecesinad PostTeamert ‘earFolow'Ip —retwanea pouTisanen er FotowUp Fig. 1 Elf ofimulioystemic therapy (MST) yeas hospialztion on caregiver aetnped suicide (CBCL) by age (a, gender (6d, and ethnic eA. ute to more rapid symptom relief compared to hospitalization. Although several clinical trials with sui- cidal youths have been conducted (Harringzon et al., 1998; Rotheram-Borus et al., 1996, 2001), to our knowledge this represents the first to demonstrate such significant treatment effects on self-harm behavior in youths. ‘An examination of the outcome slopes indicated that European Americans and African Americans followed somewhat different outcome trajectories based on creat- ment condition (Fig. 1). Although the trajectory for MST was nearly identical across echnic groups, the slope for European Americans appeared steeper than that for African Americans in the hospitalization con- dition. This finding might suggest chat African Ameri- can youths who receive standard psychiatric 188 hospitalization improve at a slower rate than their Eu- ropean American counterparts. However, given that Aftican Americans in che hospital condition began treatment with a lower overall frequency of attempted suicide (based on caregiver report), an alternative in- terpretation is that these findings simply reflect a re- gression to the mean effect (see below). Regardless, given this unusual pattern, these results clearly need to be explored in greater depth, Although MST appeared efficacious in reducing youth-rated suicidal behavior, it was not shown to be differentially effective in ameliorating three of the most robust predictors of attempted suicide in the extant literature: depressive affect, hopelessness, and suicidal ideation. Interestingly, this finding is consistene with ‘two complementary findings from previous research J. AM, ACAD. CHILD ADOLESC. PSYCHIATRY, 43:2, FEBRUARY 2004On the one hand, psychosocial interventions that are successful in treating depression and hopelessness among suicidal individuals have shown minimal effi- cacy in reducing rates of attempted suicide (Lerner and. Clum, 1990; Rotheram-Borus er al., 1996, 2001). On she other hand, interventions that reduce the frequency and severity of attempted suicide in adult samples gen- rally ate nor effective in ameliorating depressive affect {Linehan et al., 1991; Verkes er al., 1998). Together, these findings suggest that the change mechanisms re- quired for the reduction of suicidal behavior might differ foom those of treating depression, and that one cannot assume that suicidal risk decreases in tandem with depressive affect Clicical implications Youths in both treatment conditions showed sub- stantial improvements in symptom presentation, yet MST was more effective than hospitalization at reduc- ing the frequency of ateempted suicide and appeared to da so ina more rapid fashion. Although very brief, family-based interventions have not proven successful in ameliorating attempted suicide, the presene results suggest that a more intensive, family-based approach such as MST ehat addresses the multiple risk factors associated with attempted suicide should be pursued farther. ‘MST was originally designed for the treatment of amisocial behavior but has since been applied to the treatment of child maltreatment, sexual offending, and substance abuse (Henggeler et al., 1998, 2002), and large-scale randomized effectiveness vials with these populations are in progress. This study represents the first atcempt co extend MST (0 the treatment of sui- cidal youths and their families and clearly needs to be replicared and extended with an independent sample. Thus, more efforts are needed to help suicidal youths with their multiple needs and further reduce the risk for furure suicidal behavior. One such effort with fa- vorable clinical outconses has recently been completed in Hawaii (Rowland et al, submitted), and another is vunderway in Philadelphia. Limitations Given the potential significance of these findings, several limitations should be noted. Fitst, youths who attempt suicide are actually a heterogeneous group who often differ in terms of suicidal intent, method, lethal- ity, and exposure to precipitating stressors (Boergers et ai, 1998; Brent, 1997). Becaust of data limirations, we MST EFFECT OW ATTEMPTED SUICIDE were unable 10 evaluate these characteristics of at- cempted suicide and thus risk homogenizing a diverse group of youths. In addition, the temporal variation and overlap be- tween several measures used in this study suggest that cesults should be interpreted with caution. For ex- ample, caregivers who completed che CBCL were in- formed to base their reposts on che past 6 months, whereas youths who completed the YRBS were in- formed to report on behaviors occurring over the past 12 months. Thus, it is possible chat caregivers and youths weee basing their ratings of attempted suicide ‘on different time perspectives. The assessment of pa- rencal conttol presented an additional measurement concern. The internal reliability of the parental control scale for both caregiver and youth report fell below the accepted norm of 0.70; thus, resus based on his scale should be interpreced with this limitation in mind. ‘Also, in view of the fact that MST youths had sig- nificantly higher rates of attempted suicide before treat- ment, it is possible that the superior effects of MST reflect a regression t© the mean effect. Since the me- dian suicide reattempe rate for youths is only about 5% t0 15% per year (Brent, 1997), and since rates of atcempted suicide dropped substantially in both weat- ment conditions, the dramatic decrease in symprom- ology among MST youths over the L-year ascessment period may reflect the natural course of attempted sui- cide in children. We are eustently evaluating the youths at 2.5 years after the intervention to determine whether these presumed treatment effects are lasting. Finally, several characteristics of the sample may limit generalization to other populations. Even though minimal exclusion criteria were used, the sample was composed of predominantly African American and low-income families who presented at a hospital for psychiatric emergencies. Although the rate of suicide has increased among Affican Americans im recent de cades, African American youths are still underrepre- sented among suicide attempters (Grunbaum et al, 2002). Furthermore, since previous reseatch suggests that suicide attempters who receive mental health ereat- ‘ment differ in important ways from those who do not (Taylor and Stansfeld, 1984), these results may not be generalizable to community samples of suicidal youths. Disclonwre: Dre. Hengieler and Rowland are stachholder jn MST Services Inc which hat the exlsive Tens agreetenederngh the ‘Modical Universcy of Soush Carolina far the diseminaton of MST technology and intelectual propery 5. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:2, FEBRUARY 2004 189HUEY ET AL. 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