Three Psychotherapies for Suicidal Adolescents Overviewof C

Three Psychotherapies for Suicidal Adolescents: Overview
of Conceptual Frameworks and Intervention Techniques
Jonathan B. Singer1 • Kimberly H. McManama O’Brien2 • Mary
LeCloux3
Published online: 13 August 2016
� Springer Science+Business Media New York 2016
Abstract Suicide is the second leading cause of death
among youth, and as many as one in five youth report
having had at least one serious thought of suicide in the
past year. Despite the enormous emotional pain and suf-
fering associated with suicidal thoughts and behaviors, up
to 40 % of suicidal youth never receive treatment. Given
that social workers are employed in multiple settings where
suicidal children and adolescents are encountered (e.g.
schools, homeless shelters, emergency departments, out-
patient mental health agencies, private practice), they play
a critical role in the identification and treatment of suicidal

youth. In the past decade, evidence has emerged that
attachment-based family therapy, integrated cognitive
behavioral therapy, and dialectical behavior therapy can
reduce suicidal ideation and/or suicide attempt in youth.
The purpose of this article is to review the theoretical
assumptions, conceptual frameworks and key intervention
techniques for these three interventions so that clinicians
can integrate these approaches into their practice with
suicidal youth and families. Implications for practice are
integrated throughout the review.
Keywords Youth suicide � Empirically-supported
interventions � Attachment-based family therapy �
Integrated-cognitive behavioral therapy � Dialectical
behavior therapy
Suicide is the second leading cause of death among youth
ages 10–24 years, and 12 % of youth report having serious
thoughts of suicide in their lifetime (Centers for Disease
Control and Prevention, 2014; Nock et al., 2013). Reducing
suicide deaths and improving quality of life has been the
focus of federal suicide prevention programs like the Garrett

Lee Smith Memorial Act, public–private partnerships like
the National Action Alliance for Suicide Prevention, and
private initiatives like Zero Suicide. Key components of the
2012 National Strategy for Suicide Prevention include
training service providers in assessment and referral and the
delivery of high-quality mental health services (U.S.
D.H.H.S, 2012). Given that nearly half of all mental health
workers in the United States are social workers who work in
nearly every service sector (Bureau of Labor Statistics,
2016), social workers are essential in achieving the National
Strategy objectives by identifying and assessing suicide risk,
and providing high quality ongoing management and treat-
ment (Erbacher, Singer, & Poland, 2015).
Despite the development of several psychosocial inter-
ventions for suicidal youth, there is evidence that social
workers are not receiving the training and education nee-
ded to deliver these potentially life-saving interventions. A
2012 study found that although MSW program adminis-

trators and faculty agreed that suicide-related education is
important, most social work students receive 4 or fewer
hours (Ruth, Gianino, Muroff, McLaughlin, & Feldman,
2012). This is problematic because Over 90 % of social
workers will work with a suicidal client in their career
& Jonathan B. Singer
[email protected]
1
Loyola University Chicago School of Social Work, Water
Tower Campus, 820 N. Michigan Avenue, Chicago,
IL 60211, USA
2
Simmons School of Social Work, Boston Children’s
Hospital, Harvard Medical School, 300 The Fenway, Boston,
MA 02115, USA
3
West Virginia University School of Social Work,
P.O. Box 6830, Morgantown, WV 26506, USA
123
Child Adolesc Soc Work J (2017) 34:95–106

DOI 10.1007/s10560-016-0453-5
http://crossmark.crossref.org/dialog/?doi=10.1007/s10560-016-
0453-5&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s10560-016-
0453-5&domain=pdf
(Feldman & Freedenthal, 2006) and mental health profes-
sionals consistently rate working with suicidal clients as
among the most stressful of all practice situations (Ting,
Jacobson, & Sanders, 2008). To our knowledge there are
only two MSW programs in the USA that offer a course on
suicide and have evaluated pre- to post-course outcomes,
which indicated significant increases in knowledge, confi-
dence, and skills as a result of the course (Almeida,
O’Brien, Gross, & Gironda, in press; Scott, 2015). If fac-
ulty members are not likely to develop and offer stand-
alone courses on suicide-related issues, then it is essential
to have resources that they can integrate into existing
courses. Currently, faculty members have access to several
excellent reviews of suicide risk assessment (Barrio, 2007;

Joiner & Ribeiro, 2011; Ribeiro, Bodell, Hames, Hagan, &
Joiner, 2013; Shea, 2002) and several high quality sys-
tematic reviews and meta-analyses of psychosocial inter-
ventions for suicidal and self-harming youth (see Brent
et al., 2013; Calear et al., 2016; Corcoran, Dattalo, Crow -
ley, Brown, & Grindle, 2011; O’Brien, Singer, LeCloux,
Duarté-Vélez, & Spirito, 2014; Robinson et al., 2013). This
article builds off that knowledge base by providing a
concise review of theoretical assumptions and key inter-
vention techniques for psychosocial interventions for sui-
cidal youth while incorporating a key requirement in social
work education: the integration of theory and practice.
The Relationship Between Theory
and Empirically-Supported Treatments
Social work students and practitioners are expected to
understand, explain and integrate practice and theory (Na-
tional Association of Social Workers, 1996/2008; Council
on Social Work Education, 2015). In social work education,
classroom professors emphasize theory while field supervi -

sors focus on practice. A perpetual challenge for students,
practitioners, and professors is how to best integrate the two
so that theory informs practice, and practice informs theory.
Understanding the relationship between theory and practice
is particularly important when working with people who are
suicidal because of the possibility of lethal outcomes. This is
due, in part, to the fact that there are many reasons why
adolescents might want to die, and many pathways to help
adolescents discover a life worth living. Since theory ‘‘at-
tempts to retrospectively explain and to prospectively pre-
dict’’ (Thyer, 2001, p. 16), theoretically-informed treatments
provide a roadmap for where to go and how to get there. The
manualized treatments discussed in this article provide
insight into whether you should spend time addressing
affect, behavior, or cognition; whether you should focus on
the past, present, or future; and whether you should focus on
the individual, family, or group. Few social workers,
however, are trained in such treatments. Unless a practi-

tioner has been trained to fidelity in a treatment, it can be
difficult to understand how the theoretical assumptions and
constructs inform the intervention techniques.
According to Singer and Greeno (2013), frequently
noted barriers to implementing manualized treatments
include: provider concern that the treatment was not
developed with or for low-income, ethnically diverse
populations; concern that the treatment will not have better
outcomes than treatment-as-usual; the time and expense
required to get trained in manualized treatment; lack of
training opportunities and organizational support for
implementation; and a disconnect between the theoretical
orientation of the treatments and that of the provider.
Knowing which theories are associated with which inter-
ventions will help social workers decide which model best
fits their practice approach and make it easier to identify
whether they would like to pursue advanced training in
ABFT, I-CBT, or DBT-A.

Identification and Inclusion of Studies
The three treatments discussed in this article were identi -
fied based on a search of the empirical literature using
PsycINFO, PubMed and Google Scholar. Initial search
terms included: (psychotherapy OR psychosocial OR
clinical OR intervention) AND (suicid$) AND (youth OR
adolescen$). The search was limited to peer-reviewed
journal articles in English published between 1996 and
2016. This result yielded 2282 articles. Studies were
excluded if reduction of suicidal ideation, suicide attempt,
suicide or self-harm was not the primary focus of the
intervention; if they combined self-harm and suicidal
ideation/suicide attempt; if they focused only on caregivers
and not youth; if the program leader was not a clinician
(e.g. teacher implementing a school-based screening or
researcher showing video psychoeducation or mailing a
postcard); if the treatment manual was in a language other
than English; or if there was no control condition. After

applying exclusion criteria and eliminating duplicates, we
were left with 33 articles. We compared these results to
SAMHSA’s National Registry of Evidence-based Pro-
grams and Practices (http://nrepp.samhsa.gov/); the Suicide
Prevention Resource Center’s Best Practice Registry
(http://www.sprc.org/strategic-planning/finding-programs-
practices) and recent meta-analyses, systematic reviews,
and narrative reviews of psychosocial interventions for
suicidal youth (Brent et al., 2013; Calear et al., 2016;
Corcoran, Dattalo, Crowley, Brown, & Grindle, 2011;
O’Brien et al., 2014; Robinson et al., 2013).
Nine treatments met criteria for inclusion (Asarnow
et al., 2011; Diamond et al., 2010; Donaldson, Spirito, &
96 J. B. Singer et al.
123
http://nrepp.samhsa.gov/
http://www.sprc.org/strategic-planning/finding-programs-
practices
http://www.sprc.org/strategic-planning/finding-programs-
practices

Esposito-Smythers, 2005; Esposito-Smythers, Spirito,
Kahler, Hunt, & Monti, 2011; Harrington et al., 1998;
Huey et al., 2004; Mehlum et al., 2014, 2016; Rossouw &
Fonagy, 2012; Stanley et al., 2009). Of these, three were
excluded because they reported no significant difference in
outcomes between the control and experimental condition
(Asarnow et al., 2011; Donaldson et al., 2005; Harrington
et al., 1998). Among the five studies that reported signifi -
cant differences, we eliminated two (Huey et al., 2004;
Rossouw & Fonagy, 2012) from the review for the fol-
lowing reasons: Multi-systemic therapy (MST; Huey et al.,
2004) is not a theoretically-based treatment with specific
interventions. Rather, it is a framework for providing
interventions across multiple systems. Mentalization-based
therapy for adolescents (MBT-A; Rossouw & Fonagy;
2012) is an adolescent modification of a psychodynamic
therapy developed in Great Britain for adults with bor-

derline personality disorder. It is unclear whether MBT-A
is effective at reducing suicidal ideation and/or attempt
because the outcome measure is a broad category of self-
harm that includes suicidal ideation and attempt as well as
non-suicidal self-injury. Additionally there are currently no
MBT-A training opportunities in the USA.
The three remaining treatments, attachment-based fam-
ily therapy (ABFT; Diamond et al., 2010; G. S. Diamond,
G. M. Diamond, & Levy, 2013), integrated-cognitive
behavioral therapy (I-CBT; Spirito, Esposito-Smythers,
Wolff, & Uhl, 2011), and dialectical-behavior therapy for
adolescents (DBT-A; Fleischhaker et al., 2011; Mehlum
et al., 2014, 2016; Miller, Rathus, & Linehan, 2007)
demonstrated better suicide-related outcomes than control
conditions, were theoretically-based, had specific inter-
ventions, and addressed domains and problem areas com-
mon to social work that also increase risk for suicide:
depressed mood, a rupture in the parent–child relationship

(Donath, Graessel, Baier, Bleich, & Hillemacher, 2014),
substance use (Wong, Zhou, Goebert, & Hishinuman,
2013), emotion dysregulation (Pisani et al., 2013), and non-
suicidal self-injury (Klonsky, May & Glenn, 2013).
Empirical support, theoretical assumptions, and specific
interventions for each of the three treatments are presented.
Attachment-Based Family Therapy (ABFT)
Attachment-Based Family Therapy (ABFT; Diamond
et al., 2013) is the only family-based therapy designed to
reduce depression and suicide risk in adolescents. ABFT is
a 12–16 week family therapy model that integrates con-
cepts from family systems theory and attachment theory.
ABFT has demonstrated efficacy in reducing suicidal
ideation in 5 clinical trials (G. M. Diamond et al., 2012;
Diamond et al., 2010; Diamond, Creed, Gillham, Gallop, &
Hamilton, 2012; G. S. Diamond, Reis, G. M. Diamond,
Siqueland, & Isaacs, 2002).
A core assumption of family systems theory is that

interactions between family members follow pre-
dictable patterns. Interrupting and altering these patterns
results in long-lasting changes for individuals and the
family as a unit. ABFT assumes interaction patterns can
either exacerbate or reduce suicide risk. ABFT integrates a
family systems approach with attachment theory through
the parent-adolescent relationship. ABFT subscribes to the
notion that attachment is a biological instinct, with roots in
infant development, which is shaped by interpersonal
interactions throughout the lifespan (Ainsworth & Bowlby,
1991). There are two basic attachment styles—secure and
insecure. Secure attachments develop when a primary
caregiver consistently addresses an infant’s basic needs
(hunger, boredom, soothing, love, affection, etc.). Insecure
attachments develop when a primary caregiver is incon-
sistent or does not meet these basic needs. Research has
found that attachment styles are fairly stable across cultures
and across the lifespan (McConnell & Moss, 2011).

However, because they are shaped by the interpersonal
environment, attachment styles can change. A child with a
secure attachment whose sense of safety and security is
repeatedly violated (e.g. through abuse or neglect) might
develop an insecure attachment style. Conversely, a child
with an insecure attachment who experiences a primary
caregiver meeting basic needs can ‘‘earn’’ security (Main,
Hesse, & Kaplan, 2005). The capacity to earn security is
central to the effectiveness of ABFT. ABFT assumes that
one of the best ways to reduce suicide risk is to strengthen
the adolescent-parent attachment. During a course of
ABFT, which includes five treatment tasks, the therapist is
constantly listening and looking for ways for adolescents to
earn security or strengthen an already secure attachment.
Two of the techniques used to achieve this goal are called
‘‘Relational Reframe,’’ and ‘‘Attachment’’ (Diamond,
2014).
ABFT Techniques

Relational Reframe
The first intervention used in ABFT is a relational reframe
(Diamond, 2014; G. S. Diamond, G. M. Diamond, & Levy,
2014). Consistent with ABFT’s family systems perspec-
tive, the purpose of the relational reframe is for family
members to reframe adolescent suicide risk as a relational
rather than individual issue. The family might come to
therapy seeing the adolescent as the problem (e.g., ‘‘can
you help him with his depression?’’), but the reframe
ensures that they leave understanding that the family is the
Three Psychotherapies for Suicidal Adolescents: Overview of
Conceptual Frameworks… 97
123
solution. During the first session, the therapist elicits
information from the suicidal adolescent and their par-
ent(s) about what has contributed to the current suicidal
crisis, and then works with the family to see how the
interaction between the parent and the child can be a

solution to the crisis. For example, the adolescent might
say, ‘‘When I’m feeling bad I just want to go to my room. I
don’t want to talk to anyone, especially my parents. It
would be embarrassing. Dad wouldn’t know what to say
and mom would just blame herself.’’ The therapist reflects
back that it seems like he’d rather kill himself than feel
embarrassed, or make his parents uncomfortable. The
therapist notes the affect in the room (typically sad or
anxious), and draws out the parents’ longing and desire for
their adolescent to see them as safe people to turn to.
Drawing out emotion, rather than tapping into cognitions,
is consistent with the attachment-focus of the treatment.
The therapist assumes that the parents’ attachment instincts
will be triggered upon hearing their child’s pain and sad-
ness. The therapist makes the connection that both the
adolescent and parents are in pain and long for a different
kind of relationship. The therapist assures the family that
there are things they can do differently that would make it

more likely that their son would talk with them when he is
depressed or suicidal. By the end of the session, an ideal
outcome for the relational reframe is for the adolescent and
parent(s) to acknowledge a desire to be closer to each
other. The therapist then contracts with the family to work
on that goal. If the adolescent or the parent(s) is unable or
unwilling to agree to that goal, the therapist ‘‘steps down’’
to a relational goal that might be less threatening, such as
improving parent–child communication.
Attachment
The attachment task typically occurs halfway through
treatment. This intervention is a core ABFT technique
which involves a conversation between the adolescent and
his or her parent. After the relational reframe in the first
session and the attachment task, the adolescent and par-
ent(s) have been prepared to address the question, ‘‘what
makes it so difficult for the adolescent to go to the par -
ent(s) when feeling depressed and suicidal?’’ Part of the

preparation for the attachment task is providing the ado-
lescent with a narrative that frames their current struggles
as attachment issues. For example, if the adolescent does
not feel safe sharing intense emotions with a parent
because of the parent’s emotional instability, then the
attachment reframe is that the parent cannot meet a basic
need for protection and comfort. During the attachment
task the adolescent will tell the parent why it has been
difficult to come to them when depressed or suicidal. The
adolescent might say, ‘‘I don’t go to you because I’m afraid
you will freak out and start crying, which will make me
feel worse.’’ ABFT recognizes that parents might react
with statements that could be invalidating (e.g. ‘‘No, I
wouldn’t’’), critical (e.g. ‘‘How would you know if you
never do it?’’), dismissive (e.g. ‘‘You don’t understand’’ ) or
self-involved (e.g. ‘‘I’m a terrible parent, of course you
wouldn’t want to talk to me’’). These are not attachment
repairing statements. In order to prepare the parents to

respond in ways that will demonstrate that they are capable
of providing validation, affirmation, love and support, the
parent has received emotion coaching (e.g. asking for more
details, labeling emotions, providing validating statements
such as ‘‘it makes sense why you would be worried to come
to me’’). The therapist’s role is to redirect the conversation
when necessary and provide affirmation when the parent
and adolescent are having the conversation. After the
adolescent feels heard and validated, and the parent feels
successful in meeting their adolescent’s needs, there is a
shift in the attachment pattern. If the adolescent was pre-
occupied, i.e., always worried about the parent being
available, the attachment task would provide a small but
profound experience of the parent being there. The
assumption is that this shift in the mental model of the
parent–child relationship will reduce suicide risk by
increasing the adolescent’s sense of security, safety, and
protection; and the parent’s sense of competence and

connection (Diamond 2014). The gains from this inter-
vention are solidified over the second half of therapy (i.e.,
Task 5), as the adolescent repeatedly experiences the par -
ent as a safe and secure base with whom they can work
through a variety of psychosocial issues, ranging from the
least to most distressing.
Integrated Cognitive Behavioral Therapy (I-CBT)
Suicide-related thoughts and behaviors and substance use
are interrelated in adolescents (Bagge & Sher, 2008;
Goldston, 2004) and increase markedly during this devel -
opmental period, demonstrating the importance of inter-
vention during this time (Daniel & Goldston, 2009; Galaif,
Sussman, Newcomb, & Locke, 2007). Despite the strong
link between suicide-related thoughts and behaviors and
substance use, the standard of care is to treat these two
problems separately (Esposito-Smythers et al., 2012).
However, integrated services have demonstrated greater
promise than serial or parallel treatment for comorbid

substance abuse and psychiatric disorders (Esposito-Smy-
thers & Goldston, 2008; Hawkins, 2009; Sher & Zalsman,
2005). Integrated Cognitive Behavioral Therapy (I-CBT;
Esposito-Smythers, Spirito, Kahler, Hunt, & Monti, 2011)
is one such intervention for adolescents with comorbid
suicide-related thoughts and behaviors and substance abuse.
123
I-CBT uses a social cognitive learning theory perspec-
tive (Bandura, 1986) to promote change in adolescents by
helping them to relearn adaptive ways of relating to
themselves and others and develop self-efficacy in their
ability to utilize these skills. The I-CBT protocol targets the
maladaptive behaviors and beliefs that are common to the
two problems of substance use and suicide-related thoughts
and behaviors, in order reduce the amount and severity of
problems in both areas simultaneously (Esposito-Smythers

et al., 2011). When treating substance use and suicide-
related thoughts and behaviors in an integrated manner, it
is important to understand how each can exacerbate the
other. For instance, alcohol and other drug use may serve
as a means of self-medication (Kuntsche, Knibbe, Gmel, &
Engels, 2005), as a coping mechanism for depression
(Galaif et al. 2007; Sher & Zalsman, 2005), or as a way to
reduce or relieve negative affect. There is also evidence
that alcohol and other drug use facilitates suicide-related
thoughts and behaviors. Alcohol use causes disinhibition
which can increase the likelihood of acting impulsively on
suicidal thoughts (Sher, 2006), especially in the context of
heavy episodic drinking, which has been found to be
associated with increased risk of suicide attempts among
suicidal adolescents (Schilling, Aseltine, Glanovsky,
James, & Jacobs, 2009). With respect to maladaptive
cognitions and behaviors, alcohol may inhibit the cognitive
ability to use effective coping skills to deal with suicidal

thoughts, which contributes to an elevated risk for a suicide
attempt in the context of suicidal thoughts (Sher, 2006).
Therefore, when addressing alcohol and other drug use in
treatment with suicidal youth, it is critical to draw attention
to the relationship between the two problems, and by doing
so in a collaborative and informative way that does not
come across as a lecture or as telling adolescents what they
should be doing with respect to their drug and alcohol use.
To enhance collaboration and commitment to treatment,
I-CBT uses many Motivational Interviewing (MI) tech-
niques. MI is a client-centered, directive method for
enhancing intrinsic motivation to change by exploring and
resolving ambivalence (Miller & Rollnick, 2013). MI has
been used effectively with adolescents with comorbid
substance use and psychiatric symptoms (Brown et al.,
2009) because of its ability to create a therapeutic atmo-
sphere that acknowledges the choice and ambivalence of
the adolescent and supports personal change goals rather

than institutional or counselor-based goals. Because MI
uses a nonjudgmental and nonconfrontational style, it may
be particularly useful for engaging adolescents who have
not yet considered change, or may have an apparent lack of
motivation to change, their substance use or other problem
behaviors related to their suicide-related thoughts or
behaviors. Even a brief motivational interviewing inter-
vention can serve to increase negative expectancies (i.e.,
the belief that using substances will have negative effects
and consequences), increase situational confidence (i.e.,
confidence in the ability to resist the urge to use substance
in certain situations), and increase mental health and sub-
stance use treatment engagement. In doing so, brief sub-
stance use interventions have the ability to decrease
likelihood of substance use, which in turn will decrease the
frequency of substance-related suicidal thoughts and
behaviors.
I-CBT works under the premise that reduction of

suicide and substance abuse risk requires coordinated
efforts with adolescents and their parents. Individually
with the adolescent, I-CBT addresses issues with cogni-
tive distortions, coping, and communication, by working
with the adolescent on cognitive restructuring, problem
solving, affect regulation, and communication skills
(Esposito-Smythers et al., 2011). For instance, one
common cognitive distortion among suicidal adolescents
is the belief that ‘‘I am worthless.’’ This self-deprecation
can increase the likelihood of adolescents engaging in
risky behaviors such as substance use because they want
to use the substance to align themselves with these
negative views of self, distract themselves from their
distressing thoughts, or to numb themselves from their
accompanying emotions. Substance use in this context
exacerbates suicide risk by inhibiting their ability to use
coping skills and facilitating the transition from suicidal
thoughts to action.

Parental involvement has been show to enhance the
effectiveness of treatment with suicidal adolescents (Brent
et al., 2013). Strategies for inclusion of parents in the
I-CBT protocol typically involve a parent training session
about psychoeducation about emotion regulation, as well
as the importance of parental monitoring and communi-
cation (Esposito-Smythers et al., 2011). Teaching parents
about what their adolescent is experiencing, as well as
how they can effectively communicate with their ado-
lescent during times of heightened emotional distress,
increases the likelihood that parents can be a buffer,
rather than a trigger, to adolescents future suicidal crises.
Additionally, teaching parents about the importance of
monitoring their adolescents’ whereabouts, including the
peers with whom they are spending their time, influences
the likelihood that their adolescents will be spending time
with peers who don’t use substances which will in turn
decrease the likelihood of their own adolescents using

substances. Family sessions in I-CBT typically focus on
improving communication and behavioral contracting
(Esposito-Smythers et al., 2011). Addressing the suicide-
and substance-related treatment goals of the adolescent
together with the parent serves to align the parent with the
adolescent, building up the parents as a support in
achieving their treatment goals.
123
Through the simultaneous improvement in overall ado-
lescent and parent skills, adolescents can then demonstrate
reductions in substance use and suicide-related thoughts
and behaviors. For instance, in their randomized trial,
Esposito-Smythers et al. (2011) found I-CBT, relative to
enhanced treatment as usual (E-TAU), to be associated
with significantly fewer heavy drinking days and days of

marijuana use. Less global impairment as well as fewer
suicide attempts, inpatient psychiatric hospitalizations, and
emergency department visits were reported by adolescents
receiving I-CBT as compared to those receiving E-TAU.
I-CBT Techniques
In their meta-analysis of the effectiveness of brief alcohol
interventions for adolescents, Tanner-Smith and Lipsey
(2015) found the specific components of decisional balance
and goal-setting exercises to be associated with larger
reductions in alcohol consumption and alcohol-related
problems. Therefore, suggested adaptations of these
modalities for adolescents with comorbid suicide-related
thoughts and behaviors will be presented here. These
techniques are currently being utilized in a clinical trial of a
brief alcohol intervention with adolescent inpatients fol -
lowing a suicidal event (O’Brien & Spirito, 2014).
Decisional Balance
The decisional balance is a MI technique used to consider

options and systematically evoke the advantages and dis-
advantages of each (Miller & Rollnick, 2013). The deci -
sional balance typically uses four quadrants to ask about
the pros and cons regarding a decision (e.g., ‘‘what do you
like about alcohol,’’ ‘‘what don’t you like about alcohol,’’
‘‘what would be the bad things about changing your
drinking,’’ and ‘‘what would be the good things about
changing your drinking’’). The diagonal boxes are com-
plementary and may contain similar entries. Some ado-
lescents may find it confusing to distinguish between the
two, in which case, a simple pros and cons list may be more
effective. When completing the decisional balance with
adolescents, it is important to first elicit what it is they like
about their substance of choice (or other problem behavior)
before asking them about what they don’t like. It is critical
that while they are telling you what they like, you maintain
a nonjudgmental and nonconfrontational stance. Some
common reasons suicidal adolescents cite for why they like

drinking or other drug use include ‘‘helps me feel more
comfortable to talk to people at a party,’’ ‘‘makes me forget
about all the bad things going on,’’ or ‘‘like the way it
feels.’’ Reasons they don’t like drinking or other drug use
frequently include ‘‘get sick,’’ ‘‘feel sad or down the next
day,’’ or ‘‘feel bad the next day about something I did when
I was drunk.’’ Knowing these reasons can help you in the
therapeutic process to understand the functions the alcohol
or other drugs are serving for the adolescent, especially
with respect to their suicide-related thoughts and behaviors.
Clinicians must remember that this relationship is not
always unidirectional; in fact, many adolescents endorse a
bidirectional relationship between their substance use and
suicide-related thoughts and behaviors. Once this rela-
tionship is understood, then the clinician can work with the
adolescent to identify alternate ways to replace the function
that the alcohol is serving for the adolescent, especially in
cases where it is contributing to the exacerbation of sui -

cide-related thoughts and behaviors. In the I-CBT protocol,
the decisional balance is typically used in session 3 (of 13
or more sessions), but because of its flexibility, it can be
adapted for a wide range of uses in both brief and long term
treatment modalities.
Goal-Setting Exercises
In MI, goal setting exercises, such as making a change
plan, are conducted only when the client demonstrates
sufficient readiness (Miller & Rollnick, 2013). Change
plans can take many forms, but they typically include a list
of goals and steps to take to achieve those goals. It is
important that adolescents develop their own goals to
emphasize their autonomy and therefore increase motiva-
tion to adhere to the change plan. Goals often relate to
substance use or other problem behaviors that affect their
suicide-related thoughts and behaviors, but are not limited
to these areas. For example, suicidal adolescents may
decide to make a plan to reduce their alcohol use at a party,

rather than stop use altogether. They may choose to do
reduce use because they want to be able to drink a little so
they can feel comfortable at a party, but not so much that
they get drunk and do something they regret the next day. It
is recommended that the change plan identifies adults who
can help the adolescent achieve their goals, as well as
barriers that could get in the way of the adolescent’s goal
attainment. It can be helpful for the clinician to talk with
the adolescent about how the parent can be of assistance in
the change plan process. Adolescents often come up with
unique ideas that you, as the clinician, could not think up
on your own. With respect to barriers, it can be useful to
have the adolescent take you step-by-step through a situ-
ation where they typically use substances in order to
identify what the specific barriers are for that adolescent.
Once a barrier has been identified, the clinician can then
brainstorm with the adolescent what they can do they next
time the situation comes up. In the I-CBT protocol, the

change plan is typically completed at the end of session 3,
123
but can be revisited throughout the remainder of treatment
when appropriate.
Dialectical Behavior Therapy for Adolescents
(DBT-A)
DBT-A was adapted from Dialectical Behavior Therapy
(DBT; Linehan, 1993), a treatment modality that combines
principles of behavioral science, dialectical philosophy,
and Zen practice (Miller et al., 2007). DBT was initially
developed in the 1980’s to address self-harming behaviors
in women, many of whom met criteria for borderline per-
sonality disorders. DBT-A is a version of DBT that was
adapted for use with adolescents who struggle with suici -
dality, self-harm, and chronic emotion dysregulation.
These adolescents are often struggling with one or more
additional comorbid disorders, such as substance use, dis-

ordered eating, mood and anxiety disorders, and disruptive
behavior disorders (Miller et al., 2007).
DBT-A is a versatile treatment that can be used in both
inpatient and outpatient treatment centers and has also
recently been adapted to a school-based curriculum
(Mazza, Dexter-Mazza, Miller, Rathus, & Murphy, 2016).
Clinical trials of DBT-A have found it is associated with
improvements in overall psychiatric functioning, and sig-
nificant decreases in suicidal ideation and behaviors as well
as comorbid symptoms, such as non-suicidal self-injury
(NSSI) and depression (MacPherson, Cheavens, & Fristad,
2013). Additionally, a recent review and meta-analysis of
suicide-related treatments for adolescents found that, along
with CBT, DBT-related treatments had the largest effect
sizes in relation to clinical improvements (Ougrin, Tranah,
Stahl, Moran, & Asarnow, 2015).
One of the core assumptions of DBT-A is that successful
treatment involves helping the client recognize, synthesize,

and integrate ideas that seem to be in opposition to each
other;his is the main idea behind the word ‘‘dialectic.’’ In
DBT-A, the adolescent is coached to be able to tolerate
painful feelings and simultaneously contemplate the possi -
bility for change. For example, a teen who reports feeling
suicidal due to poor peer and parental relationships might
work on the following dialectic: ‘‘I might not be responsible
for all the things that are bad about my relationships, but I am
responsible for working on them to make them better.’’ A
teen whose suicidal ideation is triggered by not meeting
academic expectations (either internally or externally con-
ceived) might work on the following dialectic: ‘‘I am doing
the best I can, but I can dobetter.’’ The therapist uses a variety
of cognitive strategies in therapy throughout treatment that
allow adolescents to explore and synthesize these sorts of
dialects as they are relevant to their treatment targets.
A second core assumption of DBT-A is that adolescents
express emotions through self-harming behaviors because

they have a systemic problem with emotion dysregulation.
Systemic emotion dysregulation, according to Linehan
(1993), develops as the result of a combination of biolog-
ical pre-disposition and exposure to an ‘‘invalidating
environment.’’ The ‘‘invalidating environment’’ involves
having primary caregivers early in life who react to a
child’s emotions and behaviors with either erratic, inap-
propriate, or invalidating responses (Linehan, 1993), which
makes it difficult for children to develop the ability to
appropriately identify and modulate emotions and self-
soothe in response to distress. These individuals also have
difficulty appropriately identifying the emotions of others,
selecting appropriate responses, and/or modulating their
affect, which results in the inability to maintain a
stable sense of self (Linehan, 1993). Adolescents with a
pre-disposition to emotional dysregulation and who are
exposed to an ‘‘invalidating environment,’’ typically
develop extreme difficultly tolerating conflict, may engage

in ‘‘all or nothing’’ thinking, and/or will have irrational
fears of abandonment. As a result, they can develop
behaviors that alienate others and/or sustain dysfunctional
social relationships (Miller et al., 2007).
In DBT-A, it is assumed that suicide-related affect,
thoughts, and behaviors are ways of directing anger
towards the self and/or escaping from extreme hopeless-
ness or despair (Miller et al., 2007). Suicide-related
thoughts and behaviors and non-suicidal self-injury (NSSI)
are categorized as ‘‘life threatening behaviors’’ which are
targeted with similar interventions, and are considered one
of the first targets of treatment (Miller et al., 2007). They
are prioritized and addressed with a multi-modal approach,
which is described further below.
DBT-A Techniques
‘‘Life threatening behaviors’’ are addressed in DBT-A
through a multi-modal approach that includes individual
treatment, psychopharmacology, skills training, phone-

consultation, family work, and consultation with other
significant providers in the adolescent’s life (such as school
personnel) (Miller et al., 2007). The following section
gives a brief overview of some of the DBT-A techniques
formulated by Miller et al. (2007) that can be applied to
work with suicidal adolescents in either inpatient or out-
patient settings. While all of the techniques described
below can be integrated into individual therapy, DBT-A
skills are typically taught through skills-based training
groups on either inpatient or outpatient settings, or with a
DBT-A skills coach, so that individual therapy can focus
123
on assessing safety and monitoring the use of these skills to
manage distressing situations (Miller et al., 2007).
Emotion Regulation

One of the major assumptions of DBT is that self-harming
behaviors and suicidal thoughts stem from core problems
with emotion regulation and many of the strategies and
skills employed in DBT-A attempt to improve adolescents’
abilities to tolerate and regulate difficult emotions. One key
emotion regulation skill that is taught in DBT-A is the
concept of mindfulness. Mindfulness refers to experiencing
thoughts and feelings without attaching judgment or neg-
ativity to them. The assumption is that if one is unable to
fully experience one’s feelings, one cannot ever learn to
regulate them (Linehan, 1993). An adolescent, for exam-
ple, who experiences conflicting feelings of ‘‘love’’ and
‘‘hate’’ for an abusive parent might be encouraged to feel
each of these feelings fully, without attaching judgment or
blame to either one. The general concept of mindfulness is
found in many of the DBT-A skills, but can be integrated
into the individual therapy regularly as well by using
techniques similar to the example described above.

There are several DBT-A skills-based exercises that
teach mindfulness. In the Describe, Express, Assert,
Reinforce, (stay) Mindfully, Appear confident, Negotiate
(DEAR MAN) exercise, for example, youth are asked to
describe a situation without judgment, express their feel -
ings or emotions about it, discuss ways they could have
appropriately asserted their wishes, and to reward or rein-
force people who do respond positively to them. Being
‘‘mindful’’ refers to the ability to keep focus by repeating
their requests and ignoring attacks or threats from the other
party. This is often done with the aid of a Diary Card, in
which adolescents are asked to keep track of target
behaviors (including self-harm) and the skills they have
used each week to manage them.
Distress Tolerance
The DBT concept of radical acceptance refers to the i dea
that in order to move forward from pain, one must accept it
and experience it in its entirety. Distressful feelings are

reframed as a way the psyche informs an individual of the
need for action (Linehan, 1993). In conjunction with rad-
ical acceptance, DBT-A focuses on helping adolescents
develop core skills that help them make pain more toler-
able. The distress tolerance techniques in DBT-A target the
adolescent’s ability to tolerate painful or difficult situa-
tions. One way this can be accomplished is by teaching the
adolescent ways to self-soothe when faced with difficult or
distressing feelings. The Vision, Hearing, Smell, Taste,
Touch exercise, for example, encourages adolescents to
find ways to engage and soothe each of the five senses. By
engaging in behaviors that ‘‘soothe the body,’’ adolescents
are taught that they can learn to tolerate difficult feelings
without becoming overwhelmed by them. Other examples
of this sort of technique include using positive imagery,
prayer, and relaxation to replace negative experiences with
positive ones. An adolescent who is feeling overwhelmed
and anxious by a distressing conversation with a significant

other, for example, might be encouraged to imagine an
‘‘alternate experience,’’ where the conversation progressed
to what is considered a positive (and safe) end. Another
example might be encouraging an adolescent to use a
progressive muscle relaxation technique when feeling dis-
tressed. In this way, the adolescent can create a more
positive physical feeling in his or her body, making it
easier to tolerate difficult feelings.
Behavioral or Chain Analysis
Another core tenet of DBT is that problematic behaviors
often result from a deficiency in coping and problem
solving skills (Rizvi & Ritschel, 2014). Adolescents may
engage in self-harm, for example, when feeling over-
whelmed by emotion and unable to cope. Alternatively,
they may use self-harming behaviors as a way to com-
municate distress when feeling unable to assert their needs
effectively. One well-known cognitive-behavioral tech-
nique that has been adapted to DBT-A that attempts to

address these issues is called behavioral or chain analysis
(Miller et al., 2007).
A chain analysis can be completed at any time in
treatment, but is intended to be the first step in identifying
problematic situations that trigger a self-harming or suici-
dal event in order to generate solutions. The chain analysis
documents what happened internally and externally leading
up to a suicidal or self-injurious event (this can include
thoughts and/or behaviors), and is sometimes referred to as
a video which is stopped at every frame to identify what is
going on. Although the chain analysis technique is pri-
marily done with the adolescent, a chain analysis can be
done with the parents as well in order to gather the fullest
picture possible of what happened and what lessons can be
learned to prevent future events. The chain analysis is a
time-intensive process and typically takes a minimum of
30 min. The clinician very methodically goes through the
events with the adolescent, writes down what happened

when, and asks clarifying questions such as, ‘‘and after he
said that, how did you feel? What did you do then?’’ The
chain analysis is complete once a thorough picture is
obtained of what happened leading up to the suicide-related
event.
One goal of this technique is to identify vulnerabilities
as well as draw out strengths, resources, and solutions that
123
the adolescent might not have previously recognized. A
chain analysis can also be useful because it helps the
therapist and adolescent identify ‘‘solution’’ or ‘‘change’’
procedures that address the suicide-related behavior. The
particular focus of the change procedures often differs
depending upon the findings in the chain analysis. For
example, for an adolescent who reports engaging in self-
harming behavior after becoming enraged during a fight

with a parent, the therapist might work on helping the
adolescent identify some distress tolerance techniques to
manage emotions in the moment as well as some inter-
personal effectiveness skills that could have been used to
make the interaction with the parents more productive.
The chain analysis also allows the adolescent to re-ex-
perience situations involving difficult or painful feelings in
a safe and removed way. During the chain analysis, the
therapist can help adolescents tolerate difficult feelings
without engaging in self-harming behaviors and help the
teen learn to manage his or her affect (Rizvi & Ritschel,
2014). In this way, the chain analysis technique is also very
much consistent with the DBT concepts of radical accep-
tance and distress tolerance. In the example above, in
addition to identifying antecedents and alternative strate-
gies to the situation, the therapist might help the youth
modulate feelings of anger, frustration or sadness triggered
by the argument with the parent. Additionally, the therapist

could encourage the use of mindfulness and distress tol-
erance techniques that could be used to fully experience
these feelings while still learning to manage them.
Discussion
Despite the value placed on understanding the intersection
between theory and practice, there are very few resources
that provide students and practitioners with insight into this
intersection with specific treatments (for a comparable
article on substance use disorders see Wells, Kristman-
Valente, Peavy, & Jackson, 2013; see also the Springer and
Rubin book series ‘‘Clinician’s Guide to Evidence-Based
Practice’’). This review provides the theoretical assump-
tions, conceptual frameworks, and key intervention tech-
niques for three probably efficacious psychotherapies for
suicidal youth: attachment-based family therapy (ABFT),
integrated-cognitive behavioral therapy (I-CBT) and
dialectical behavior therapy (DBT). The selection of these
three treatments was based on several criteria, including:

empirical support for reduction of suicidal ideation or
attempt; an explicit relationship between the interventions
and the theories; theoretical diversity (ABFT is an emo-
tion-focused, attachment-oriented family-based interven-
tion; I-CBT and DBT are grounded in cognitive-behavioral
theory with humanistic and mindfulness components);
evaluation with low-income people of color; and avail-
ability of a treatment manual for further study. In addition
they address clinical issues that are regularly addressed by
social workers including mood disorders, parent–child
conflict, substance use, emotion dysregulation, and non-
suicidal self-injury.
Considerations and Limitations
One important consideration related to these treatments is
the feasibility of implementing them with fidelity in day-to-
day social work practice (Singer & Greeno, 2013).
Becoming certified in each of these treatments, for exam-
ple, can take several years and thousands of dollars.

Practitioners cannot say they are providing ‘‘DBT, ABFT,
or I-CBT’’ unless they have received the requisite formal
training. Attending online or in-person non-certification
continuing education workshops allows practitioners to
learn and integrate approach-specific techniques and to say
that their practice is ‘‘informed’’ by these manualized
treatments.
Secondly, there are several limitations to the existing
research-base and the conceptual frameworks for each of
these treatments. For ABFT, research participants in the
United States have primarily been low-income African
American families living in Philadelphia which might limit
generalizability to more affluent or racially diverse sam-
ples. The primary outcome of ABFT research has been
reduction in suicidal ideation and depression which means
it has never been evaluated for preventing suicide attempts
or deaths. As with all manualized treatments, ABFT has a
specific theoretical orientation (attachment and systems

theory). ABFT therapists enter the treatment relationship
with the intention of helping families see the current sui-
cidal crisis through an attachment lens. Clinicians who
practice from a solution-focused or narrative perspective
might find this a priori assumption to be counter to their
client-centered treatment approach. Indeed, ABFT is
described as ‘‘client-respectful,’’ rather than ‘‘client-cen-
tered’’ (Diamond et al., 2010). With I-CBT, the role of
medication management is not explicitly addressed in the
protocol (Esposito-Smythers et al., 2012), which is
important because of the possibility of abusing prescription
medication, and the ongoing controversy about the role of
medication and increased suicide risk (Sharma, Guski,
Freund, & Gøtzsche, 2016). Another possible limitation of
I-CBT is that the focus on substance use and suicide may
lead other risky behaviors to be ignored if not observed or
asked about in the context of treatment. In addition,
replication of I-CBT in randomized trials with other sam-

ples (e.g., juvenile justice) is warranted. Criticisms of DBT
have included concerns that change mechanisms may be
123
related more to the structure of DBT (e.g., high levels of
supervision, consistency and stability of treatment, and the
high level of motivation of providers) as opposed to the
techniques themselves (Scheel, 2000), as well as the need
for a high level of organizational support in order for the
treatment to be effective (Swales, Taylor, & Hibbs, 2012).
Additionally, while there is initial empirical support for the
effectiveness of DBT-A, more randomized clinical trials
are needed (MacPherson et al., 2013).
We hope that by addressing theory in detail, this review
addresses some of the concerns about fit between the
treatment’s and the provider’s theoretical orientation.
Although there is great utility in understanding how and

why these psychotherapies address suicide risk, individual
and family therapies are not the only modalities that have
seen support in reducing suicide risk. For example, two
recent studies analyzed outcomes from community-based
youth suicide prevention programs across the USA and
found that these programs reduced youth suicide attempts
and deaths (Garraza, Walrath, Goldston, Reid, & McKeon,
2015; Walrath, Garraza, Reid, Goldston, & McKeon,
2015).
Although all three therapies have the goal of reducing
suicide risk in youth, the differences in theoretical
assumptions have important implications for how and when
to intervene. Whereas ABFT and I-CBT provide guidance
for when and how to work with families, DBT provides
guidance for when and how to work in groups. ABFT is an
affective-based therapy, whereas I-CBT and DBT are
cognitive-based interventions. Although all three include
skill-building, ABFT teaches skills to parents, and I-CBT

and DBT teach skills to youth. While all treatments have
been evaluated in outpatient settings, only DBT-A has been
evaluated in an inpatient setting. Each therapy was devel -
oped to address suicide risk within different psychiatric
disorders, including depression (ABFT), substance abuse
(I-CBT) and borderline personality disorders (DBT). These
differences are not the eccentric whims of the developers,
but are based on differing theoretical assumptions about
what leads to change. When social workers understand the
theoretical differences, they can make decisions about
which interventions are theoretically consistent and which
are not.
In sum, working with suicidal youth is complex and
fraught with anxiety for both the client and the clinician.
Potentially efficacious treatments reduce some of that
burden by providing a theoretically-informed pathway to
navigating this complex and potentially life-threatening
situation. Social work education programs can accelerate

the speed with which providers are able to deliver treat-
ments for suicidal adolescents by offering semester-long
electives in any of the interventions listed in this article,
post-graduate certificate programs in partnership with the
model developers, and technology mediated learning such
as webinars or podcast series.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no
conflict of
interest.
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CME Article
PSYCHIATRIC ANNALS • Vol. 49, No. 6, 2019 269

Suicide in Adolescents
Sade Udoetuk, MD; Sindhu Idicula, MD; Qammar Jabbar,
MBBS; and Asim A. Shah, MD
ABSTRACT
Suicide is a leading cause of death
in many nations around the world. De-
spite increased awareness of depres-
sion and suicidality in adolescents, spe-
cific groups continue to be affected by
this growing health problem. In this ar-
ticle, the authors review literature and
statistics surrounding suicide in ado-
lescents and young adults. Specifically,
we examine the epidemiology of sui-
cide in adolescents; highlight protec-
tive and risk factors and warning signs
of adolescent suicide; explore the roles
of technology, prevention program-
ming, and screening tools for youth
who are at risk; and discuss treatment
modalities for this patient population.
[Psychiatr Ann. 2019;49(6):269-272.]
I
n the adolescent and young adult
population, suicide continues to be
a growing and difficult challenge in
the United States and globally. World-
wide, suicide is the second leading cause
of death in adolescents and young adults
age 15 to 29 years.1 In the United States,
it has become the second leading cause

of death (behind unintentional injury)
for young people age 10 to 24 years.2
For younger adolescents, the number of
suicide incidents for those age 10 to 14
years is 517, compared to 6,252 among
adolescents and young adults age 15 to
24 years.2 It is notable that suicide ac-
counts for approximately 60% of deaths
compared to unintentional injury in the
younger category, and approximately
47% of deaths compared to unintention-
al injury in the older group.2
Gender does seem to play a role in
the incidence and expression of suicidal-
ity. According to the Centers for Disease
Control and Prevention, adolescent boys
and young adult men (age 15-24 years)
have a suicide completion rate that is
approximately 4 times higher than age-
matched girls and young adult women.
However, adolescent girls report a sig-
nificantly higher rate of suicidal ideation
than boys (22% in girls, 11.9% in boys),
as well as suicide plans (17% in girls, 10%
in boys), and suicide attempts (9% in
girls, 5% in boy).3 Additionally, girls are
twice as likely as boys to present to emer-
gency departments with self-inflicted
injury, a well-established risk factor for
future suicide.4 Also, suicide completion
rates in adolescent girls have grown over
time.2
Being a part of an ethnic or other mi-

nority population may also play a role.
In particular, Native Americans have
the highest rate of suicide for people age
10 to 24 years.5 Although historically
having a lower suicide rate, it is notable
that the rate has been steadily increas-
ing among African American adoles-
cents.6 Studies of adolescents in Europe
and North America have found that
immigrant and first-generation youth
have higher suicide rates than their na-
tive peers.7,8 People who identify as part
of the LGBTQI (lesbian, gay, bisexual,
transgender, queer/questioning, intersex)
community are also highly impacted,
with meta-analyses revealing double the
number of suicide attempts compared to
control populations.9
RISK FACTORS VERSUS PROTECTIVE
FACTORS VERSUS WARNING SIGNS
It is well established that certain
psychiatric disorders increase the like-
Sade Udoetuk, MD, is an Associate Professor, Menninger
Department of Psy-
chiatry and Behavioral Sciences, Baylor College of Medicine.
Sindhu Idicula, MD,
is an Associate Professor, Menninger Department of Psychiatry
and Behavioral
Sciences, Baylor College of Medicine. Qammar Jabbar, MBBS,
is a Medical Officer,
Children’s Hospital Karachi. Asim A. Shah, MD, is a Professor
and the Executive
Vice Chair, Menninger Department of Psychiatry and

Behavioral Sciences; and
a Professor, Department of Community and Family Medicine,
Baylor College of
Medicine.
Address correspondence to Sade Udoetuk, MD, Menninger
Department of Psy-
chiatry and Behavioral Sciences, Baylor College of Medicine,
1977 Butler Boulevard,
Houston, TX 77030; email: [email protected]
Disclosure: The authors have no relevant financial relationships
to disclose.
doi:10.3928/00485713-20190509-01
270 Copyright © SLACK Incorporated
CME Article
lihood of suicidality in adults. For ex-
ample, patients with depression are
20 to 30 times more likely to commit
suicide than the general population.10,11
One analysis showed that more than
one-half of adolescents who committed
suicide did not have a diagnosed men-
tal health or substance use disorder12
and, therefore, likely had not engaged
in treatment. Therefore, it is imperative
for all health clinicians (not just mental
health professionals) to be mindful of
risk factors and warning signs for sui-
cidal behaviors in adolescents.
Much attention has been directed

toward identifying factors that put
adolescents at risk, serve a protective
function, or warn of higher acute risk
of suicide completion. Protective fac-
tors are important to consider both to
assess where a person is as well as to
improve factors that may decrease the
likelihood of suicide attempts or com-
pletion. Protective factors include lack
of access to deadly weapons, access to
mental health services, positive con-
nections with school and peers, family
stability, religious involvement, and the
ability to solve problems and overcome
adversity.13-15
Risk factors for suicidality increase
the likelihood of suicide completion
over a lifetime. Although risk factors
are often assessed in mental health
care settings, they do little in terms of
predicting an increased likelihood of
suicide completion in the near future.
Warning signs, on the other hand,
serve as more acute signs that someone
may be at more risk of suicide comple-
tion. Imminent risk factors for suicide
completion include factors such as
nonsuicidal self-injury (NSSI), previ-
ous suicide attempts, psychopathology,
peer victimization, a history of sexual or
physical trauma, social isolation, poor
problem-solving and coping skills, low
self-esteem, dysfunction in the fam-
ily, repeated exposure to violence, and
ease of means to deadly weapons.16,17 In

particular, NSSI confers the highest el-
evation in risk, even higher than previ-
ous suicide attempt, as published in the
Treatment of Resistant Depression in
Adolescent study.17
Warning signs were developed in a
Consensus Statement by the Ameri-
can Association of Suicidology and
can be easily remembered by the mne-
monic, “IS PATH WARM,” as follows:
Increased Substance use; no sense of
Purpose in life; Anxiety, agitation or
sleep disturbance; feeling Trapped;
Hopelessness; Withdrawal from family,
friends, society; uncontrolled Anger or
rage, revenge-seeking; Reckless or risky
activities, seemingly without thinking;
dramatic Mood changes.
Assessment of warning signs may
give physicians a chance to both assess
and treat vulnerability factors in people
that put them at higher risk of immi-
nent self-harm or suicide. As stated
above, most adolescents who complete
suicide do not have a diagnosed mental
health condition; therefore, the role of
the pediatrician becomes particularly
important in recognizing the warning
signs of suicide in their patient popu-
lation. Upon recognizing these signs,
pediatricians should be comfortable
asking direct questions about suicidal
thoughts and plans and should also be

equipped to refer their patients to men-
tal health professionals as needed to
ensure proper treatment and follow-up
care.18
THE ROLE OF TECHNOLOGY
There has been a lot of attention fo-
cused on the use of social media and
its effect on suicide in adolescents.
One study found that cyberbullying
can increase suicidal ideation by 15%
and suicide by 9%.19 Unfortunately,
the Internet is filled with information
that instructs people about different
ways to commit suicide. There is even
a phenomenon called “cybersuicide,” in
which a person livestreams his or her
suicide act for online viewership. Still,
the Internet provides a semblance of
connectivity for adolescents who are
able to find support networks and kin-
ship online. There are even smartphone
apps that are available to help users
access support systems and preventive
measures.20 Thus, it must be emphasized
that the monitoring an adolescent’s use
of technology is an important reality of
parenting in this technological age.
PREVENTION OF SUICIDE
Suicide prevention programs have
gained prevalence as communities have
sought ways of decreasing suicide in

children and adolescents. Widespread
programs such as public service an-
nouncements, gate-keeper training
programs (increasing awareness of sui-
cidality in school staff ), and targeted
psychoeducation programs have been
implemented. Evidence of their effec-
tiveness in reducing suicidal behaviors
has been mixed. One study found that
there was benefit to school- and com-
munity-based programs in decreasing
adolescent suicidality.21 However, a re-
view article found that adolescents who
have risk factors may be less likely to
seek help after such initiatives.22 And,
another study suggested that physician-
education and decreased access to fire-
arms proved to be the most effective
means of reducing adolescent suicide.23
SCREENING TOOLS
Unfortunately, there is no gold stan-
dard for assessing suicidality in adoles-
cents. Still, a variety of screening tools
have been developed to screen for sui-
cidal ideation and can be applied in
multiple clinical settings from emer-
gency departments to general practi-
tioner offices and range from 4- to 20-
item assessments.
The Depressive Symptom Inven-
tory - Suicidality Subscale is a 4-item
self-report questionnaire designed to
identify the frequency and intensity

CME Article
PSYCHIATRIC ANNALS • Vol. 49, No. 6, 2019 271
of suicidal ideation and impulses over
the most recent 2-week period. It was
developed as part of a larger depressive
symptom index called the Hopelessness
Depression Symptom Questionnaire.24
Scores on each item range from 0 to 3
and, for the inventory, from 0 to 12, with
higher scores reflecting greater severity
of suicidal ideation. Some preliminary
data have supported the scale’s internal
consistency and validity.
The General Health Question-
naire-12 is a 12-item self-report ques-
tionnaire designed to identify those
patients awaiting general practitioner
consultations who may require further
evaluation due to generalized emotional
distress. Scores range from 0 to 12, with
higher scores representing more dis-
tress. The scale has accrued reasonable
reliability and validity data.
The Center for Epidemiologic Stud-
ies Depression Scale is a 20-item ques-
tionnaire developed for use in epide-
miological surveys to identify persons
with depressive symptoms.25 Its scores
range from 0 to 60, with higher scores

reflecting more depressive symptoms.
The scale has been widely used in epide-
miological surveys, with demonstrated
reliability and validity.
Other screening tools that can po-
tentially be used in adolescents include
the Columbia Suicide Severity Rating
Scale and the Nurses Global Assess-
ment of Suicide Risk.
TREATMENT OF ADOLESCENT
SUICIDE
Adolescent suicide is often the re-
sult of multiple, complicated factors
that can be difficult to pinpoint until
after an attempt is made and even once
a survivor is in treatment. Furthermore,
there is evidence that suicidality during
adolescence is not of the same nature as
a mental illness in adults, but instead
more closely linked to neurological,
hormonal, and social changes associated
with puberty.26 Typically, there is no
single intervention that can be credited
with reducing suicidality in adolescents;
therefore, a patient-centered, multi-
modal-approach is usually necessary for
success.
Patients who have suicidal intention
and plan, or who have recently attempt-
ed a suicidal act will more likely than
not require inpatient psychiatric hospi-

talization. Patients who appear to have
lower risk factors for suicide but pres-
ent with frequent somatic complaints
or who joke often about suicide may
require frequent follow-up with mental
health providers as their risk for suicide
might be higher than expected.
Pharmacology efforts have been tar-
geted toward the treatment of comor-
bid conditions. As depressive symptoms
are most commonly associated with
suicidality in adolescents, antidepres-
sants are often used as first-line medi-
cations. Paradoxically, antidepressants
have been given a black-box label from
the US Food and Drug Administration
for increasing the risk of suicide ide-
ation in adolescents and young adults.27
Therefore, the clinician must weigh the
risk-benefit ratio of treating a major de-
pressive disorder (MDD) with the risk
of increased suicidality in the pediatric
patient. A 2016 meta-analysis of anti-
depressant use for youth with MDD
found fluoxetine to be the best option.28
Lithium is known to reduce suicidality
in adults with bipolar disorder; how-
ever, one analysis found insufficient data
to make similar claims in children and
adolescents.29
Therapeutic interventions aimed at
adolescents with risk factors for sui-
cide with the largest effect sizes were
dialectical-behaviorial therapy (DBT),

cognitive-behavioral therapy, and men-
talization-based therapy.30 DBT, in
particular, was found to reduce depres-
sion, self-harm, and suicidal ideation
in adolescents.31 Further studies about
the use of electroconvulsive therapy and
ketamine infusions in adolescents will
be needed to establish their role in this
population.
CONCLUSION
Suicidality is a growing crisis in ado-
lescents around the world. More stud-
ies of the factors contributing to and
the nature of suicidal behavior in this
patient population are needed to ensure
appropriate preventive and treatment
strategies. Although it is a collective
societal effort to better humanity for
the future, pediatricians, psychiatrists,
and mental health providers play a dis-
tinct role in protecting children from
psychogenic distress and destruction.
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Reproduced with permission of copyright owner. Further
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Parker Family Episode 3
Program Transcript
FEMALE SPEAKER: I want to take care of her. I really do. I
mean, she's my
mom, and she's not getting any younger. But I deserve my own
life, my own
place. And I'm always tired of feeling like I'm suffocating all
the time. It's just-- It's
so confusing. I love her, you know?
FEMALE SPEAKER: I understand that you want a place of your
own to live. You
mentioned before that you and your mother argue a lot.
FEMALE SPEAKER: A lot? How about all the time? And all
that stuff she hoards,
it's just like, I'm drowning in it. It's like there's more room for
her junk than there is
for us. It just drives me crazy. Right to the hospital sometimes.
FEMALE SPEAKER: How many times have you been
hospitalized?
FEMALE SPEAKER: Let's see. Three times in four years. I
think I mentioned to
you that I'm bipolar, and I'm lousy dealing with stress. Oh.
Wait, um, there was
another time that I was in the hospital. I tried to commit
suicide. I guess I was

pretty lousy at that too, otherwise I wouldn't be here.
FEMALE SPEAKER: What made you want to do it? I was a
teenager. And when
you're a teenager, you find a reason every day to try to kill
yourself, right? I was--
I was depressed.
I remember one night I went out with some of my friends. And,
um, they were all
looking up at the sky and talking about how pretty the stars
were. And all I could
think about was that that sky was nothing more than a black
eye. It was lifeless,
and it could care less about any of us.
When they finally let me go home from the hospital, my family-
- wow-- what a trip
they were. They didn't want to talk about what I had tried to do.
That was off-
limits. I tried to kill myself. And I they acted like nothing ever
happened. I've never
told anybody that before.
FEMALE SPEAKER: Are you seeing a psychiatrist now?
FEMALE SPEAKER: Um, I go to a clinic, and I see him once a
month. I also go
to drop-in centers for group sessions, mostly for my depression.
FEMALE SPEAKER: What about medications?
FEMALE SPEAKER: Hell, yeah. They're my lifesaver.
FEMALE SPEAKER: What are you taking?

©2013 Laureate Education, Inc. 1
FEMALE SPEAKER: Let's see. For the bipolar I take lithium,
Paxil. Oh. Wait a
minute. I made a list so I would not forget the medications that
I take. Let's see. I
take lithium, Paxil, Abilify, Klonopin--
Additional Content Attribution
MUSIC:
Music by Clean Cuts
Original Art and Photography Provided By:
Brian Kline and Nico Danks
©2013 Laureate Education, Inc. 2
Theorem 28 (Problem 17). Given a segment AB and a ray

−−→
CD, there is a point X on
−−→
CD so that AB ∼= CX.
Proof. Let AB and
−−→
CD be given.
Figure 1: Given starting point for
Theorem 28
Theorem 29 (Problem 18). Given two points A and B (see
Figure 2, there is a third
point C not on
←→
AB such that A, B, and C form an equilateral triangle.
Proof. Refer to Figure2.
Figure 2: Given starting point
and suggested construction for
Theorem 29
1
Theorem 30 (Problem 21). Given ∠ BAC and a ray
−−→
DE, there is a ray
−−→
DH on a given

side of line
←→
DE so that ∠ BAC ∼= ∠ EDH.
Proof. Suppose we have ∠ BAC and a ray
−−→
DE. Using a
compass, measure AB and copy this length along ray
−−→
DE
at point D. Let G be the point on
−−→
DE such thatAB ∼=
DE (such a point exists by Theorem 28).
Figure 3: Given starting point
and start of construction for The-
orem 30
Theorem 31 (Problem 22). Every angle has a bisector.
Proof. Refer to Figure 4. As in Theorem 30, our con-
struction relies on creating congruent triangles, and prov-
ing the triangles are congruent as a way to show the an-
gles are congruent (and therefore that we have bisected
the angle). Let ∠ BAC be given. Use a compass to cre-
ate circle f with center A and radius AB. Let D be the
point of intersection of f with
−→
AC. Next, construct circle
g with center B and radius BD, and construct circle h

with center D and radius DB. Let E be one of the points
of intersection of h and g.
We will prove that 4AED ∼= 4AEB.
Figure 4: Angle bisector con-
struction
2
Theorem 32 (Problem 24). There is a line perpendicular to a
given line through a given
point not on the line.
Proof. Refer to Figure 5. Let line
←→
AB and point C not
on the line be given. Construct segment AC. If ∠ BAC
is a right angle, then AC is the perpendicular and we
are done. If not, construct a circle with center at C and
radius AC. Let D be the other point of intersection of
the circle with
←→
AB, and construct CD. Next, construct
. . .
Figure 5: Perpendicular con-
struction
Theorem 33 (Problem 25). There is a line perpendicular to a
given line through a given
point on the line.

←→
AB and point C
on the line be given. Construct circle k with center C
and positive radius (any length will work), and let D and
E be the points of intersection of the line with k. At
point D, construct circle m with center D and radius
DE. Similarly, at point E, construct circle n with center
E and radius DE. Let F be a point of intersection of m
and n, and construct DF and EF.
We will prove that 4CFE ∼= 4CFD.
Figure 6: Second perpendicular
construction
3
Theorem 34 (Problem 26). Every segment has a midpoint.
←→
AD be given. Con-
struct a circle with center at A and radius AD, and a
circle at D with radius AD, and let C and E be the
points of intersection of the two circles. Construct AC,
DC, AE, and DE. From here, . . .
Figure 7: Start of midpoint con-
struction
Theorem 35. The base angles of an isosceles triangle are

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