Attachment Based Family Therapy for Suicidal Adolescents

Suicide is the third leading cause of death for American adolescents. Nearly one million
adolescents a year attempt suicide and about 500,000 adolescents a year are admitted to
psychiatric hospitals for suicide attempts or serious suicidal ideation. This leads to high
emotional costs for families and financial cost for the health system. Yet, no medication,
and less than 10 psychotherapy studies have focused on suicidal youth and findings are mixed.
There has been a call for new and innovative approaches for depression treatment highlights
the need for alternative interventions for suicidal youth as well. Attachment-Based Family
Therapy (ABFT) offers a promising alternative to prior treatments. It is a manualized family
therapy targeting processes associated with suicide and depression. ABFT seeks to improve the
adolescent-caregiver relationship by increasing the family's capacity for discussing and
negotiating affectively charged issues in the relationship. Improvements in the attachment
relationship provide adolescents with improved capacity for affect regulation and the ability
to use the caregiver as a source of protection and support. These strengths buffer
adolescents against suicide and other risk behaviors. Four studies have demonstrated that
ABFT can reduce suicidal ideation and depressive symptoms with an average effect size of .97.
Unfortunately, interpretation of these studies is compromised by lack of a controlled
comparison treatment. This study aims to test the efficacy of ABFT using a comparison group
that controls for treatment dose, duration, therapist expertise, ecological factors, and
family involvement. The study includes one year follow-up data, assessment staff blind to
treatment condition and tests of the purported active ingredients of ABFT. Putative change
processes will be tested including: a)adolescents' expectancies for parent availability, b)
emotion regulation during parent-adolescent conflict discussions, and c) resolution of loss
and abuse. To test this, Dr. Kobak, a leading adolescent attachment researcher, will use the
Adult Attachment Interview and observational coding of the family interaction task to test
these treatment mechanisms. If successful, the findings will provide evidence for both the
efficacy and specificity of a family based treatment mechanism. The investigators will
recruit and randomize 130 adolescents to 16 weeks of ABFT or Family-Enhanced Non-directive
Supportive Therapy (FE-NST). Assessments will be conducted at baseline, 8, 16, 32 and 52
weeks. The primary and secondary aims assess whether ABFT reduces suicidal ideation,
depression, family conflict, and future suicide attempts more effectively than control.
Exploratory aims test a) whether ABFT can improve parent adolescent attachment, b) if
attachment mediates outcome, and if a history of trauma, parental depression or family
conflict moderate outcome. The study targets adolescents with severe and persistent suicidal
ideation selected from inner city, minority youth.

Inclusion Criteria:

- Adolescents between the ages of 12 and 18

- Adolescents endorse severe suicidal ideation (SIQ-JR > 31) and moderate depression
(BDI-II > 20) at two time points (1 to 3 days)

- At least one primary parent or caregiver must participate in the assessment and
treatment. This could be a biological parent, stepparent, grandparent, other relative,
or a foster parent, who has at least frequent contact with the subject. When possible
both parents will participate in the assessment and treatment. Legal custody is always
considered (e.g., divorced parents). Having all family members present at every
session is not required. Many individual meetings with the subject or the parent are
planned in both treatments.

Exclusion Criteria:

- Evidence of imminent risk of harm to self or others that cannot be safely treated on
an outpatient basis

- Evidence of psychotic features [as reported on the Diagnostic Interview Schedule for
Children; Voice Diagnostic Interview Schedule for Children (VDISC)]

- Evidence of suffering from severe cognitive impairment (e.g., mental retardation,
severe developmental disorders) as evidenced by educational records, parental report
and/or clinical impression).

- Subjects taking antidepressant medication for depression for less than 6 weeks prior
to the screening.