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Program Profile: Care, Assess, Respond, Empower (CARE)

Evidence Rating: Promising - One study Promising - One study

Date: This profile was posted on November 08, 2011

Program Summary

A school-based, brief assessment and crisis intervention for youth at risk for suicide. The program is rated Promising. There were findings of attitudinal change not evidenced in behavioral change. In two studies, there was a reduction in suicide-risk behaviors and depression over the short and long-term.

Program Description

Program Goals

CARE (Care, Assess, Respond, Empower), also called Counselors CARE (C–CARE), is a school-based, brief assessment and crisis intervention for youth at risk for suicide. The CARE protocol is designed to empower youths and engage social support by connecting youths at risk of suicide to a caring person from their personal lives or from the school environment. Parents are contacted and instructed in providing support and understanding during the suicide-risk-assessment process. The goal of CARE is to decrease suicidal behaviors and related risk factors, and increase personal and social assets, by using a standardized individual prevention approach delivered by trained staff in school.

 

Program Theory

CARE integrates brief interventions and social network support/influence approaches to reduce suicide-risk behaviors and factors. The CARE intervention introduces youths to an alternative perspective on their situation, acknowledges distress, reinforces strengths, actively interrupts suicide-risk behaviors, and provides both a connection to and mechanisms for accessing sources of help and support from caring adults at home and at school.

 

Target Population

CARE is designed and best suited for adolescents ranging from 14 to 19 years old who are at risk of suicide.

 

Program Components

CARE integrates principles of behavior change and maintenance by building up skill acquisitions and social support. The program teaches skills related to stress management, emotion control, coping strategies, and seeking help when needed. By teaching teens these skills and letting them know it is acceptable to seek help during stressful periods, it is believed that negative behaviors (suicide ideation) and mental conditions (depression) will be reduced.

 

The CARE protocol consists of three main components that are typically completed in 3½ to 4 hours. The first part is a 1½- to 2-hour, one-to-one, computer-assisted suicide assessment called the Measure of Adolescent Potential for Suicide (or MAPS). This component includes a motivational introduction and then an assessment of direct suicide risk factors (suicide attempts or threats), related risk factors (depression, high anxiety, and hopelessness), and protective factors (coping strategies and social support resources).

 

The assessment interview is followed by a brief 2-hour motivational counseling session conducted by trained staff—typically advanced-practice nurses, counselors, or social workers. During the counseling session, the assessment results are summarized with the youth, and shared perceptions are validated. Positive coping strategies are introduced and reinforced along with an action plan for enhancing support resources.

 

The third component of CARE is the social network “connection” intervention. During this intervention, each youth is personally connected with a case manager in the school (a counselor or a trained school nurse) or with the youth’s favorite teacher to foster communication between the youth and school personnel. The youth also chooses a parent/guardian to communicate with by phone to serve as another social connection. The intent of the school and parent contacts is to enhance social network connections, support, and future access to help. The CARE protocol also includes a follow-up reassessment of suicide risk and protective factors and a booster motivational counseling session, typically 9 weeks after the initial counseling session.

Evaluation Outcomes

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Study 1

Although Hooven and colleagues (2010) report some significant findings, these are associated with attitudinal change and were not evidenced in behavioral change. As such, the preponderance of evidence demonstrates null effects in regard to affecting behavior in this study.

 

Short-Term Effects

Care, Assess, Respond, Empower (C–CARE) was effective at reducing risk factors and increasing protective factors for suicide across all intervention groups at the postintervention assessment. All groups showed immediate and significant results in reducing suicide ideation and threats, depression, hopelessness, anxiety, and anger. Protective factors such as coping, self-efficacy, and family support increased as well.

 

While all the intervention groups showed significant improvements over time, the combined and intensive youth and parent interventions (P&C–CARE) group displayed greater reductions in negative behavior and greater improvement in positive factors than the Parents CARE (P–CARE) and C–CARE intervention groups, and also the minimal-intervention (MI) comparison group. Although the P&C–Care and C–CARE significantly improved more than the MI comparison group, P–CARE was not statistically significant on many measures from the comparison group. This suggests that the most effective interventions include a multifaceted approach that involved both the youths and the parents.

 

Long-Term Effects

Similar to the short-term effects, a long-lasting decline was evident for all three intervention groups (C–CARE, P–CARE, and P&C–CARE) at 6 years from the baseline assessment. Measures of depression, anger, and suicidal behaviors showed a drop at postintervention assessment and continued a steady decline over the follow-up periods. Though the intervention groups showed a significant improvement in attitudinal change over time, these changes did not translate into behavioral changes.


Study 2

Suicide Risk Behaviors

Eggert and colleagues (2002) found immediate significant reductions in suicide-risk behaviors in both intervention groups (C–CARE and Coping and Support Training [CAST]) as well as in the comparison group over time. There were significant declines in levels of suicidal ideation, threats, and attempted suicides from baseline to the first follow-up assessment at 4 weeks out; however, there were no significant differences among the groups.

 

Depression

All three groups also evidenced a significant decline in measures of depression. Additionally, there were significant group effects, indicating changes by intervention group. CAST and C–CARE teens had lower levels of depression than the comparison group at the 10 week follow-up.

 

Drug Use

Drug use, drug control problems, and adverse drug consequences also showed reductions across all three groups. C–CARE and CAST teens had greater declines in drug use behavior than the comparison condition, but these failed to reach statistical significance.

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Evaluation Methodology

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Study 1

Hooven and colleagues (2010) studied the long-term effectiveness of Care, Assess, Respond, Empower (CARE), using a quasi-experimental design with three intervention/treatment groups and a comparison group. The study sample was drawn from 20 high schools in urban and suburban areas of the Pacific Northwest. A total of 2,000 youths were screened with the suicide risk screen (SRS) instrument. Students who screened in as at risk of suicide were retained for the study. Students who were not deemed currently at risk were excluded from the study. The initial screening identified 615 youths at risk for suicide. Overall, the sample was 61 percent female and 67 percent white, with a mean age of 15.9 years.

 

On completion of the SRS instrument, participants were randomly assigned to receive one of four conditions: Parents CARE (P–CARE), Counselors CARE (C–CARE), a combination of the youth and parent interventions (P&C–CARE), or the minimal-intervention comparison condition (MI). Youths assigned to any of the treatment conditions completed a 1½- to 2-hour assessment interview, followed by a brief counseling protocol and the facilitation of social connections with parents and school personnel, which lasted about another 1½ to 2 hours. At 2½ months from baseline assessment and initial counseling, a booster session consisting of a follow-up interview, a brief counseling protocol, and a repeat of the social connection was completed. The random assignment of teens and their parents to the intervention and comparison conditions produced the following groups: 155 subjects receiving P–CARE, 153 subjects receiving C–CARE, 164 subjects receiving P&C–CARE, and 143 receiving the MI comparison condition.

 

Parents of teens assigned to the P–CARE intervention completed two home visits with CARE staff, lasting about 2 hours each. During these visits parents learned suicide prevention “first aid” and how to support their teen through difficult times with skills adapted from the CARE curriculum given to youths. A parent booster session, conducted by phone, was administered 2½ months after the baseline assessment. During this phone call the teen’s suicide-risk status was reviewed and specific strategies that were previously taught and aimed at reconnecting the youth to social support were reinforced.

 

The teens assigned to the C–CARE condition received the aforementioned assessment and brief counseling session as the other interventions. However, in this condition parents did not receive additional training or home visitations to further support the programmatic elements of CARE. Teens receiving the P&C–CARE intervention had the same assessment, counseling sessions, and booster sessions as the other interventions. Their parents also received the home visits and suicide prevention “first aid” that parents in the P–CARE intervention had been given. Separating out the intervention groups in this manner allowed the researchers to determine the effectiveness of each component of CARE as well as the effects of combining them.

 

The MI comparison group was included as a necessary part of the research design and ethical concerns when dealing with youths at risk for suicide. Teens assigned to MI participated in a brief (15- to 30-minute) assessment interview, using the 22-item Screen for Youth Suicide Risk, followed by a risk feedback and mobilization of support resources at home and at school. This was designed to simulate the usual intervention provided by school personnel. If at any point during the study a youth was considered to be at imminent risk of suicide, regardless of group assignment, all available help and counseling were to be brought in to take care of the teen, who would be removed from the study. No such incidents occurred during the course of the study.

 

To assess the long-term effects of CARE, there were two follow-up study contacts made during young adulthood by phone. These phone calls were 1-hour assessment interviews used to check up on study subjects. The time from baseline—ranging from 2.5 to 8.0 years for all follow-up interviews—was incorporated into the analysis. The retention rate was 86 percent (530 study participants) of the original 615 participants who were included in the long-term young adult follow-up study. Fourteen percent had left the initial study before the start of the long-term follow-up.

 

All participants completed the High School Questionnaire (HSQ) that measures suicidal behaviors (thoughts, threats, attempts), depression, and drug involvement. Suicide-risk behaviors were measured in two ways: direct behavior and distress factors. Direct behavior consisted of suicidal thoughts, notes, threats, and attempts. Protective factors acquired at baseline include self-efficacy/coping and family support. A respondent was deemed to be at an elevated suicide risk if he or she reported a previous suicide attempt or had high scores on the depression scale (4 and above on a scale of 6). Substance use and abuse were measured as the frequency of use within the last 30 days of alcohol and illicit drugs (cocaine, opiates, inhalants, etc.).

 

Latent class growth models were used to determine patterns of change from postintervention to long-term follow-up. This method of longitudinal analysis is well suited for detecting differences among groups over time. Such an analytic plan allows for estimates of growth trajectories (behavior change over time) while accounting for the differences in the length of time from baseline to follow-up. Missing data was considered missing at random, and proper adjustments were made in the model to account for this.

 

Study 2

Eggert and colleagues (2002) used a three-group, repeated-measures, randomized prevention trial to study the effectiveness of CARE on 341 potential dropouts from seven high schools. The design included random assignment by school to one of two experimental conditions or to the “usual care” control condition. Adolescents were assigned to intervention groups through block randomization procedures. The starting condition for each school was randomly determined, and then study conditions were rotated according to the following sequence; usual care control condition, then C–CARE, then Coping and Support Training (CAST), and finally a no-intervention or “pause” condition. Study conditions were not repeated at any high school, nor were they nested within schools. Randomizing intervention conditions by school kept experimental and control conditions from occurring in the same school simultaneously, minimizing the possibility for contamination. The no-intervention condition allowed potential carryover effects within schools to dissipate over time.

 

Participants, potential dropouts, and youths at risk of suicide were selected using a two-part process. First, the pool of potential subjects was screened to identify potential dropouts by drawing on indicators that have been known to predict dropouts (low academic performance, poor attendance, and any earlier attempt or history of dropping out). Potential dropouts were then invited to join the study, at which point they were given the suicide risk screen instrument to identify those at risk for suicide. Risk level was based on seven items, which included suicide risk behaviors (thoughts, threats, prior attempts), depression, and drug involvement. Youths determined to be at risk of suicide were retained for the study; all others were excluded.

 

The final sample included students from 9th to 12th grade, ranging from 14 to 19 years old. The racial composition was 39.9 percent white, 12.9 percent biracial or mixed ethnicity, 12.9 percent Asian/Pacific Islander, 12.3 percent African American, 7.0 percent Hispanic, 2.1 percent American Indian, 3.8 percent other, and 9.1 percent unknown. More than half  the sample (56.6 percent) had one or more school moves in middle or high school, and just under half (48.3 percent) had experienced a divorce. The death of a parent was experienced by 12 percent of the sample.

 

Youth at high risk for suicide were then assigned to one of two experimental groups: C–CARE (n=117) or CAST (n=103). Teens assigned to C–CARE immediately started receiving the 4-weeklong intervention. Youths placed into the CAST group started receiving the 6-weeklong intervention after the C–CARE intervention was finished. Those assigned only to C–CARE did not receive the CAST intervention. The control group (n=121) received the individualized “usual care” protocol at the same time the intervention groups were receiving C–CARE.

 

The C–CARE intervention is a one-to-one, 2-hour assessment interview followed by a 1½-hour to 2-hour counseling session and social “connections” intervention with parents and school personnel. C–CARE is delivered by trained research staff—typically advanced practice nurses or social workers. The motivational counseling session concentrates on delivering empathy and support, sharing personal information, and reinforcing positive coping skills and help-seeking behaviors.

 

The CAST intervention is a combination of the above C–CARE intervention, followed by a small group prevention program consisting of 12 individual sessions each 1 hour long. These sessions consist of small groups that work on skills training and social support. The sessions were delivered over 6 weeks to groups of six or seven adolescents by trained master’s level high school teachers, counselors, or nurses with considerable school-based experience. Each session incorporated key objectives, skills, and an implementation plan detailing activities to be carried out by the CAST Leader. The subject and content of these sessions targeted mood management, drug-use control, and school performance. Each session consisted in part of helping youth apply newly acquired skills and gain support from family and other trusted adults.

The usual care control condition simulated the procedures typically used by school staff to deal with youth at suicide risk. Beck’s Suicide Ideation and Intent Scales were used to assess youths at risk of suicide. After the brief (30 minute) assessment, staff followed a short social-connections procedure and notified parents and select school personnel.


All participants filled out the HSQ at baseline assessment and at three follow-up assessments that coincided with the delivery of the intervention. The first follow-up assessment occurred at 4 weeks from baseline, when the C–CARE or “usual care” conditions had been implemented. The second follow-up occurred at 10 weeks from baseline or with the conclusion of the CAST intervention. The last assessment was completed 9 months from baseline.

 

The HSQ was used to measure suicide-risk behaviors, related risks, and protective factors. Suicide risks were seen as a group of self-destructive thoughts and behaviors including prior suicide attempts, written or verbalized threats of suicide, and suicidal thoughts. Related risks included measures of depression, anxiety, illicit drug use and control problems, and adverse drug consequences denoting addiction or dependency. Repeated-measures analysis of variance (ANOVA) was used to assess trends in the data over time. This trend analyses can detect changes in behavior, measured as trajectories, and as such can determine whether an intervention altered the behavior in question.

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Cost

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There is no cost information available for this program.
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Other Information

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Because the studies that comprised this program's evidence base do not demonstrate effects in a consistent direction, a single study icon is used to depict the extent of evidence.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Hooven, Carole, Jerald R. Herting, and Karen A. Snedker. 2010. “Long-Term Outcomes for the Promoting CARE Suicide Prevention Program.” American Journal of Health Behavior 34:721–36.

Study 2
Eggert, Leona L., Elaine Adams Thompson, Brooke P. Randell, and Kenneth C. Pike. 2002. “Preliminary Effects of Brief School-Based Prevention Approaches for Reducing Youth Suicide—Risk Behaviors, Depression, and Drug Involvement.” Journal of Child and Adolescent Psychiatric Nursing 15(2):48–64.
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Additional References

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These sources were used in the development of the program profile:

Eggert, Leona L., Elaine Adams Thompson, Jerald R. Herting, and Liela J. Nicholas. 1995. “Reducing Suicide Potential Among High-Risk Youth: Tests of a School-Based Prevention Program.” Suicide & Life-Threatening Behavior 25:276–96. (This study was reviewed but did not meet Crime Solutions' criteria for inclusion in the overall program rating.)

Randell, Brooke P., Leona L. Eggert, and Kenneth C. Pike. 2001. “Immediate Postintervention Effects of Two Brief Youth Suicide Prevention Interventions.” Suicide and Life-Threatening Behavior 31:41–61.

Thompson, Elaine Adams, Leona L. Eggert, Brooke P. Randell, and Kenneth C. Pike. 2001. “Evaluation of Indicated Suicide Risk Prevention Approaches for Potential High School Dropouts.” American Journal of Public Health 91:742–52.
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Related Practices

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Following are CrimeSolutions.gov-rated practices that are related to this program:

Mentoring
This practice provides at-risk youth with positive and consistent adult or older peer contact to promote healthy development and functioning by reducing risk factors. The practice is rated Effective in reducing delinquency outcomes; and Promising in reducing the use of alcohol and drugs; improving school attendance, grades, academic achievement test scores, social skills and peer relationships.

Evidence Ratings for Outcomes:
Effective - One Meta-Analysis Crime & Delinquency - Multiple crime/offense types
Promising - More than one Meta-Analysis Drugs & Substance Abuse - Multiple substances
Promising - One Meta-Analysis Education - Multiple education outcomes
Promising - One Meta-Analysis Mental Health & Behavioral Health - Psychological functioning
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Program Snapshot

Age: 14 - 19

Gender: Both

Race/Ethnicity: Black, American Indians/Alaska Native, Asian/Pacific Islander, Hispanic, White, Other

Geography: Suburban, Urban

Setting (Delivery): School

Program Type: Cognitive Behavioral Treatment, Conflict Resolution/Interpersonal Skills, Crisis Intervention/Response, Family Therapy, Mentoring, Parent Training

Current Program Status: Active

Listed by Other Directories: Model Programs Guide, National Registry of Evidence-based Programs and Practices

Program Developer:
Leona Eggert
Professor Emerita
University of Washington, Department of Psychosocial and Community Health
Box 357263
Seattle WA 98195-8732
Phone: 206.543.8736
Email

Program Director:
Reconnecting Youth, Inc.
P.O. Box 20343
Seattle WA 98102
Phone: 425.861.1177
Fax: 888.352.2819
Website
Email

Researcher:
Elaine Thompson
Professor Emerita
University of Washington, Department of Psychosocial and Community Health
Box 357263
Seattle WA 98195–7263
Phone: 206.543.8555
Fax: 206.685.9551
Email

Training and TA Provider:
Beth McNamara
Director of Programs and Training
Reconnecting Youth, Inc.
P.O. Box 20343
Seattle WA 98102
Phone: 425.861.1177
Fax: 888.352.2819
Website
Email