Kathryn R. Fox

Safety planning interventions (SPIs) may prevent suicidal behavior among adolescents, but many adolescents in need do not receive an SPI. Self-guided digital SPIs could reach many vulnerable youth, but the quality of adolescents' self-produced digital safety plans is unknown. In this longitudinal study, we analyzed 180 safety plans created using a novel SPI web-application by adolescents aged 13-18 (53% non-Hispanic white, 61% women) with past-year suicidal thoughts or behaviors. We rated safety plan quality and completeness using a validated scoring system, and participants reported safety plan usage at one-month follow-up. Of all safety plans, 78% were rated as at least "Satisfactory." Adolescents' safety plans were mostly complete, with an average completeness score of 15.32 out of 19 (SD = 2.85). Safety plan quality was moderate, with an average quality score of 10.47 out of 18 (SD = 2.02). Safety plan scores did not differ significantly by participant age. At one-month follow-up, 33% of participants reported having used their safety plan. Adolescents whose safety plans were more complete were more likely to use their plan (OR = 1.26, p < .01), but quality and global impression did not predict use. Of those who used their safety plan, 93% said it was at least "somewhat" helpful. Safety plan scores did not predict adolescent-rated plan helpfulness. Adolescents can use self-guided SPIs to create satisfactory safety plans without clinician guidance. Larger-scale testing of such tools is warranted, including to better understand associations between safety plan characteristics and suicide-relevant outcomes.

Objective: Many self‐destructive behaviors, including eating disorder (ED) behaviors (restrictive eating, binge eating, and purging), and nonsuicidal self‐injury (NSSI), serve an emotion regulation function. To date, it has been assumed that this is pro ‐hedonic in nature (e.g., to decrease negative affect). However, contra ‐hedonic motivations (to increase/maintain negative affect, decrease positive affect) are prevalent during adolescence and may also reinforce self‐destructive behaviors. In this study, we explored the presence, frequency, and clinical characteristics of contra‐hedonic functions of ED behaviors and NSSI among adolescents. Method: Participants were drawn from a larger longitudinal study and recruited online via social media. The present study included a transdiagnostic sample of 137 adolescents (75.91% White, 9.0% Hispanic, 75.18% female, mean age = 15.10 years) who completed surveys assessing the frequency, severity, contra‐hedonic, and pro‐hedonic functions of ED behaviors and NSSI. Results: Adolescents reported engaging in restrictive eating, binge eating, purging, and NSSI for each contra‐hedonic function assessed, with 81% of participants endorsing at least one contra‐hedonic function of ED behaviors and/or NSSI. Contra‐hedonic motivations were highest for NSSI compared to ED behaviors and were consistently associated with a desire to self‐punish. Conclusions: This study sheds light on a largely unexplored dimension of reinforcement functions of ED behaviors and NSSI: adolescents may not only engage in these behaviors to feel better, but also to make themselves feel worse. Further characterization of both pro‐ and contra‐hedonic functions of maladaptive behaviors in adolescents represents a promising avenue through which behavioral interventions can be more precisely designed and targeted.

Objective: The distinct associations of coaches' and teammates' beliefs about ideal body weight/shape with athletes' disordered eating remain unclear. This study examined how athletes' perceptions of their coaches' and teammates' weight‐ and shape‐related beliefs were associated with eating disorder symptoms and body dissatisfaction among National Collegiate Athletic Association (NCAA) swimmers. We hypothesized that both perceived coaches' and teammates' beliefs would be significantly associated with eating disorder symptoms and body dissatisfaction. Method: Participants were 190 in‐season NCAA swimmers (81% female) who completed a newly developed brief questionnaire designed to assess perceived coach and teammate weight/shape‐related beliefs (Coach and Teammate Weight/Shape Beliefs Questionnaire; CTWSBQ), as well as scales assessing eating disorder symptoms (Eating Disorder Examination—Questionnaire, EDE‐Q) and thinness‐ and muscularity‐related body dissatisfaction (ATHLETE Questionnaire Your Body and Sports subscale and Drive for Muscularity Scale, respectively). Multiple linear regression was used to model disordered eating as a function of CTWSBQ Teammate and Coach scores and covariates. Results: Only the CTWSBQ Teammate score was significantly associated with EDE‐Q Global (ΔR ² = 0.04) and ATHLETE (ΔR ² = 0.04) scores after adjustment for both demographic and psychological covariates. CTWSBQ Coach, but not Teammate, scores were significantly associated with Drive for Muscularity scores (ΔR ² = 0.02) after adjustment for covariates. Discussion: Findings from this cross‐sectional study suggest distinct patterns of association for perceived teammate versus coach weight/shape‐related beliefs across eating disorder symptoms, thinness‐related concerns, and muscularity‐related concerns in NCAA swimmers. Future work should test these patterns prospectively and determine whether they can inform prevention and education content for athletes and coaches.

Background: Youth suicide is a critical public health crisis. Subscription-based parental digital monitoring apps have emerged to monitor youths’ web-based activities and promptly alert parents in case of detected suicide risk. Parents’ responses to digital suicide risk alerts could significantly influence their children’s immediate and long-term well-being. However, parent experiences receiving these alerts and their impact on parent–child and co-parent relationships remain unclear. Objective: This study aimed to examine parental perceptions of digital suicide risk alerts, as well as characterize parents’ emotional, cognitive, and behavioral responses to alert receipts, and evaluate the impact on their relationships with their child and co-parent. Methods: Parents subscribed to the MMGuardian app (Pervasive Group Inc) who received a suicide risk alert were invited to complete a web-based survey. The survey assessed demographics, experiences with emotional, cognitive, and behavioral responses to alerts, and the impact on parent–child and co-parent relationships. Results: The final sample included 217 parents with an average age of 40.1 (SD 6.82) years and who were predominantly women (183/217, 84.3%), White (189/217, 87.1%), and non-Hispanic (183/217, 84.3%). Approximately 32% (69/217) of parents reported learning for the first time that their child may be at risk for suicide or self-harm through this alert. Parents reported a moderate level of concern about their child’s self-injurious thoughts and behaviors risk based on review of the alert (mean 2.12, SD 0.985). Parents reported experiencing a range of negative emotions in response to receiving a risk alert, with nervousness and sadness being the most common. Self-blame was the most strongly endorsed cognitive response, while thoughts of hopelessness, permanence (eg, “My child is never going to be okay”), and skepticism (eg, “My child is manipulating me”) were less common. Common behavioral actions taken after receiving the alert involved telling their child they loved them, talking with their child to learn more, validating their child’s thoughts and feelings, helping their child use coping skills, and discussing mental health with their child. Approximately 72% (156/217) of parents reported that the alert positively impacted their closeness with their child. Participants were between moderately and quite a bit in sync (mean 2.25, SD 1.26) with their co-guardian regarding alignment in perceptions of their child’s current risk as well as their corresponding thoughts, emotions, and plans related to child risk. Conclusions: Findings highlight several points for potential intervention to better support parents in navigating responding to their child’s possible suicide risk. As digital parental monitoring tools grow in popularity, research is essential to optimize these tools for the benefit of children and families. Improved understanding of the impact of digital suicide risk alerts will guide the development of effective digital support tools, empowering parents to help both themselves and their child.

Sexual and gender minority adolescents face elevated rates of self-injurious thoughts and behaviors (SITBs) relative to peers, yet fewer studies have examined risk in these youth, and reasons for higher risk remain unclear. Modeling SITBs using traditional statistical models has proven challenging. More complex machine learning approaches may offer better performance and insights. We explored and compared multiple machine learning models of suicide ideation, suicide attempts, and non-suicidal self-injury-both past-year frequency and dichotomous lifetime occurrence-among adolescents of diverse gender identities and sexual orientations. Data came from a large adolescent survey (N = 2,452) including psychological and demographic features. We compared prediction performance between generalized linear models, random forest models, and gradient boosting decision tree models using the full sample. Contrary to hypotheses, we found that these models generally performed comparably. We then selected the best-performing model families to run follow-up comparisons between cisgender and gender minority adolescents and between heterosexual and sexual minority adolescents. Depression was consistently the top-ranked feature across all models save one, in which discrimination was the top-ranked feature for lifetime occurrence of suicide attempt in the gender minority group. In addition, loneliness was more important in the gender minority group relative to the cisgender group for models of suicidal ideation. Discrimination and loneliness emerged as important features in predicting SITBs amongst gender minorities. Future work should examine these factors both as possible statistical predictors of SITB risk and as treatment targets for gender minority youth.

Disclosure of self-injurious thoughts and behaviors (SITBs) can serve as a catalyst to receiving mental health and lifesaving care; yet, many young people do not disclose these experiences to their therapists. In this study we aimed to identify barriers to adolescents disclosing their SITBs to their therapists and to compare these barriers across non-disclosure of suicidal ideation, suicidal behavior, and non-suicidal self-injury. Participants (n = 292) all had lived experience of at least one SITB and were an average age of 15.55 years, with the majority identifying as cisgender girls (68.15%). Using inductive content analysis of open-ended responses, six main categories of disclosure barriers were identified. These overarching barriers were: Agency Theft, Irrelevance, Therapeutic (Mis)Alliance, Internalized Stigma, Anticipated Stigma, and Lacking Disclosure Self-Efficacy. The majority (85.29%) of subordinate barriers were common across the three SITBs. Adolescents may hesitate to disclose their SITBs to their therapists for many reasons; prioritizing the therapeutic relationship and working collaboratively with adolescents could be instrumental in not only fostering disclosure but also an overall more positive therapeutic experience.

Objective Suicidal thoughts and behaviors are a leading cause of death, injury, and hospitalization among adolescents. Few evidence-based interventions exist, and these tend to be inaccessible for most youth. Electronic safety plan interventions represent a new avenue to disseminate an evidence-based suicide prevention tool. However, it is not clear whether youth find electronic, self-guided safety plans helpful, nor whether they will use the resulting safety card when experiencing suicidal thoughts or urges. This study examines adolescents' perceptions and use of an electronic, self-guided safety plan intervention. Method We recruited 322 adolescents with a past-year history of suicidal thoughts or behaviors, ages 13-17 (55.9% white and non-Hispanic; majority reporting diverse sexual orientations and genders) online via social media to participate in this two-part longitudinal study. At baseline, participants completed the electronic safety plan interventions and reported on key aspects of its usefulness and areas of improvement. Participants reported their use and perceptions of the plan one month later. Results Results suggested that adolescents understood, liked, and believed they would use a self-guided safety plan. One month later, about 1/3 of youth who experienced suicidal thoughts or urges used their safety card. Open-ended responses highlighted several features that adolescents enjoyed, including clarity, ease of use, and privacy. Participants also highlighted key areas for improvement, including formatting and language. Conclusion This study provides initial support for adolescent use of electronic self-guided safety plans. Next steps include updating this intervention based on youth feedback and testing the effectiveness of this tool using gold standard research methods.