Developing Text-based Support for Parents of Suicidal Adolescents After Emergency Department Visits: A Multi-component Intervention Pilot
Phase: NA
Conditions: Suicide
Sponsor: University of Michigan

 
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Developing Text-based Support for Parents of 
Adolescents After an Emergency Department Visit 
 
IRB Approval Date: January 2, 2024 
 
NCT05058664 
 
 

 
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RESEARCH PROTOCOL  
 
FULL STUDY TITLE: Developing text-based support for parents of suicidal adolescents after 
emergency department visits: A multi-component intervention pilot  
 
SHORT STUDY TITLE: Developing text-based support for parents of adolescents after an emergency 
department visit  
 
 
BACKGROUND 
Suicide, the second leading cause of death among 13 to 17-year-olds in the United States,1 is a major 
public health crisis. Emergency departments (EDs) increasingly serve as the first and only line of 
clinical contact for suicidal adolescents,2-4 many of whom experience post-discharge suicide attempts 
and related crises requiring return ED visits.5-7 Unfortunately, a considerable number of youth at risk for 
suicide seen in EDs do not link to outpatient treatment or, if they do, these services may be delayed or 
prematurely discontinued.8-11 During this high-risk period, parents or other caregivers are often at the 
forefront of suicide prevention, yet they report feeling overwhelmed and unsure about how to best care 
for their child’s post-discharge needs.12-14 Thus, intervening with suicidal youth and their families during 
or shortly after an ED visit offers a promising window of opportunity to prevent post-discharge crises.  
 
Thus, to improve post-ED bridging care and reduce youth suicidal crises, we propose to develop and 
pilot an adaptive, text-based intervention targeting two interrelated domains: (1) supporting parents in 
promoting the safety and well-being of suicidal adolescents and (2) providing support directed at 
enhancing parents’ own well-being.  
 
Text messages offer an accessible continuity of care strategy after ED care, as they are nearly 
ubiquitous in the United States,22 and have been used to support a range of behavioral and health 
outcomes.23-27 Because suicidal adolescents are heterogeneous with respect to varying levels of 
suicide risk33,34—and parents may experience varying caregiving challenges and stress—a texting 
intervention should ideally be tailored to address parents’ unique and changing needs. Aiming to 
maximize outcomes while minimizing burden, a Just-In-Time Adaptive Intervention (JITAI) is an 
intervention design that adapts the provision of mobile-based interventions to meet the dynamically 
changing needs of individuals in the “real” world.35,36 This study will build the foundation for an effective 
JITAI for parents of suicidal youth by investigating the feasibility and acceptability of employing a micro-
randomized trial (MRT)—an experimental design used for optimizing JITAIs.38 
 
STUDY PURPOSE 
This study seeks to develop and pilot an adaptive, text-based intervention for parents of suicidal youth 
transitioning from ED care. The study will address an urgent need for efficacious continuity of care 
strategies for suicidal youth post ED care using a scalable approach. The study’s aims are as follows:  
 
Aim 1 (Non-Clinical Trial): 
 
Finalize text-based intervention components in preparation for the pilot study. Drawing on 
theoretical and clinical considerations, as well as our preliminary parent focus group data, we will 
develop text messages focused on two domains: (1) messages encouraging parental provision of 
adolescent-focused (A-F) support (e.g., suicide prevention activities, communication, tips for supporting 
at-risk youth); and (2) messages providing parent-focused (P-F) support (e.g., affirmation, tips for 
parents’ own well-being). Text messages will be iteratively refined based on input from experts and 
parents.  
 

 
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Aim 2: 
 
2a: As part of Aim 2, Pilot the text-based intervention to demonstrate its feasibility and 
acceptability. Parents of suicidal adolescents seeking ED services will be randomized to one of three 
groups: a control group or one of two 6-week intervention groups receiving either the A-F or A-F plus P-
F texting components. Beyond feasibility and acceptability, we will explore the effect of intervention 
groups on the proposed mechanism (parental self-efficacy) and distal outcomes (engagement in 
suicide prevention activities) assessed over 2-, 6-, and 12-weeks post ED visit. Follow-up youth 
outcomes (e.g., suicide attempt and ED visit) will also be explored. 
 
2b: As part of Aim 2, pilot an embedded MRT to inform the development of a JITAI for parents of 
suicidal youth. Because all elements of A-F are seen as essential, while P-F support may require 
adaptation, the A-F plus P-F arm will include an embedded MRT involving two daily randomizations to 
P-F message vs. no message conditions for the duration of the 6-week intervention. We will explore if, 
and when, the P-F message vs. no message condition influences within-person proximal outcomes 
(parental stress, mood) assessed daily for the 6 weeks. 
 
Aim 1 is preparatory non-trial work to Aim 2 - the clinical trial.   
 
METHODS 
Participants and Study Enrollment Criteria: Participants will include adolescent-parent pairs 
recruited from Psychiatric Emergency Services (PES) at the University of Michigan. Research 
assistants will screen admission logs for participant eligibility based on adolescents’ age (13-17) and 
presenting problem due to (1) last-week suicidal ideation and/or (2) recent (within a month) suicide 
attempt/behavior (actual, interrupted, aborted suicide attempt). Exclusion criteria will include (1) youth 
with severe cognitive impairment or altered mental status (e.g., psychosis, manic state), (2) youth with 
severe aggression/agitation, (3) no availability of a legal guardian, or (4) parents not owning a cell 
phone with text messaging capability. Eligible PES patients and their parents will be approached by 
research assistants for parent/guardian consent and adolescent assent during recruitment shifts.  
 
Eligible participants who provide consent/assent will participate in Aim 1 or Aim 2.  Separate 
consent/assent forms for Aim 1 and Aim 2 will be provided at enrollment. Methods specific to Aims 1 
and 2 are described below.  
 
Unless listed in the Primary Analysis under “Data Analysis for Aim 2” section, all outcomes and 
assessments are exploratory or ancillary.  
 
Aim 1 (Non-Clinical Trial) Methods: 
 
Initial Development of Text Messages: An initial “bank” of text messages for the A-F and P-F 
intervention components will be developed using an iterative process. This process will draw on (a) 
relevant theory, (b) best-practice recommendations, (c) content area knowledge, and (d) our research 
team’s preliminary data drawn from previous focus groups conducted with parents of suicidal 
adolescents after ED discharge. The tone of the messages will incorporate Motivational Interviewing 
(MI) principles as an additional strategy to increase parents’ self-efficacy and motivation to implement 
the suggested recommendations and tips for adolescent- and parent-directed support. Some messages 
will incorporate links to additional online resources or information. 
 
Description of Components and Sample Messages: 
 

 
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Adolescent-focused support (A-F component): The A-F texting component will include content 
consistent with best-practice recommendations for parents to buffer youth against suicide risk. This will 
incorporate messages focusing on: (1) restricting access to lethal means; (2) recognizing and attending 
to suicide warning signs; (3) encouraging adolescent’s use of coping strategies; (4) ways parents can 
support and assist the youth in using the safety plan; (5) monitoring and supervising the youth with 
sensitive queries about mood and suicidality; (6) responding in a sensitive manner to disclosures of 
distress and suicidality; (7) tips for communication; (8) providing emotional support and engaging in 
activities promoting connectedness; and (9) reminders about crisis resources.  
 
Parent-focused support (P-F component): The P-F texting component will include content focused on 
providing parent-directed support (e.g., encouragement, affirmations), as well as tips for parents’ self-
care and own well-being.  
 
Procedures for Obtaining Parent Feedback in Aim 1: Parents meeting inclusion/exclusion criteria, 
as described above, will be recruited during or shortly after their adolescent’s ED visit. Parents will 
provide feedback during or following the ED visit using an online survey to maximize retention. We will 
compile parents’ ratings of messages with regard to the extent to which each message was perceived 
positively (5-point scale ranging from “disliked a lot” to “liked a lot”). For each message, parents’ 
specific feedback will also be solicited and used to modify or discard specific messages. Moreover, 
parents will be asked to provide their opinions regarding message content they would prefer to receive 
as well as the proposed structure of the text-based intervention (e.g., frequency and duration of text 
messages). Feedback will be obtained with a survey build using a Qualtrics survey system, and the 
survey will take approximately 20-30 minutes to complete. Participating parents will be compensated 
$30, and their feedback will be used to finalize the bank of messages.  
 
 
Aim 2 Methods: 
 
Overview of Aim 2 Procedures: 
After providing informed consent / assent, participants will be enrolled in the study. After completing a 
baseline survey, parent-adolescent pairs will be randomized to one of three groups: control (standard 
ED care), A-F texting component alone, or A-F in combination with P-F texting component. Parents 
randomized to either A-F or A-F plus P-F intervention groups will receive the text-based intervention 
over a course of six weeks following their adolescent’s ED discharge. The P-F component includes an 
embedded MRT, which will allow us to examine the feasibility and acceptability of conducting an MRT, 
as well as explore if and under what conditions receiving the P-F message may be most beneficial. 
Participants who are randomized to receive the P-F texting component (as part of the A-F + P-F 
intervention arm) will be randomized twice each day (morning and evening) to either receive or not 
receive the P-F message at each randomization; at each randomization, the probability of either 
receiving or not receiving the P-F message will be 50%. As such, parents receiving the P-F component 
will receive between none and two P-F messages on any given day, on average receiving one P-F 
message on any given day. Over the course of the 6-week intervention, parents in the A-F condition will 
receive 1 message each day, and parents in the A-F + P-F condition will receive between 1-3 
messages, based on randomization (on average, 2 messages each day). 
 
Assessment Procedures for Aim 2: 
Participating parents and adolescents will complete baseline assessment during the index ED visit. 
Parents and adolescents will be asked to complete baseline measures using Qualtrics on a study-
provided tablet computer. Participants will also be provided the option of filling out the measures using 
a paper and pencil format if they prefer or if any technological difficulties are encountered that would 

 
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prevent the completion of the surveys on a tablet computer. Parents and adolescents will each receive 
$10 for completing the baseline assessment. Follow-up assessments will be conducted approximately 
2, 6, and 12 weeks after enrollment. Parents and adolescents will complete assessments at 2 and 6 
weeks using online surveys (using Qualtrics software). Parents will be compensated $20, and 
adolescents will be compensated $15 for completing each of the two online surveys. The 12-week 
follow-up, which will be used to assess youth suicide attempts and return ED visits, will be conducted 
over the telephone by a trained research interviewer. Adolescents and parents will each receive $30 for 
completing the 12-week assessment. Chart data will also be abstracted to obtain relevant clinical 
information (e.g. psychiatric diagnoses, reason for hospitalization, previous hospitalizations). Finally, 
parent satisfaction with intervention components will also be assessed. 
 
Aim 2 assessments were not collected for assessing primary or exploratory outcomes unless noted 
within the Aim 2 data analysis section. 
 
Baseline Assessments 
 
Parents at Baseline:  
- 
Demographics 
- 
DERS-SF  
- 
Parental Self-Efficacy Scale  
- 
PSC-17  
- 
Mental Health Service Utilization Scale  
- 
Multidimensional Scale of Perceived Social Support  
- 
PHQ-4  
- 
PHQ-10  
- 
CGSQ-SF7  
- 
Family History Screen  
- 
GF-FAD  
- 
Social/Emotional Support 
- 
PANAS  
- 
Munich Chronotype Questionnaire  
- 
Safety measures (home environment lethal means restriction) 
 
Adolescents at Baseline: 
- 
Demographics  
- 
DERS-SF  
- 
AUDIT-C  
- 
C-SSRS  
- 
NIDA-modified ASSIST  
- 
NSSI  
- 
PHQ-9  
- 
GAD-7  
- 
Brief Hopelessness Scale  
- 
Self-Efficacy to Cope with Suicidal Thoughts and Urges Scale  
- 
Self-Rated Expectations of Risk  
- 
Parent-Family Connectedness Scale  
- 
GF-FAD  
- 
Parent-Family Connected Scale  
- 
Pediatric Family Relationships  
 
Follow-Up Assessments at 2, 6 and 12 weeks 

 
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Parents: 
- 
Parents’ engagement in suicide prevention activities  
- 
Parental Self-Efficacy Scale (parental coping self-efficacy)  
- 
Social/Emotional Support  
- 
PHQ-4 (depression and anxiety symptoms)  
- 
PHQ-10 (areas of functioning in daily life) 
- 
CGSQ-SF7 (caregiver stress) 
- 
PANAS (positive and negative affect)  
- 
Mental Health Service Utilization Scale (only at 6 and 12 weeks) 
- 
Intervention Feedback (only at 6 weeks) 
- 
Multidimensional Scale of Perceived Social Support (only at 12 weeks) 
- 
 
 
Adolescents: 
- 
Parents’ engagement in suicide prevention activities  
- 
PHQ-4 (depression and anxiety symptoms)  
- 
PHQ-10 (areas of functioning in daily life) 
- 
Brief Hopelessness Scale (hopelessness) 
- 
Self-Efficacy to Cope with Suicidal Thoughts and Urges Scale (suicide coping self-efficacy)   
- 
Self-Rated Expectations of Risk (perceived suicidal behavior risk) 
- 
Parent-Family Connectedness Scale (perceived connectedness to parents/family) 
- 
Pediatric Family Relationships (family support) 
- 
Mental Health Service Utilization (only at 12 weeks) 
- 
C-SSRS (only at 12 weeks) 
 
Daily Surveys: 
All parents will respond to brief daily surveys over the 6-week intervention. Two brief (1-2 min) online 
surveys will be sent to parents’ phone each day (morning and afternoon/evening) via text message 
using a secure automated delivery system. Parents will be provided with approximately 2 hours to 
complete the daily survey. To increase adherence, parents will be provided with an incentive of $2 for 
each daily survey. Items will be brief and drawn from known and validated scales.   
 
Data Analysis for Aim 2: 
 
Primary Analysis: We will obtain descriptive data related to intervention feasibility and acceptability as 
measured by: (1) percentage of eligible participants who agree to participate in the study, (2) 
percentage of participants who complete follow-up assessments, (3) of those randomized to the texting 
intervention, percentages of parents who remain active (i.e. do not request to stop receiving 
messages), and (4) parents’ satisfaction with the intervention.  
 
Exploratory Analyses: In exploratory analyses, we will explore the effect of intervention on the proposed 
mechanism of change (parental self-efficacy) assessed at 2-, 6-, and 12-weeks post enrollment, we will 
use multi-level analyses for continuous variables (linear mixed-effects models). We will also conduct 
exploratory analyses of the effect of intervention on the proposed distal outcome of parental 
engagement in supportive and suicide prevention activities, assessed at 2-, 6-, and 12-weeks post 
enrollment. Analyses will be conducted using an intent-to-treat approach. Finally, we will describe 
differences between intervention vs. control regarding youth suicidal behavior outcomes at the 12-week 
follow-up. 
 

 
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We will conduct exploratory analyses on the primary proximal outcome (parental stress) using a 
generalization of regression developed for analyzing MRT data, specifically developed to ensure 
unbiased estimated of effects of time-varying treatments (i.e. sending a P-F message vs. not) on a 
time-varying outcomes (i.e. parental stress). Finally, for the exploratory analyses on the secondary 
proximal outcome, i.e. parental positive and negative affect, we will also use the generalization of 
regression analyses to explore if, on average across participants, receiving the P-F message is 
associated with a decrease in parental negative affect and an increase in positive affect.  
 
RISK MANAGEMENT  
The use of trained research staff for completing assessments will ensure that any potential safety 
issues are identified and appropriately addressed in accordance with study protocol. The PI will closely 
supervise research staff. Ensuring that any potential safety issues are appropriately addressed will be 
enhanced by the availability of an on-call psychologist. To this end, the study will have a 
comprehensive Risk Management Protocol detailing guidelines for managing safety concerns, including 
responding to high suicide risk and appropriate documentation. In particular, adolescents’ suicidal 
ideation and behavior will be assessed at the time of the 12-week assessment. Trained research 
interviewers conducting the assessments will complete an Action Plan, detailing criteria and steps for 
initiating consultation with an on-call psychologist and includes documenting whether or not a 
participant met the study’s high-risk criteria. The on-call supervisor will be available by telephone during 
scheduled assessments in case an adolescent meets high suicide risk criteria (e.g., recent suicidal 
ideation with thoughts of method, suicidal intent and/or plan; and/or disclosure of suicidal behavior 
since index ED visit). An endorsement of responses items indicating a high level of risk will result in the 
research staff member initiating the Action, which specifies next steps (e.g., contact the adolescent’s 
parent/guardian; contact the on-call psychologist; provide recommendations in consultation with the on-
call psychologists; contact emergency services, if needed).  
 
 
CONFIDENTIALITY 
The study team will be trained in maintaining the confidentiality of participant data, and every effort will 
be made to ensure that study data storage practices will ensure that data cannot be linked to a 
particular person. Unique identification numbers will be assigned to all participants. Participants’ names 
and study IDs will be kept in a separate file from study data. All linking files will be maintained in a 
secure password-protected file on a secure server. All data will be coded with this ID rather than with a 
name. Electronic data files (e.g. surveys) will not contain any identifying information. Consent forms will 
be stored separately from data. Steps will also be taken to minimize breaches of confidentiality 
associated with the data collection tools used in the study. Online surveys will be developed in 
Qualtrics, with no identifying information collected via Qualtrics.  
 
 
 

 
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