CARE (Care, Assess, Respond, Empower) (OJJDP Model Program Guide)

Office of Justice Programs, Innovation - Partnerships – Safer Neighborhoods

Office of Juvenile Justice and Delinquency Prevention (OJJDP) Serving Children, Families and Communities

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CARE (Care, Assess, Respond, Empower)

Intervention:

CARE (Care, Assess, Respond, Empower), formerly called Counselors CARE (C–CARE), is a school-based, brief assessment and crisis intervention for youth at risk for suicide. The CARE protocol is a theory-based intervention designed to empower youth and to activate social support by connecting a given youth to a caring person readily available to him or her in his or her high school, contacting and instructing parents in providing support and understanding, and providing a supportive environment during the assessment process. The goal of CARE is to decrease suicidal behaviors and related risk factors and to increase personal and social assets by using a standardized individual prevention approach delivered by trained staff in school.

CARE integrates prevention approaches that are known to be effective with adolescents, specifically for reducing suicide potential, including a social network support/influence approach and a brief intervention approach. The CARE intervention introduces youth to an alternative perspective on his or her 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.

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 (MAPS). This component includes a motivational introduction and then an assessment of direct suicide risk factors, related risk factors, and protective factors, including stressors, depression, hopelessness, anxiety, suicidal behaviors, risky behaviors, drug involvement, personal resources and coping strategies, and social support resources.

The assessment interview is followed by a 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, shared perceptions are validated and discrepancies are clarified, positive coping strategies are reinforced, and an action plan for enhancing support resources is developed.

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. A telephone connection is also made with the parent or guardian of the youth’s choice. The intent of the school and parent contacts is to enhance social network connections, support, and future accessibility of 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. CARE was designed so that the protocol could be implemented in conjunction with an evidence-based suicide prevention program. In initial evaluations, CARE was typically augmented with CAST (Coping and Support Training), a 6-week small-group life skills training and social-support program for youth at risk of suicide.

Evaluation Methodology:

Study 1
Hooven and colleagues (2010) studied the long-term effectiveness of 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.

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.

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.

Evaluation Outcome:

Study 1
Although Hooven and colleagues (2010) report some significant findings, these are associated with attitudinal change and were not evidenced in behavioral change.

Short-Term Effects
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.

Other Information:

References:

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 and Life-Threatening Behavior 25(2):276–96.

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.

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.

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(1):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(5):742–52.

Program Specification:

New Rating:

Promising

Re-reviewed Date:

June 2011

Program Type:

Cognitive Behavioral Treatment

Conflict Resolution / Interpersonal Skills

Leadership and Youth Development

Ethnicity:

American Indian or Alaska Native

Asian

African American

Native Hawaiian or Other Pacific Islander

Hispanic or Latino (of any race)

White

Gender:

Both

Age:

14 - 19

Target Settings:

Suburban

Urban

Problem Behaviors:

Aggression/Violence

Alcohol,Tobacco and Other Drug Use

Family Functioning

Risk & Protective Factors:

Risk

Family

Poor family attachment / Bonding

Individual

Antisocial behavior and alienation / Delinquent beliefs / General delinquency involvement / Drug dealing

Early onset of aggression and/or violence

Favorable attitudes toward drug use/Early onset of AOD use/Alcohol and/or drug use

Life stressors

Mental disorder / Mental health problem / Conduct disorder

Poor refusal skills

School

Dropping out of school

Low academic achievement

Low academic aspirations

Negative attitude toward school / Low bonding / Low school attachment / Commitment to school

Truancy / Frequent absences

Protective

Family

Good relationship with parents / Bonding or attachment to family

Individual

Healthy / Conventional beliefs and clear standards

High individual expectations

Perception of social support from adults and peers

Positive / Resilient temperament

Positive expectations / Optimism for the future

Self-efficacy

Social competencies and problem solving skills

School

Strong school motivation / Positive attitude toward school

Student bonding (attachment to teachers, belief, commitment)

Additional Information:

SAMHSA: NREPP

Status:

Program is in operation at this time.

Performance Measures:

Suggested OJJDP Performance Measures for the Program Types(s):

Mental Health Services
Cognitive Behavioral Treatment
Logic Model: PDF
Performance Matrix:PDF
Delinquency Prevention
Leadership and Youth Development
Logic Model: PDF
Performance Matrix:PDF

Contact Information:

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