Academic journal article Education & Treatment of Children

Age Appropriate No-Suicide Agreements: Professionals' Ratings of Appropriateness and Effectiveness

Academic journal article Education & Treatment of Children

Age Appropriate No-Suicide Agreements: Professionals' Ratings of Appropriateness and Effectiveness

Article excerpt


No-suicide or no-harm agreements (NSA'S) are frequently used with suicidal adults, but little research exists on NSA's with children. To ascertain experts' opinions, 368 randomly sampled professional psychologists who specialized in children read one of six vignettes describing a suicidal youth and a therapist who used a NSA, then rated the appropriateness and effectiveness of the intervention. The vignettes varied the child's age (6, 9, or 12 years) and academic history (problems/no problems), and were paired with one of three age-appropriate NSA's, creating 18 treatments. A 3 (NSA Reading Level) x 3 (Child's Age) x 2 (Academic Performance) MANOVA followed by ANOV As indicated that psychologists mildly to moderately favored written NSA's regardless of reading level. An implication is that the process of getting the agreement may be more important that its wording.

One difficulty in research about suicidal children and/or adolescents is that few, if any studies, have addressed developmental levels. In fact, with few exceptions such as research on children's concepts of death (Speece & Brent, 1984), the closest that most studies have come to addressing developmental levels has been simply to use age as a correlate. One is left to speculate about the importance of cognitive and moral development and their impact upon childhood and/or adolescent suicide.

Developmental levels, which include both age and academic functioning, are important in other behavior management approaches. For example, a review of child behavior therapy treatment studies indicated that the child's developmental level was the only moderator of treatment outcomes (Durlak, Fuhrman, & Lampman, 1991). In terms of suicide prevention, one place where developmental levels would seem to be especially appropriate would be in no-suicide agreements, because they require reading and comprehension as well as the ability to make and hold a commitment. The American Psychological Association (APA) Code of ethics states that psychologists "use language that is reasonably understandable to the recipient of those services (APA, p. 1600)." One of the features of age-appropriate no-suicide agreements is that they provide language that is suitable to the child's developmental level.

No-suicide agreements (sometimes called no-harm agreements or no-suicide contracts) involve the client agreeing to refrain from any deliberate or accidental self-harm for a specified period, usually until the next appointment with the therapist, and to call specified phone numbers if he or she feels incapable of maintaining the agreement. Originally intended as an assessment as well as intervention tool, no-suicide agreements are often recommended for adults experiencing suicidal ideation (Assey, 1985; Bongar, 1991; Cox, 1979; Drye, Goulding, & Goulding, 1973; Hipple & Cimbolic, 1979; Neville & Barnes, 1985; Twiname, 1981). Though such agreements have also been recommended for use with adolescents (McBrien, 1983), their appropriateness and effectiveness when used with adolescents and children is far from clear. Research on no-suicide agreements with any age group is sparse (Mahrer & Bongar, 1993). However, other types of behavioral contracts have been recommended for suicidal families (McLean & Taylor, 1994) and children with emotional and behavioral difficulties (Ruth, 1996). Thus, conventional wisdom supports using no-suicide agreements with adults, and related research supports using other types of behavioral agreements with children, but little research has been done on these agreements with any age groups.

Some research supports the use of no-suicide agreements. When 63 practice teachers responded to a vignette about a suicidal 9 or 15-year-old that varied the level of suicide risk (mild, moderate, or severe), their responses were about the same regardless of the student's age or risk. The teachers took every threat seriously, though they were ambivalent about using either a verbal or written no-suicide agreement (Davidson & Range, 1997). …

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