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A Randomized Controlled Trial: Attachment-Based Family and Nondirective Supportive Treatments for Youth Who Are Suicidal
Open accessAbstract
Objective To evaluate the efficacy of attachment-based family therapy (ABFT) compared with a family-enhanced nondirective supportive therapy (FE-NST) for decreasing adolescents' suicide ideation and depressive symptoms.Method A randomized controlled trial of 129 adolescents who are suicidal ages 12- to 18-years-old (49% were African American) were randomized to ABFT (n = 66) or FE-NST (n = 63) for 16 weeks of treatment. Assessments occurred at baseline and 4, 8, 12, and 16 weeks. Trajectory of change and clinical recovery were calculated for suicidal ideation and depressive symptoms.Results There was no significant between-group difference in the rate of change in self-reported ideation (Suicidal Ideation Questionnaire-Jr; F 1,127 = 181, p = .18). Similar results were found for depressive symptoms. However, adolescents receiving ABFT showed a significant decrease in suicide ideation (t 127 = 12.61, p < .0001; effect size, d = 2.24). Adolescents receiving FE-NST showed a similar significant decrease (t 127 = 10.88, p < .0001; effect size, d = 1.93). Response rates (ie, ≥50% decrease in suicide ideation symptoms from baseline) at post-treatment were 69.1% for ABFT versus 62.3% for FE-NST.Conclusion Contrary to expectations, ABFT did not perform better than FE-NST. The 2 treatments produced substantial decreases in suicidal ideation and depressive symptoms that were comparable to or better than those reported in other more intensive, multicomponent treatments. The equivalent outcomes could be attributed to common treatment elements, different active mechanisms, or regression to the mean. Future studies will explore long-term follow up, secondary outcomes, and potential moderators and mediators.Clinical trial registration information Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.
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“Based on previous trials [21, 23], we estimate a 35% dropout rate.”
From The effectiveness and cost-effectiveness of attachment-based family therapy for young adults with high suicidal ideation: protocol of a randomized controlled trial (2024) · cites this paper as [23]
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“Several studies have demonstrated the effectiveness of ABFT for adolescents and young adults at risk for suicide [26–28].”
From Evaluating attachment-based family therapy in residential treatment in the United States: does adolescents' increased attachment security to caregivers lead to decreases in depressive symptoms? (2024) · cites this paper as [27]
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“However, effectiveness studies have shown mixed results on suicidal ideation [21, 23, 28, 29].”
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“For example, two randomized controlled clinical trials in the United States were conducted with samples in which a large percentage of teens (74% in the first trial and 49% in the second trial) identified as Black/African American (48, 62, 63), a group in the United States that has been historically marginalized and very likely to contend with race/ethnicity-related stress and trauma.”
From Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety (2023) · cites this paper as [48]
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“Including ABFT in the treatment of adolescent anxiety may be particularly beneficial for adolescents from historically marginalized communities, as ABFT was originally developed with these populations in mind (48–50).”
From Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety (2023) · cites this paper as [48]
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Citations
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“Treatment outcomes also might have resulted from mechanisms specific to ABFT and FE-NST.(38) In ABFT, the primary aim is to improve trust and communication in the parent–adolescent dyad.”
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“The failure to confirm the superiority of ABFT over FE-NST is consistent with many RCTs of 2 active treatments that fail to demonstrate the superiority of a specific treatment.(41,42) However, there are several notable limitations to the present findings.”
ResultAttachment-based family therapy for depressed adolescents.
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“This compares favorably to a meta-analysis that failed to find significant decreases in suicide attempts when active interventions were compared with TAU.33,34 In the Treatment Study of Adolescent Suicide Attempters (TASA),35 consisting of medication plus CBT plus family, 12% of participants made an attempt within 6 m…”
ResultPrevalence of and Risk Factors for Lifetime Suicide Attempts Among Blacks in the United States
Joe, S., Baser, R. E., Breeden, G., Neighbors, H. W., & Jackson, J. S. (2006) · JAMA · doi:10.1001/jama.296.17.2112 · Cited by 227
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“5%, comparable to similar studies.(11,35) For treatment dose, ABFT was delivered as a single modality by a community therapist, generally once a week (mean 14 sessions).”
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“Suicide rates for minority youth have increased,(15) yet minorities remain under-represented in clinical trials.(16) METHOD Participants”
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MethodCommon Factors in Couple and Family Therapy
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A Conceptual and Methodological Analysis of the Nonspecifics Argument
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“When adolescents view parents as sensitive, safe, and available, they are more likely to turn to parents for support that can buffer against common triggers for depressive feelings and suicide ideation (eg, grief and loss, bullying, school failure, romantic relationships, and family conflict).(7) Studies have demonstr…”
BackgroundSelf-citationFeasibility of attachment based family therapy for depressed clinic-referred Norwegian adolescents
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“ABFT also has been successfully disseminated to community settings.(9,10) Clinical Vignette”
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“As a result, interpretations of findings from studies using TAU as a comparison group are tenuous.(3) Surprisingly, there have been few RCTs for adolescents who are suicidal that have compared 2 manualbased, supervised, monitored treatments provided within the same research center.”
ResultConceptual model on application of chi-square test in education and social sciences
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“The c(2) analyses assessed treatment retention.(28) The pattern-mixture model approach assessed whether missing data had a substantive influence on results.”
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“Hierarchical generalized linear modeling was used to accommodate the binary outcome (ie, suicide attempts), while accounting for clustering of repeated measures within each subject.(26) Effect size was measured using the Cohen d for continuous outcomes and odds ratios for the binary outcome.”
MethodSample size and power calculations in repeated measurement analysis
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“ABFT also has been successfully disseminated to community settings.(9,10) Clinical Vignette”
BackgroundThe treatment of SSRI‐Resistant Depression in Adolescents (TORDIA): in search of the best next step
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“In the Treatment Study of Adolescent Suicide Attempters (TASA),(35) consisting of medication plus CBT plus family, 12% of participants made an attempt within 6 months.(36) In another study, 25% of participants in a skills training condition and 12% in an NST condition reattempted suicide during the treatment phase.”
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“For the SIQ-JR and the BDI, the main efficacy analysis modeled the rate of log-linear change from baseline to 16 weeks (end of active treatment).(25) All patients were included in the hierarchical linear model corresponding to a full intent-to-treat analysis.”
MethodSelf-citationGallop, R., Dimidjian, S., Atkins, D. C., & Muggeo, V. M. R. (2021) · Journal of Data Science · doi:10.6339/jds.201104_09(2).0006 · Cited by 9
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Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth
Glenn, C. R., Esposito, E. C., Porter, A. C., & Robinson, D. J. (2019) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2019.1591281 · Cited by 219
“RCT replication was less helpful for the status of Psychodynamic Therapy–Family-Based, “brand name” ABFT (Diamond et al., 2018, 2010), which is now rated as Level 4: Experimental for reducing SI and SA in youth.”
InfluentialSuicide and Suicide Risk in Adolescents
Hua, L. L., Lee, J., Rahmandar, M. H., Sigel, E. J., COMMITTEE ON ADOLESCENCE, & COUNCIL ON INJURY, V. (2024) · Pediatrics · doi:10.1542/peds.2023-064800 · Cited by 205
Kothgassner, O. D., Robinson, K., Goreis, A., Ougrin, D., & Plener, P. L. (2020) · Borderline Personality Disorder and Emotion Dysregulation · doi:10.1186/s40479-020-00123-9 · Cited by 163
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Witt, K. G., Hetrick, S. E., Rajaram, G., Hazell, P., Taylor Salisbury, T. L., Townsend, E., & Hawton, K. (2021) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013667.pub2 · Cited by 149
Attachment-based family therapy: Theory, clinical model, outcomes, and process research
Diamond, G., Diamond, G. M., & Levy, S. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.07.005 · Cited by 91
Self-citation
Metadata
- Authors
- Diamond, G. S., Kobak, R. R., Krauthamer Ewing, E. S., Levy, S. A., Herres, J. L., Russon, J. M., & Gallop, R. J.
- Affiliations
- Drexel University (US)
- University of Delaware (US)
- The College of New Jersey (US)
- Virginia Tech (US)
- West Chester University (US)
- Corresponding author
- Diamond, Guy S.
- ORCID
- Venue
- Journal of the American Academy of Child & Adolescent Psychiatry
- Publisher
- Elsevier BV
- Published
- 2019-07
- Volume
- 58
- Issue
- 7
- Pages
- 721-731
- ISSN
- 0890-8567 (ISSN-L)
- PMC
- PMC6491252
- OpenAlex
- W2898714608
- Cited by
- 147
- References
- 45
- Citations by year
- 2026: 13 · 2025: 19 · 2024: 13 · 2023: 24 · 2022: 15 · 2021: 41 · 2020: 9 · 2019: 11
- FWCI
- 17.92
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Academy of Child & Adolescent Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- VTechWorks (Virginia Tech) (submittedVersion, public-domain)
- Funders
- National Institute of Mental Health (5R01MH091059-03)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Counseling, Therapy, and Family Dynamics
- Keywords
- attachment-based family therapy, suicidal adolescents, suicidal ideation, depressive symptoms, family therapy, treatment efficacy, regression to the mean, African American adolescents
- MeSH terms
- Adolescent, Child, Depression, Family Therapy, Female, Humans, Male, Object Attachment, Pennsylvania, Suicide, Attempted, Reactive Attachment Disorder, Self Report, Suicidal Ideation
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