Exploring parent support needs during and after adolescent suicide crisis emergency department visits – A qualitative investigation

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Parents have reported feeling as though they are not appropriately supported to provide the critical life sustaining care their adolescent needs after discharge from the emergency department. This study sought to understand what types of support parents need as a result of the emergency department presentation. Method Semi-structured, online interviews were conducted between February and May 2023. Individuals were eligible to participate if they were parents (biological, step, or adoptive) of adolescents (12–18 years old) who had attended an Australian emergency department for suicide crisis since January 2018. Data was analysed via reflexive thematic analysis. Results Twenty biological parents participated in interviews (average age: 46.9 years). Reflexive thematic analysis indicated there were three domains of support parents’ desired: 1) information about, and active involvement in, the emergency department care, 2) information about how to keep their adolescent safe and support recovery, and 3) tools to support parents’ own wellbeing. Conclusions These findings provide a preliminary outline of the support parents need and what resources may need to be developed to educate and support parents, which could be integrated into the emergency department procedures. Improving the way in which parents are supported to care for their adolescent may help reduce recurrent incidents of adolescent suicide attempts. suicide emergency department parent adolescent suicide attempt qualitative Introduction Adolescents are the age cohort most likely to present to an emergency department (ED) during a suicide crisis (suicidal thoughts, feelings, plans or behaviours), in many developed countries, including Australia (1). Adolescents are also the age group which is most often hospitalised in Australia for suicide crisis (2), most likely via an ED presentation. Parents play a vital role in assisting their adolescent to access crisis care such as emergency departments and ongoing mental healthcare in the community (3). However, parents often experience their own struggles during this time, including heightened stress, anxiety, fear and depression (4). Parents who are psychologically distressed are less able to make effective decisions about their child’s care (5), suggesting parents are possibly struggling to provide appropriate care to their suicidal adolescent at a time when it is most critical. Parents who understand the treatment directives and options for their child’s care experience less distress than those who aren’t provided such support (6). Such parents may be better able to make care decisions for their child, due to both increased education and improved psychological wellbeing. Numerous studies have demonstrated the benefits of providing education and support to parents of suicidal adolescents. Several studies have shown that parents respond positively to means restriction education when provided during the ED presentation, with up to 100% of parents engaging in means restriction two-three weeks after hospital discharge (7-9). Furthermore, gatekeeper education training for parents has shown to improve parental confidence in keeping their adolescent safe from future suicide crises (10, 11). Family-based therapy has also demonstrated a reduction in suicidal ideation in suicidal adolescents (12, 13). Concerningly however, parents report feeling unsupported by the ED staff and processes and ill equipped to provide care to their adolescent after they are discharged from the hospital (14, 15). The period after ED discharge is often one of great concern for parents who subsequently undertake profound lifestyle alterations, such as leaving or reducing employment and abstaining from social interactions and events to provide constant monitoring and support to their child, with significant consequences for the parent and the family unit (4). Also, there are often long delays between discharge and when the adolescent is able to connect with community based mental health services (16), placing increased pressure on parents to cope and navigate this turbulent time. Providing parents more support and evidence-based information about to how care for their adolescent and themselves may reduce the likelihood of repeat suicide crises and improve engagement with community programs (17). Despite the vital role parents play supporting their adolescent after hospital discharge, there has been no research, to the authors knowledge, investigating the support needs of parents during the period surrounding the ED presentation. As such, this qualitative study sought to investigate what supports parents require when they accompany their suicidal adolescent, both during and immediately following the ED visit. Methods Setting This qualitative study was approved by University of New South Wales Human Research Ethics Committee (HC220756). Written consent was obtained from all participants prior to data collection. This study draws upon data collected as part of a larger study which explored parents’ experience of accompanying their adolescent child, who was experiencing suicide crisis, to the ED. The findings from which are currently under review. Recruitment Twenty participants were recruited from the Australian community between January and March 2023, via Black Dog Institute’s social media channels (Meta, X, and LinkedIn). After engaging with the social media posts, potential participants were redirected to the study website, which provided study details and prompted them to complete the participant information sheet before completing a screening questionnaire to assess eligibility. To be eligible, participants must be a biological, step, or adoptive parent who had accompanied their adolescent child (12–18 years) to an Australian ED in the previous five years (i.e., since January 2018) for suicide crisis (ideation, feelings, plans or attempts). There were no exclusion criteria. Eligible participants completed the consent form prior to registering for the study. Participation was voluntary and participants were free to withdraw from the study at any time prior to data analysis. Data collection Data were collected via online, semi-structured one-on-one interviews between February and May 2023. Interviews were conducted via a secure videoconferencing platform by the lead author (DR) and three peer researchers (SP, SA and JL) who had been trained and supported to conduct the interviews. Interviews continued until saturation of information was reached, and were digitally recorded, and de-identified before being sent to a third-party service for transcription. The interview guide was developed in consultation with six peer researchers who are parents (including SP, SA and JL) with a lived experience of accompanying their suicidal adolescent to the ED. The interview guide included a single question regarding the support the participants would have liked to receive: “what support options would you have liked to be provided for yourself during the ED visit?”. Due to the nature of interviews, support needs were also raised by participants in other sections of the interview and these responses were included in this analysis. Analysis Data was analysed following the six steps of Reflexive Thematic Analysis ( 18 ) and was led by the lead author (DR). First, in-depth familiarisation with the interview transcripts was conducted which involved full immersion with the data corpus and repeated reading and reflecting on the transcripts. During this step, interviewers reviewed the transcripts of the interviews they conducted to produce one-page summaries before discussing the shared ideas across the interviews as a group. Next, transcripts were read line-by-line and initial codes developed by the lead author who has extensive experience conducting qualitative analysis in suicide prevention research. These codes were then reviewed and discussed with the research team (DR, FS, LM and KB) for purposes of reflexivity and to determine the final set of codes. At this phase, the codes relating to the support parents wanted during the ED presentation were removed from the larger dataset, as it presented a different domain of investigation compared to exploring the ED experience itself. This support data was then analysed separately following the same process as above, and more detailed codes developed. These codes were used as building blocks and sorted into ‘clusters of meaning’ ( 19 ) to then produce a set of three themes that were identified by the research team. These themes acted as central organising concepts to assemble the types of support parents wanted during this critical time. Rigour was maintained throughout the analysis process through continued reflexivity throughout the research process during which the lead author maintained a detailed audit trail and a reflection journal, and a team approach to the analysis. Results Participant characteristics Twenty biological parents with a mean age of 46.9 years (SD = 4.3, range 40–55 years) completed interviews. Most participants were female (n = 18, 90%), roughly half were employed full time (n = 11, 55%), and 75% (n = 15) were married. The average age of the adolescent at the time of presentation was 15.35 years (SD = 1.79, range: 11–18 years), most adolescents were identified as female (n = 12, 60%), 25% as male (n = 5), 10% non-binary (n = 2), and 5% as gender fluid (n = 1). Three quarters (n = 15) of the presentations were for a suicide attempt, the remaining for suicidal thoughts. For half of the participants (n = 10) this was their first presentation to the ED for their adolescents’ suicide crisis. Participants’ most recent ED presentation for suicide crisis occurred between early 2018 and March 2023. Thematic Analysis Reflexive thematic analysis resulted in identification of three themes outlining the types of support parents wanted as a result of the ED presentation: 1) Information to reduce the uncertainty of the ED presentation, 2) strategies to keep their adolescent safe and support recovery, 3) support for parent wellbeing. A breakdown of each theme and related codes can be found in Table 1 . Table 1 Outline of themes and codes Theme Code 1. “I really wanted to know what was happening” What to expect during hospital presentation An opportunity to discuss adolescent crisis with staff 2. “Fundamental basic things that you need to do or watch for or ask to keep someone safe” What is necessary after discharge How to access psychological support for their adolescent Where to find non-clinical help for adolescent Education about suicide crises 3. “It's not actually just our children that are going through it, we are going through it with them” Where parents can access psychological support Recognition and compassion from ED staff Quick and easy ideas to support parent wellbeing 1. “I really wanted to know what was happening” Participants would have liked to receive more information about the hospital presentation, including what they were to expect in terms of treatment and outcomes, as well as an opportunity to discuss their adolescents’ crisis with staff. What to expect during hospital presentation : Participants reported wanting to be provided information about what their adolescents’ care would look like during their time in the ED and, if necessary, their inpatient admission. This included being told what treatment options there were and what outcomes of interventions, such as those to reduce lethality of an overdose, would indicate. Parents felt that being provided this information would have made the ED presentation easier for them: “And I really wanted to know what was happening, what was going on, what were they doing, what tests, because it just gave me something to hold onto, like, [what] are they expecting?” (Participant 3). An opportunity to discuss adolescents’ crisis with staff : Parents wanted an opportunity to discuss the context and nature of their adolescent’s suicide crisis with ED staff to help them feel a sense of control and as though they are valued during the presentation. “[The parent perspective is] relevant information. It’s relevant. … Actually, being heard as the carer as well, what your genuine concerns actually are. When we all know our young people the best … and we are just not listened to … and don’t have the capacity to fight the system to be heard” (Participant 18) 2. “Fundamental basic things that you need to do or watch for or ask to keep someone safe” Parents would like more information about how to provide the care their adolescent needs once they are discharged from the ED or hospital. This includes general information about how to keep them safe, information about accessing psychological support services in the community, where to find other, non-clinical, support for their adolescent, and education about mental health and suicide. What is necessary after discharge : Parents discussed wanting a recovery ‘roadmap’, so they felt confident to proceed with their adolescent’s care after discharge. The types of information parents wanted included: warning signs to look out for which may be indicative of a future suicide incident, what medications to consider as treatment, safety plans, helpline numbers and when is an appropriate time to contact them, and what types of services are available. Parents reported wanting information provided verbally by hospital staff and as printed material they could refer to later. “I think a lot of my stress would've been alleviated if I had a little more, more confidence in my ability. I, I mean, really, like that's your primary goal, right? Is to keep you, keep your child safe and to have, you know, whatever form it takes, the ability to build up that confidence, … everyone's going to need different stuff.” (Participant 19) How to access psychological support services : Participants reported wanting information about how to navigate the mental healthcare system, access to peer support workers or social workers, and for the hospital to arrange appointments with mental health clinicians in the community. Navigating the mental healthcare system was challenging for parents but they acknowledged access to this support was vital: “you're not going to fix them that very next day, but you can at least put in motion a very, like, high frequency process to … an expedited process to help them get the help that they obviously need.” (Participant 7) Where to find other forms of help for adolescent : Parents recognised that while the intensity of the suicide crisis may wane, the underlying mental health problems were likely to persist. As such, parents wanted more information about psychological support options for their adolescent, which were the most appropriate for their adolescent’s presenting concerns. “I think it would be amazing if parents in crisis like this were actually given, like a like an advocate, like a social worker case worker to kind of help them navigate the system. What's, what's actually available, what other options are there what other programs might help you know, what, you know, because someone who actually knows how to do it.” (Participant 14) Information about suicide crisis : Parents discussed wanting more information about suicide crisis, so they were in the best possible place to care for their adolescent; “I think that's really important that people actually have a much better understanding of suicide and how the experience of that person in that time…” (Participant 19). One parent noted the benefit of engaging with suicide specific training, such as ASIST, so that parents had the skills and confidence to have conversations about suicide with their child. 3. “It's not actually just our children that are going through it, we are going through it with them” Participants recognised the value in making sure they were mentally well so they could provide the best care for their adolescent. This included wanting information about how to access psychological support for themselves, tips for caring for themselves, and the power of informal support such as recognition and compassion from hospital staff. Where parents can get psychological support : Participants highlighted the importance of support to access their own psychological support, particularly since this was often not on their priority list. Parents felt that support from the ED to access and engage with psychological support would have made a significant difference to their ability to provide the ongoing support their adolescent required. “What would have been helpful is if they said to me … ‘This situation's very hard for you and whether or not you feel that now we recommend you get to counselling. Here's a card of someone you can talk to.’ … Because if you are doing well, then you can look after the child better and these next few days [and] weeks are going to be really taxing.” (Participant 3) Recognition and compassion from ED staff : Parents felt informal support, such as displays of compassion and verbal recognition of the struggles they were experiencing from the staff in the ED would go a long way in helping their psychological wellbeing during this time. “And there's that very real possibility that the carer is going to break down and start crying and say, ‘look, I'm not okay’. … So, it is being able to, to hold that carer in that moment …” (Participant 18) Tips for parent wellbeing : Parents wanted information about simple but impactful tips which can help improve their mental wellbeing, such as getting time outside, eating balanced meals, and validation/permission to feel a range of emotions: “… you are allowed to want to vent, you are allowed to be angry. You're allowed to be frustrated. You're allowed to be sad. You're allowed to have all of those feelings, [and] finding safe places to move through the feelings” (Participant 1) Discussion Parents provide vital support and care, beyond the scope of usual parenting, to their adolescent during and following an ED presentation for suicide crisis. However, parents are rarely given sufficient support to provide this unique care. This study aimed to understand what types of support parents need when they attend the ED with their adolescent child who is experiencing a suicide crisis, so parents can best support the adolescent and reduce their subsequent risk. Qualitative analysis identified three domains of support which parents desired: 1) information about, and active involvement in, the ED care, 2) information about how to keep their adolescent safe, and support their recovery, 3) tools to support parents’ wellbeing. Providing information about the adolescent’s treatment and care during the emergency department visit, delivered with care and at the right time, is one simple way to support parents during the ED visit. Studies exploring parents of ill adolescents and children found explaining hospital treatment processes was beneficial for parent and child outcomes ( 20 , 21 ). Keeping individuals abreast of treatment processes and providing concrete prognosis goals has been found to reduce distress experienced by parents of children and adolescents with cancer ( 6 ). Given the high degree of psychological distress experienced by parents of adolescents experiencing a suicide crisis ( 4 ), it is important to maximise simple, effective support mechanisms to improve outcomes for parents. Incorporating elements of caregiver engagement when treating suicidal adolescents, as is seen with parents of other ill children ( 22 ), into hospital employee training and procedures may effectively improve parent confidence and skills in providing care after discharge ( 23 , 24 ). Parents in this study frequently identified wanting to be provided with more information about how to access psychological support for their adolescent after being discharged from the ED or hospital. Parents in many developed countries have reported their mental health systems are difficult to navigate ( 25 ). In Australia, patients are often impacted by difficulties accessing services because of insufficient availability and long waiting lists ( 26 , 27 ). Furthermore, community mental health services targeted towards adolescents often have high entry thresholds, meaning in many instances, adolescents are only able to utilise services after they attempted suicide ( 16 ). Parents report being overwhelmed and struggling to understand how to navigate this complex system. ED staff have reported local services are complex, with numerous service offerings (which frequently change), making it difficult for them to know what services they should be recommending for individuals experiencing self-harm or suicide crisis ( 28 ). As such, ED staff may not be well-equipped to provide effective discharge care plans for this group. They may also lack the time and knowledge to develop care plans collaboratively with the young person and their parent or caregiver ( 29 , 30 ). Furthermore, adolescents do not often speak with a mental health clinician in the ED ( 31 ) and general ED staff are unlikely to have training or knowledge of mental health or suicide specific service options ( 28 , 30 ). Therefore, resources which help ED staff and help-seekers identify and contact psychological services may help increase the uptake of such services ( 32 ), and effective methods of providing such information should be investigated. This is likely to have a profound impact through increasing parent confidence in ED staff ( 33 ), improve adolescent access to appropriate resources ( 34 ), and empower hospital staff to confidently provide care thereby reducing the feelings of futility experienced by staff ( 35 ). Parents wanted information to help them with their own wellbeing so that they are able to provide the best possible care to their adolescent. Parents’ declining mental health surrounding an adolescent’s suicide crisis is frequently noted in the literature, particularly increased anxiety, depression and fear ( 4 ). Anxiety and depression have been linked with decreased cognitive functioning ( 36 ), which may impact a parent’s ability to make the best decisions about their adolescent’s care. Parents in this study highlighted the importance of receiving support for themselves throughout this journey, starting with compassion from ED staff, through to accessing psychological support in the community. Small acts of kindness from hospital staff, such as compassion and recognition of their feelings, helped individuals feel supported and gave them hope they could get through difficult periods ( 37 ). Peer support programs for parents of suicidal adolescents have also demonstrated an improvement in parent wellbeing ( 38 ). Worryingly, a lack of compassion from ED staff during the ED presentation is not only distressing for parents and their adolescents but is likely to reduce later treatment engagement ( 39 ), which may increase their risk of future suicide crises. Parents in this study also noted the positive impact of simple tips to maintain their own wellbeing during this period. This suggests parents do not necessarily require in-depth and voluminous support from hospital staff, but compassion such as offering cup of tea, recognition of theirs’ difficulties, and simple wellbeing strategies may have positive outcomes. This study has several strengths; this novel investigation of parent needs during an ED presentation with their suicidal adolescent allows us to make an important contribution to the scant evidence surrounding parents’ support needs. Next, the incorporation of lived experience expertise and voice in the development of the interview guide, data collection and analysis. Finally, the rigorous and detailed analysis process has resulted in greater clarity about parents’ support needs. However, there are also a few limitations of note. First, most parents in this study were female, and the support needs of fathers may be different, particularly when considering the lower rates of mental health support service utilisation by males generally ( 40 ). However, data indicates that mothers are more likely to engage in services for their adolescent, particularly with respect to mental health concerns ( 41 ). Second, the data included in this study was extracted from interviews which encompassed multiple topics, and a more focused, in-depth qualitative exploration of parent needs may uncover additional support requirements. That said, the sample size was substantial, and consistency across participant reports suggests that the themes reported here are likely robust. Third, participants’ most recent ED presentation for suicide crisis were as far back as five years prior to the interview, therefore recollection of their needs during the ED presentation may be diminished. However, this may be countered by the added benefit of more time navigating the system after crisis, enabling participants to have a better understanding of what has been helpful since the visit and therefore noting that earlier access to such support could have been beneficial. Together, these findings suggest that parents have a considerable appetite for information which empowers them to provide necessary care for their adolescent, rather than wanting others, such as a healthcare professional, to completely take over this care. If empowered appropriately, parents may feel more confident to support their adolescent once home in the community ( 42 ), thereby reducing the risk of future suicidal crises and relieving some of the pressure on the ED. Additionally, these findings provide a preliminary evidence base of what support parents require during the ED presentation, which could easily be incorporated into standard care delivery as they are in alignment with person-centred care practices already prioritised in healthcare settings ( 43 ). Despite this, few measures have been considered to address these support needs before now. Further research is needed to understand what support parents find the most helpful, and identify what gaps exist between the support parents need and what is currently being provided in ED settings. Such information, alongside these findings, could be further developed through co-design practices to ensure that interventions or training are more aligned with parent needs ( 44 ). Co-designed interventions with parents of young people in high-risk populations, such as trans youth or children with ADHD, have shown to effectively improve parent confidence supporting their children and improvements in parent wellbeing ( 45 , 46 ). Healthcare providers could also benefit from training on how some of the simple support needs, such as compassionate and informative interactions with parents, could be integrated into their care delivery to suicidal adolescents. Conclusion Parents require a variety of supports as a result of the ED presentation and their adolescent’s suicidal crisis. Parents identified the need to be informed and educated so they feel empowered to provide the care their adolescents require. Simple steps to improve parental wellbeing are extremely important to ensure parents are in the best possible position to provide the life-preserving care their adolescent after discharge from the hospital. These findings provide a preliminary outline of the parental supports that could easily be integrated into the ED procedures and which resources may need to be developed to educate and support parents. Abbreviations ED Emergency department Declarations Ethics approval and consent to participate The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the University of New South Wales Human Research Ethics Committee (HC220756). Clinical trial number: not applicable. Consent for publication Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to ethical considerations. Competing interests The authors declare that they have no competing interests. Funding DR is supported by an Australian Government Research Training Program Scholarship and UNSW Tyree Institute of Health Engineering. The funding sources had no role in study design, data collection, analysis or interpretation, reporting or publication. Authors’ contributions All authors have made significant contributions to the study and the manuscript. DR, FS, KB and LM designed the study. DR led the writing of the manuscript, supported by all authors. Data collection was completed by DR, SAP, SOA and JL. Data analysis was conducted by DR, with support from all authors. All authors read and approved the final manuscript. Acknowledgements We would like to acknowledge the parents who participated in this study, and the peer researchers who make up this project’s lived experience advisory group. Sharing their experiences was undoubtedly difficult, but without their insights this study would not have been possible. References Ceniti AK, Heinecke N, McInerney SJ. Examining suicide-related presentations to the emergency department. Gen Hosp Psychiatry. 2020;63:152–7. https://doi.org/10.1016/j.genhosppsych.2018.09.006 . 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Gen Hosp Psychiatry. 2015;37(6):581–6. https://doi.org/10.1016/j.genhosppsych.2015.06.018 . True G, Pollock M, Bowden CF, Cullen SW, Ross AM, Doupnik SK et al. Strategies to care for patients being treated in the emergency department after self-harm: Perspectives of frontline staff. Journal of emergency nursing. 2021; 47(3): 426 – 36. e5. 10.1016/j.jen.2020.12.016 Baffsky R, Rheinberger D, McGillivray L, Torok M. Factors that influence young people’s experiences of emergency suicide care in Australia: a qualitative study. Int J Mental Health. 2024;1–18. https://doi.org/10.1080/00207411.2024.2347678 . McGorry PD, Mei C, Chanen A, Hodges C, Alvarez-Jimenez M, Killackey E. Designing and scaling up integrated youth mental health care. World Psychiatry. 2022;21(1):61–76. 10.1002/wps.20938 . Fu X, Yang J, Liao X, Shen Y, Ou J, Li Y, et al. Parents’ and medical staff’s experience of adolescents with suicide-related behaviors admitted to a general hospital in China: qualitative study. BMC Psychiatry. 2021;21:1–8. https://doi.org/10.1186/s12888-021-03057-w . Cadorna G, Vera San Juan N, Staples H, Johnson S, Appleton R. Systematic review and metasynthesis of qualitative literature on young people's experiences of going to A&E/emergency departments for mental health support. Child Adolesc Mental Health. 2024;29(3):266–75. https://doi.org/10.1111/camh.12683 . Rheinberger D, Wang J, McGillivray L, Shand F, Torok M, Maple M, et al. Understanding emergency department healthcare professionals' perspectives of caring for individuals in suicidal crisis: A qualitative study. Front Psychiatry. 2022;13:918135. 10.3389/fpsyt.2022.918135 . Lindert J, Paul KC, Lachman ME, Ritz B, Seeman TE. Depression-, anxiety-, and anger and cognitive functions: findings from a longitudinal prospective study. Front Psychiatry. 2021;12:665742. 10.3389/fpsyt.2021.665742 . McKay K, Shand F. Advocacy and luck: Australian healthcare experiences following a suicide attempt. Death Stud. 2018;42(6):392–9. 10.1080/07481187.2017.1359218 . Hopkins L, Kuklych J, Pedwell G, Woods A. Supporting the support network: The value of family peer work in youth mental health care. Commun Ment Health J. 2021;57:926–36. 10.1007/s10597-020-00687-4 . Rosebrock HY, Batterham PJ, Chen NA, McGillivray L, Rheinberger D, Torok MH, et al. Nonwillingness to return to the emergency department and nonattendance of follow-up care arrangements following an initial suicide-related presentation. Crisis. 2021. 10.1027/0227-5910/a000812 . Han J, Batterham PJ, Calear AL, Randall R. Factors influencing professional help-seeking for suicidality. Crisis. 2017. 10.1027/0227-5910/a000485 . West C, Honey A. The involvement of fathers in supporting a young person living with mental illness. J Child Fam stud. 2016;25:574–87. https://doi.org/10.1007/s10826-015-0230-7 . Czyz EK, Horwitz AG, Yeguez CE, Ewell Foster CJ, King CA. Parental self-efficacy to support teens during a suicidal crisis and future adolescent emergency department visits and suicide attempts. J Clin Child Adolesc Psychol. 2018;47(sup1):S384–96. 10.1080/15374416.2017.1342546 . World Health Organization. Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services. (2018). Report No.: 9241514035. Available from: https://www.who.int/publications/i/item/9789241514033 Slattery P, Saeri AK, Bragge P. Research co-design in health: a rapid overview of reviews. Health Res policy Syst. 2020;18:1–13. https://doi.org/10.1186/s12961-020-0528-9 . Leitch S, Sciberras E, Rinehart N, Evans S. Co-designed mindful parenting for parents of children with ADHD: A pilot and feasibility study. Child Psychiatry Hum Dev. 2023;54(2):406–20. 10.1007/s10578-021-01260-0 . Morgan H, van Hall H-W, Moore JK, Lin A, Perry Y. A Pilot Group Program for Parents of Trans Young People at a Specialized Pediatric Gender Diversity Service. LGBTQ + Family: An Interdisciplinary Journal. 2024: 1–15. https://doi.org/10.1080/27703371.2024.2347495 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5792251","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401270442,"identity":"a8304876-e619-4ca9-81b7-c7a0e46cdaee","order_by":0,"name":"Demee Rheinberger","email":"data:image/png;base64,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","orcid":"","institution":"Black Dog Institute","correspondingAuthor":true,"prefix":"","firstName":"Demee","middleName":"","lastName":"Rheinberger","suffix":""},{"id":401270443,"identity":"26dd4438-f7cd-4fb5-b8d9-6f5ded5e6672","order_by":1,"name":"Katherine Boydell","email":"","orcid":"","institution":"Black Dog Institute","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Boydell","suffix":""},{"id":401270444,"identity":"4d67f4ec-4c68-41aa-a812-ab4a361839a2","order_by":2,"name":"Susanne Oliver Armstrong","email":"","orcid":"","institution":"Black Dog Institute","correspondingAuthor":false,"prefix":"","firstName":"Susanne","middleName":"Oliver","lastName":"Armstrong","suffix":""},{"id":401270445,"identity":"e9c1a1c0-e366-4a69-814a-824bf1667af4","order_by":3,"name":"Sally Ann Pollard","email":"","orcid":"","institution":"Black Dog Institute","correspondingAuthor":false,"prefix":"","firstName":"Sally","middleName":"Ann","lastName":"Pollard","suffix":""},{"id":401270446,"identity":"e5ef0f54-1752-43b6-87b4-d18c883db53c","order_by":4,"name":"Julia Lessing","email":"","orcid":"","institution":"Black Dog Institute","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"","lastName":"Lessing","suffix":""},{"id":401270447,"identity":"48fc6df7-178e-4eca-a9eb-045bbfff612e","order_by":5,"name":"Lauren McGillivray","email":"","orcid":"","institution":"Black Dog Institute","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"","lastName":"McGillivray","suffix":""},{"id":401270448,"identity":"23ed271d-adfd-4686-9c0a-5072b91fa935","order_by":6,"name":"Fiona Shand","email":"","orcid":"","institution":"Black Dog Institute","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Shand","suffix":""}],"badges":[],"createdAt":"2025-01-09 01:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5792251/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5792251/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73930489,"identity":"1f6f1853-e298-4633-b060-4702d1d733d1","added_by":"auto","created_at":"2025-01-16 05:58:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":461956,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5792251/v1/4ef89ad8-abb9-4ef2-9651-4f2fd2986383.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring parent support needs during and after adolescent suicide crisis emergency department visits – A qualitative investigation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdolescents are the age cohort most likely to present to an emergency department (ED) during a suicide crisis (suicidal thoughts, feelings, plans or behaviours), in many developed countries, including Australia (1). Adolescents are also the age group which is most often hospitalised in Australia for suicide crisis (2), most likely via an ED presentation. Parents play a vital role in assisting their adolescent to access crisis care such as emergency departments and ongoing mental healthcare in the community (3). However, parents often experience their own struggles during this time, including heightened stress, anxiety, fear and depression (4). Parents who are psychologically distressed are less able to make effective decisions about their child\u0026rsquo;s care (5), suggesting parents are possibly struggling to provide appropriate care to their suicidal adolescent at a time when it is most critical.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParents who understand the treatment directives and options for their child\u0026rsquo;s care experience less distress than those who aren\u0026rsquo;t provided such support (6). Such parents may be better able to make care decisions for their child, due to both increased education and improved psychological wellbeing. Numerous studies have demonstrated the benefits of providing education and support to parents of suicidal adolescents. Several studies have shown that parents respond positively to means restriction education when provided during the ED presentation, with up to 100% of parents engaging in means restriction two-three weeks after hospital discharge (7-9). Furthermore, gatekeeper education training for parents has shown to improve parental confidence in keeping their adolescent safe from future suicide crises (10, 11). Family-based therapy has also demonstrated a reduction in suicidal ideation in suicidal adolescents (12, 13).\u003c/p\u003e\n\u003cp\u003eConcerningly however, parents report feeling unsupported by the ED staff and processes and ill equipped to provide care to their adolescent after they are discharged from the hospital (14, 15). The period after ED discharge is often one of great concern for parents who subsequently undertake profound lifestyle alterations, such as leaving or reducing employment and abstaining from social interactions and events to provide constant monitoring and support to their child, with significant consequences for the parent and the family unit (4). Also, there are often long delays between discharge and when the adolescent is able to connect with community based mental health services (16), placing increased pressure on parents to cope and navigate this turbulent time. Providing parents more support and evidence-based information about to how care for their adolescent and themselves may reduce the likelihood of repeat suicide crises and improve engagement with community programs (17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the vital role parents play supporting their adolescent after hospital discharge, there has been no research, to the authors knowledge, investigating the support needs of parents during the period surrounding the ED presentation. As such, this qualitative study sought to investigate what supports parents require when they accompany their suicidal adolescent, both during and immediately following the ED visit.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThis qualitative study was approved by University of New South Wales Human Research Ethics Committee (HC220756). Written consent was obtained from all participants prior to data collection. This study draws upon data collected as part of a larger study which explored parents\u0026rsquo; experience of accompanying their adolescent child, who was experiencing suicide crisis, to the ED. The findings from which are currently under review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003eTwenty participants were recruited from the Australian community between January and March 2023, via Black Dog Institute\u0026rsquo;s social media channels (Meta, X, and LinkedIn). After engaging with the social media posts, potential participants were redirected to the study website, which provided study details and prompted them to complete the participant information sheet before completing a screening questionnaire to assess eligibility. To be eligible, participants must be a biological, step, or adoptive parent who had accompanied their adolescent child (12\u0026ndash;18 years) to an Australian ED in the previous five years (i.e., since January 2018) for suicide crisis (ideation, feelings, plans or attempts). There were no exclusion criteria. Eligible participants completed the consent form prior to registering for the study. Participation was voluntary and participants were free to withdraw from the study at any time prior to data analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected via online, semi-structured one-on-one interviews between February and May 2023. Interviews were conducted via a secure videoconferencing platform by the lead author (DR) and three peer researchers (SP, SA and JL) who had been trained and supported to conduct the interviews. Interviews continued until saturation of information was reached, and were digitally recorded, and de-identified before being sent to a third-party service for transcription. The interview guide was developed in consultation with six peer researchers who are parents (including SP, SA and JL) with a lived experience of accompanying their suicidal adolescent to the ED. The interview guide included a single question regarding the support the participants would have liked to receive: \u0026ldquo;what support options would you have liked to be provided for yourself during the ED visit?\u0026rdquo;. Due to the nature of interviews, support needs were also raised by participants in other sections of the interview and these responses were included in this analysis.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eData was analysed following the six steps of Reflexive Thematic Analysis (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and was led by the lead author (DR). First, in-depth familiarisation with the interview transcripts was conducted which involved full immersion with the data corpus and repeated reading and reflecting on the transcripts. During this step, interviewers reviewed the transcripts of the interviews they conducted to produce one-page summaries before discussing the shared ideas across the interviews as a group. Next, transcripts were read line-by-line and initial codes developed by the lead author who has extensive experience conducting qualitative analysis in suicide prevention research. These codes were then reviewed and discussed with the research team (DR, FS, LM and KB) for purposes of reflexivity and to determine the final set of codes. At this phase, the codes relating to the support parents wanted during the ED presentation were removed from the larger dataset, as it presented a different domain of investigation compared to exploring the ED experience itself. This support data was then analysed separately following the same process as above, and more detailed codes developed. These codes were used as building blocks and sorted into \u0026lsquo;clusters of meaning\u0026rsquo; (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) to then produce a set of three themes that were identified by the research team. These themes acted as central organising concepts to assemble the types of support parents wanted during this critical time. Rigour was maintained throughout the analysis process through continued reflexivity throughout the research process during which the lead author maintained a detailed audit trail and a reflection journal, and a team approach to the analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eTwenty biological parents with a mean age of 46.9 years (SD\u0026thinsp;=\u0026thinsp;4.3, range 40\u0026ndash;55 years) completed interviews. Most participants were female (n\u0026thinsp;=\u0026thinsp;18, 90%), roughly half were employed full time (n\u0026thinsp;=\u0026thinsp;11, 55%), and 75% (n\u0026thinsp;=\u0026thinsp;15) were married. The average age of the adolescent at the time of presentation was 15.35 years (SD\u0026thinsp;=\u0026thinsp;1.79, range: 11\u0026ndash;18 years), most adolescents were identified as female (n\u0026thinsp;=\u0026thinsp;12, 60%), 25% as male (n\u0026thinsp;=\u0026thinsp;5), 10% non-binary (n\u0026thinsp;=\u0026thinsp;2), and 5% as gender fluid (n\u0026thinsp;=\u0026thinsp;1). Three quarters (n\u0026thinsp;=\u0026thinsp;15) of the presentations were for a suicide attempt, the remaining for suicidal thoughts. For half of the participants (n\u0026thinsp;=\u0026thinsp;10) this was their first presentation to the ED for their adolescents\u0026rsquo; suicide crisis. Participants\u0026rsquo; most recent ED presentation for suicide crisis occurred between early 2018 and March 2023.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThematic Analysis\u003c/h2\u003e \u003cp\u003e Reflexive thematic analysis resulted in identification of three themes outlining the types of support parents wanted as a result of the ED presentation: 1) Information to reduce the uncertainty of the ED presentation, 2) strategies to keep their adolescent safe and support recovery, 3) support for parent wellbeing. A breakdown of each theme and related codes can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutline of themes and codes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1. \u0026ldquo;I really wanted to know what was happening\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat to expect during hospital presentation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAn opportunity to discuss adolescent crisis with staff\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e2. \u0026ldquo;Fundamental basic things that you need to do or watch for or ask to keep someone safe\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat is necessary after discharge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow to access psychological support for their adolescent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhere to find non-clinical help for adolescent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducation about suicide crises\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3. \u0026ldquo;It's not actually just our children that are going through it, we are going through it with them\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhere parents can access psychological support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecognition and compassion from ED staff\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuick and easy ideas to support parent wellbeing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e1. \u0026ldquo;I really wanted to know what was happening\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants would have liked to receive more information about the hospital presentation, including what they were to expect in terms of treatment and outcomes, as well as an opportunity to discuss their adolescents\u0026rsquo; crisis with staff.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWhat to expect during hospital presentation\u003c/span\u003e: Participants reported wanting to be provided information about what their adolescents\u0026rsquo; care would look like during their time in the ED and, if necessary, their inpatient admission. This included being told what treatment options there were and what outcomes of interventions, such as those to reduce lethality of an overdose, would indicate. Parents felt that being provided this information would have made the ED presentation easier for them: \u003cem\u003e\u0026ldquo;And I really wanted to know what was happening, what was going on, what were they doing, what tests, because it just gave me something to hold onto, like, [what] are they expecting?\u0026rdquo; (Participant 3).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAn opportunity to discuss adolescents\u0026rsquo; crisis with staff\u003c/span\u003e: Parents wanted an opportunity to discuss the context and nature of their adolescent\u0026rsquo;s suicide crisis with ED staff to help them feel a sense of control and as though they are valued during the presentation. \u003cem\u003e\u0026ldquo;[The parent perspective is] relevant information. It\u0026rsquo;s relevant. \u0026hellip; Actually, being heard as the carer as well, what your genuine concerns actually are. When we all know our young people the best \u0026hellip; and we are just not listened to \u0026hellip; and don\u0026rsquo;t have the capacity to fight the system to be heard\u0026rdquo; (Participant 18)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e2. \u0026ldquo;Fundamental basic things that you need to do or watch for or ask to keep someone safe\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Parents would like more information about how to provide the care their adolescent needs once they are discharged from the ED or hospital. This includes general information about how to keep them safe, information about accessing psychological support services in the community, where to find other, non-clinical, support for their adolescent, and education about mental health and suicide.\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWhat is necessary after discharge\u003c/span\u003e: Parents discussed wanting a recovery \u0026lsquo;roadmap\u0026rsquo;, so they felt confident to proceed with their adolescent\u0026rsquo;s care after discharge. The types of information parents wanted included: warning signs to look out for which may be indicative of a future suicide incident, what medications to consider as treatment, safety plans, helpline numbers and when is an appropriate time to contact them, and what types of services are available. Parents reported wanting information provided verbally by hospital staff and as printed material they could refer to later. \u003cem\u003e\u0026ldquo;I think a lot of my stress would've been alleviated if I had a little more, more confidence in my ability. I, I mean, really, like that's your primary goal, right? Is to keep you, keep your child safe and to have, you know, whatever form it takes, the ability to build up that confidence, \u0026hellip; everyone's going to need different stuff.\u0026rdquo; (Participant 19)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHow to access psychological support services\u003c/span\u003e: Participants reported wanting information about how to navigate the mental healthcare system, access to peer support workers or social workers, and for the hospital to arrange appointments with mental health clinicians in the community. Navigating the mental healthcare system was challenging for parents but they acknowledged access to this support was vital: \u003cem\u003e\u0026ldquo;you're not going to fix them that very next day, but you can at least put in motion a very, like, high frequency process to \u0026hellip; an expedited process to help them get the help that they obviously need.\u0026rdquo; (Participant 7)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWhere to find other forms of help for adolescent\u003c/span\u003e: Parents recognised that while the intensity of the suicide crisis may wane, the underlying mental health problems were likely to persist. As such, parents wanted more information about psychological support options for their adolescent, which were the most appropriate for their adolescent\u0026rsquo;s presenting concerns. \u003cem\u003e \u0026ldquo;I think it would be amazing if parents in crisis like this were actually given, like a like an advocate, like a social worker case worker to kind of help them navigate the system. What's, what's actually available, what other options are there what other programs might help you know, what, you know, because someone who actually knows how to do it.\u0026rdquo; (Participant 14)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInformation about suicide crisis\u003c/span\u003e: Parents discussed wanting more information about suicide crisis, so they were in the best possible place to care for their adolescent; \u003cem\u003e\u0026ldquo;I think that's really important that people actually have a much better understanding of suicide and how the experience of that person in that time\u0026hellip;\u0026rdquo; (Participant 19).\u003c/em\u003e One parent noted the benefit of engaging with suicide specific training, such as ASIST, so that parents had the skills and confidence to have conversations about suicide with their child.\u003c/p\u003e\u003cp\u003e \u003cem\u003e3. \u0026ldquo;It's not actually just our children that are going through it, we are going through it with them\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003cp\u003eParticipants recognised the value in making sure they were mentally well so they could provide the best care for their adolescent. This included wanting information about how to access psychological support for themselves, tips for caring for themselves, and the power of informal support such as recognition and compassion from hospital staff.\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWhere parents can get psychological support\u003c/span\u003e: Participants highlighted the importance of support to access their own psychological support, particularly since this was often not on their priority list. Parents felt that support from the ED to access and engage with psychological support would have made a significant difference to their ability to provide the ongoing support their adolescent required. \u003cem\u003e\u0026ldquo;What would have been helpful is if they said to me \u0026hellip; \u0026lsquo;This situation's very hard for you and whether or not you feel that now we recommend you get to counselling. Here's a card of someone you can talk to.\u0026rsquo; \u0026hellip; Because if you are doing well, then you can look after the child better and these next few days [and] weeks are going to be really taxing.\u0026rdquo; (Participant 3)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRecognition and compassion from ED staff\u003c/span\u003e: Parents felt informal support, such as displays of compassion and verbal recognition of the struggles they were experiencing from the staff in the ED would go a long way in helping their psychological wellbeing during this time. \u003cem\u003e\u0026ldquo;And there's that very real possibility that the carer is going to break down and start crying and say, \u0026lsquo;look, I'm not okay\u0026rsquo;. \u0026hellip; So, it is being able to, to hold that carer in that moment \u0026hellip;\u0026rdquo; (Participant 18)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTips for parent wellbeing\u003c/span\u003e: Parents wanted information about simple but impactful tips which can help improve their mental wellbeing, such as getting time outside, eating balanced meals, and validation/permission to feel a range of emotions: \u003cem\u003e\u0026ldquo;\u0026hellip; you are allowed to want to vent, you are allowed to be angry. You're allowed to be frustrated. You're allowed to be sad. You're allowed to have all of those feelings, [and] finding safe places to move through the feelings\u0026rdquo; (Participant 1)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Parents provide vital support and care, beyond the scope of usual parenting, to their adolescent during and following an ED presentation for suicide crisis. However, parents are rarely given sufficient support to provide this unique care. This study aimed to understand what types of support parents need when they attend the ED with their adolescent child who is experiencing a suicide crisis, so parents can best support the adolescent and reduce their subsequent risk. Qualitative analysis identified three domains of support which parents desired: 1) information about, and active involvement in, the ED care, 2) information about how to keep their adolescent safe, and support their recovery, 3) tools to support parents\u0026rsquo; wellbeing.\u003c/p\u003e \u003cp\u003e Providing information about the adolescent\u0026rsquo;s treatment and care during the emergency department visit, delivered with care and at the right time, is one simple way to support parents during the ED visit. Studies exploring parents of ill adolescents and children found explaining hospital treatment processes was beneficial for parent and child outcomes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Keeping individuals abreast of treatment processes and providing concrete prognosis goals has been found to reduce distress experienced by parents of children and adolescents with cancer (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Given the high degree of psychological distress experienced by parents of adolescents experiencing a suicide crisis (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), it is important to maximise simple, effective support mechanisms to improve outcomes for parents. Incorporating elements of caregiver engagement when treating suicidal adolescents, as is seen with parents of other ill children (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), into hospital employee training and procedures may effectively improve parent confidence and skills in providing care after discharge (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Parents in this study frequently identified wanting to be provided with more information about how to access psychological support for their adolescent after being discharged from the ED or hospital. Parents in many developed countries have reported their mental health systems are difficult to navigate (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In Australia, patients are often impacted by difficulties accessing services because of insufficient availability and long waiting lists (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Furthermore, community mental health services targeted towards adolescents often have high entry thresholds, meaning in many instances, adolescents are only able to utilise services after they attempted suicide (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Parents report being overwhelmed and struggling to understand how to navigate this complex system. ED staff have reported local services are complex, with numerous service offerings (which frequently change), making it difficult for them to know what services they should be recommending for individuals experiencing self-harm or suicide crisis (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). As such, ED staff may not be well-equipped to provide effective discharge care plans for this group. They may also lack the time and knowledge to develop care plans collaboratively with the young person and their parent or caregiver (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Furthermore, adolescents do not often speak with a mental health clinician in the ED (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and general ED staff are unlikely to have training or knowledge of mental health or suicide specific service options (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Therefore, resources which help ED staff and help-seekers identify and contact psychological services may help increase the uptake of such services (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and effective methods of providing such information should be investigated. This is likely to have a profound impact through increasing parent confidence in ED staff (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), improve adolescent access to appropriate resources (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and empower hospital staff to confidently provide care thereby reducing the feelings of futility experienced by staff (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Parents wanted information to help them with their own wellbeing so that they are able to provide the best possible care to their adolescent. Parents\u0026rsquo; declining mental health surrounding an adolescent\u0026rsquo;s suicide crisis is frequently noted in the literature, particularly increased anxiety, depression and fear (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Anxiety and depression have been linked with decreased cognitive functioning (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), which may impact a parent\u0026rsquo;s ability to make the best decisions about their adolescent\u0026rsquo;s care. Parents in this study highlighted the importance of receiving support for themselves throughout this journey, starting with compassion from ED staff, through to accessing psychological support in the community. Small acts of kindness from hospital staff, such as compassion and recognition of their feelings, helped individuals feel supported and gave them hope they could get through difficult periods (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Peer support programs for parents of suicidal adolescents have also demonstrated an improvement in parent wellbeing (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Worryingly, a lack of compassion from ED staff during the ED presentation is not only distressing for parents and their adolescents but is likely to reduce later treatment engagement (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), which may increase their risk of future suicide crises. Parents in this study also noted the positive impact of simple tips to maintain their own wellbeing during this period. This suggests parents do not necessarily require in-depth and voluminous support from hospital staff, but compassion such as offering cup of tea, recognition of theirs\u0026rsquo; difficulties, and simple wellbeing strategies may have positive outcomes.\u003c/p\u003e \u003cp\u003e This study has several strengths; this novel investigation of parent needs during an ED presentation with their suicidal adolescent allows us to make an important contribution to the scant evidence surrounding parents\u0026rsquo; support needs. Next, the incorporation of lived experience expertise and voice in the development of the interview guide, data collection and analysis. Finally, the rigorous and detailed analysis process has resulted in greater clarity about parents\u0026rsquo; support needs. However, there are also a few limitations of note. First, most parents in this study were female, and the support needs of fathers may be different, particularly when considering the lower rates of mental health support service utilisation by males generally (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). However, data indicates that mothers are more likely to engage in services for their adolescent, particularly with respect to mental health concerns (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Second, the data included in this study was extracted from interviews which encompassed multiple topics, and a more focused, in-depth qualitative exploration of parent needs may uncover additional support requirements. That said, the sample size was substantial, and consistency across participant reports suggests that the themes reported here are likely robust. Third, participants\u0026rsquo; most recent ED presentation for suicide crisis were as far back as five years prior to the interview, therefore recollection of their needs during the ED presentation may be diminished. However, this may be countered by the added benefit of more time navigating the system after crisis, enabling participants to have a better understanding of what has been helpful since the visit and therefore noting that earlier access to such support could have been beneficial.\u003c/p\u003e \u003cp\u003e Together, these findings suggest that parents have a considerable appetite for information which empowers them to provide necessary care for their adolescent, rather than wanting others, such as a healthcare professional, to completely take over this care. If empowered appropriately, parents may feel more confident to support their adolescent once home in the community (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), thereby reducing the risk of future suicidal crises and relieving some of the pressure on the ED. Additionally, these findings provide a preliminary evidence base of what support parents require during the ED presentation, which could easily be incorporated into standard care delivery as they are in alignment with person-centred care practices already prioritised in healthcare settings (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Despite this, few measures have been considered to address these support needs before now. Further research is needed to understand what support parents find the most helpful, and identify what gaps exist between the support parents need and what is currently being provided in ED settings. Such information, alongside these findings, could be further developed through co-design practices to ensure that interventions or training are more aligned with parent needs (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Co-designed interventions with parents of young people in high-risk populations, such as trans youth or children with ADHD, have shown to effectively improve parent confidence supporting their children and improvements in parent wellbeing (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Healthcare providers could also benefit from training on how some of the simple support needs, such as compassionate and informative interactions with parents, could be integrated into their care delivery to suicidal adolescents.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e Parents require a variety of supports as a result of the ED presentation and their adolescent\u0026rsquo;s suicidal crisis. Parents identified the need to be informed and educated so they feel empowered to provide the care their adolescents require. Simple steps to improve parental wellbeing are extremely important to ensure parents are in the best possible position to provide the life-preserving care their adolescent after discharge from the hospital. These findings provide a preliminary outline of the parental supports that could easily be integrated into the ED procedures and which resources may need to be developed to educate and support parents.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by the University of New South Wales Human Research Ethics Committee (HC220756). Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to ethical considerations.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eDR is supported by an Australian Government Research Training Program Scholarship and UNSW Tyree Institute of Health Engineering. The funding sources had no role in study design, data collection, analysis or interpretation, reporting or publication.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eAll authors have made significant contributions to the study and the manuscript. DR, FS, KB and LM designed the study. DR led the writing of the manuscript, supported by all authors. Data collection was completed by DR, SAP, SOA and JL. Data analysis was conducted by DR, with support from all authors.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the parents who participated in this study, and the peer researchers who make up this project\u0026rsquo;s lived experience advisory group. Sharing their experiences was undoubtedly difficult, but without their insights this study would not have been possible. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCeniti AK, Heinecke N, McInerney SJ. Examining suicide-related presentations to the emergency department. 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A Pilot Group Program for Parents of Trans Young People at a Specialized Pediatric Gender Diversity Service. LGBTQ\u0026thinsp;+\u0026thinsp;Family: An Interdisciplinary Journal. 2024: 1\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/27703371.2024.2347495\u003c/span\u003e\u003cspan address=\"10.1080/27703371.2024.2347495\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"suicide, emergency department, parent, adolescent, suicide attempt, qualitative","lastPublishedDoi":"10.21203/rs.3.rs-5792251/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5792251/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdolescents are the age cohort most likely to attend an emergency department for suicide crisis, often accompanied by a parent. Parents have reported feeling as though they are not appropriately supported to provide the critical life sustaining care their adolescent needs after discharge from the emergency department. This study sought to understand what types of support parents need as a result of the emergency department presentation.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eSemi-structured, online interviews were conducted between February and May 2023. Individuals were eligible to participate if they were parents (biological, step, or adoptive) of adolescents (12\u0026ndash;18 years old) who had attended an Australian emergency department for suicide crisis since January 2018. Data was analysed via reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty biological parents participated in interviews (average age: 46.9 years). Reflexive thematic analysis indicated there were three domains of support parents\u0026rsquo; desired: 1) information about, and active involvement in, the emergency department care, 2) information about how to keep their adolescent safe and support recovery, and 3) tools to support parents\u0026rsquo; own wellbeing.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e These findings provide a preliminary outline of the support parents need and what resources may need to be developed to educate and support parents, which could be integrated into the emergency department procedures. Improving the way in which parents are supported to care for their adolescent may help reduce recurrent incidents of adolescent suicide attempts.\u003c/p\u003e","manuscriptTitle":"Exploring parent support needs during and after adolescent suicide crisis emergency department visits – A qualitative investigation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-16 05:34:16","doi":"10.21203/rs.3.rs-5792251/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"882e7417-b7c8-41ab-a7e5-06fefaa908ca","owner":[],"postedDate":"January 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-16T06:38:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-16 05:34:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5792251","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5792251","identity":"rs-5792251","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}