Program Profile: Care, Assess, Respond, Empower (CARE)

This is a brief school-based, suicide-prevention program that seeks to reduce suicide risks and co-occurring health-related behaviors (such as depression and drug use). The program is rated Ineffective. Intervention youth reported statistically significant lower levels of depression, compared with usual-care comparison group youth, but there were no statistically significant effects on suicide-risk behaviors, drug-involvement behaviors, drug-use control problems, and adverse drug consequences.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

Program Goals/Target Population

CARE (Care, Assess, Respond, Empower), also called Counselors–CARE (C–CARE), is a school-based, brief assessment and crisis intervention for youth at risk for suicide. The program targets youth (ages 14 to 19) at risk for suicide and at risk for dropping at of school. The goal of the CARE program protocol is to reduce suicide-risk behaviors (such as suicide ideations) and correlated co-occurring risk behaviors (such as depression and drug involvement).

Because these youths are at risk for suicide, CARE uses a standardized individual assessment and crisis intervention protocol approach, which incorporates five key prevention strategies (Pentz 1993): 1) information or assessment feedback strategies, 2) access to help, 3) adult motivation and support, 4) peer support, and 5) social and life skills training. In particular, the intervention is designed to enhance and increase youths’ personal life-skills competencies and social support resources (referred to as mediating factors) at home and at school.

Program Components/Key Personnel

The CARE protocol consists of three main components that are typically completed in 3½ to 4 hours. In the first component, youths complete a 2-hour, one-on-one, computer-assisted suicide assessment called the Measure of Adolescent Potential for Suicide (or MAPS). This component includes a motivational introduction and then an assessment of direct suicide risk factors (suicide attempts or threats), related risk factors (depression, high anxiety, and hopelessness), and protective factors (coping strategies and social support resources).

In the second component, a brief (1½- to 2-hour) motivational counseling session is completed. During this counseling session, staff (typically advance-practice nurses or social workers) summarize assessment results with the youth. Staff then provide youths empathy and support to encourage them to share personal information, reinforce positive coping skills and help-seeking behaviors, and increase access to help. In addition, staff may create an action plan for enhancing support resources.

The third component of CARE is the social network “connection” intervention. During this phase, each youth is linked with a school-based “caseworker” (a counselor or a trained school nurse) or with the youth’s favorite teacher to foster communication between the youth and school personnel. In addition, a parent/guardian of the youth’s choice is contacted (by phone) to enhance immediate support, access to help, and communication among the youth, school personnel, and parents.

The CARE protocol also includes a follow-up reassessment of suicide risk and protective factors and a booster motivational counseling session, typically 9 weeks after the initial counseling session.

Study

Eggert and colleagues (2002) conducted a three-group, repeated-measures randomized controlled trial to evaluate the effects of CARE (Care, Assess, Respond, Empower) on potential high school dropout youths’ suicide-risk behaviors and co-occurring health-related problem behaviors (such as drug use). Seven schools (which represented two Pacific Northwest urban school districts) were randomly assigned to one of two experimental conditions (either CARE or Coping and Support Training [CAST]) or the standard “usual care” comparison condition. Using block randomization procedures, youths were assigned to the study conditions (CARE intervention group = 117 students; standard usual-care comparison group = 121 students; CAST = 103 students). The study authors randomly determined the “start” condition for each of the schools, then systematically assigned study conditions according to the following rotated sequence: 1) usual-care control condition, 2) CARE, and 3) CAST. A fourth condition, no-intervention or “pause” condition, was added to the end of sequence to minimize the possibility for contamination; this no-intervention condition allowed potential carryover effects within schools to dissipate over time. The CrimeSolutions review of this study focused on the comparisons between the CARE intervention group and the usual-care group.

Youths were recruited to participate in the study using a two-step process. The first step included creating a pool of potential school dropouts (from each school), drawing on indicators that have been known to predict school dropouts (such as low academic performance, poor attendance, and any earlier attempt or history of dropping out). For the second step, youths from the pool of potential dropouts were randomly sampled (by computer) to be invited to participate in the study. These youths then completed a seven-item Suicide Risk Screen instrument to determine each youth’s risk level, which assessed suicidal risk behaviors (thoughts, threats, prior attempts), depression, and drug involvement. Youths who screened in at risk of suicide were retained for the study; all others were excluded.

Youths in the CARE intervention group were 52.1 percent male, and the average age of youth was 15.7 years. CARE youth received a one-on-one, 2-hour assessment interview followed by a 1.5-hour to 2-hour counseling session and social “connections” intervention with parents and school personnel. Youths in the usual-care comparison group were 50.8 percent males, and the average age of youth was 15.6 years. Youth in usual care comparison group received the standard protocol executed by school personnel in response to youth at risk for suicide. There were no statistically significant differences between youth in intervention and comparison groups in baseline characteristics.

Data were collected at three timepoints: 1) Time 1 at baseline (or preintervention); 2) Time 2 at 4 weeks after baseline; and 3) Time 3 at 10 weeks (approximately 2 months) after baseline. Outcomes of interest included suicide-risk behaviors (such as suicide ideation [which involved suicidal thoughts in general and thoughts attributable to drug use], direct suicide threats [verbal threats], and suicide attempts in the past month [frequency of prior attempts]) and related co-occurring behaviors. Co-occurring behaviors included 1) depression (which was defined as having depressed feelings, hopelessness, and anxiety); 2) drug involvement (during the past month, the frequency of alcohol use, marijuana use, and use of hard drugs such as cocaine, opiates, inhalants); 3) drug-use control problems (continuing to drink after one or two drinks, using more than intended, making oneself feel sick from using); and 4) adverse drug consequences, which involved having problems with friends or family, feeling guilty or depressed after using, getting in trouble at school, and stealing or damaging property.

All the outcomes were measured using the High School Questionnaire (HSQ), using a seven-point Likert scale (ranging from 0 = never/not at all to 6 = always/many times). A repeated-measures multivariate analysis of variance (MANOVA) was used to determine differences between youth in the CARE intervention group and the usual-care comparison group at the 10-week follow-up. The study authors did not conduct subgroup analysis.

Before implementing the Care, Assess, Respond, Empower (CARE) protocol, the intervention was first pilot-tested. During this period, Eggert and colleagues (2002) conducted assessment interviews, which were videotaped and reviewed weekly to assess the assessment and crisis intervention protocol (i.e., CARE). Separately, interviewers and the CARE Program Coordinator rated randomly selected videotapes to monitor and evaluate CARE implementation.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Eggert, Leona L., Elaine Adams Thompson, Jerald R. Herting, and Liela J. Nicholas. 1995. “Reducing Suicide Potential Among High-Risk Youth: Tests of a School-Based Prevention Program.” Suicide & Life-Threatening Behavior 25:276–96.

Hooven, Carole, Jerald R. Herting, and Karen A. Snedker. 2010. “Long-Term Outcomes for the Promoting CARE Suicide Prevention Program.” American Journal of Health Behavior 34:721–36.

Hooven, Carole, Elaine Walsh, Kenneth C. Pike, and Jerald R. Herting. 2012. “Promoting CARE: Including Parents in Youth Suicide Prevention.” Family & Community Health 35(3):225–35. (This study was reviewed but did not meet CrimeSolutions criteria for inclusion in the overall program rating).

Pentz, Mary Ann. 1993. “Benefits of Integrating Strategies in Different Settings.” In American Medical Association State-of-the-Art Conference on Adolescent Health Promotion: Proceedings. Arlington, Va.: National Center for Education in Maternal and Child Health, 15–34.

Randell, Brooke P., Leona L. Eggert, and Kenneth C. Pike. 2001. “Immediate Postintervention Effects of Two Brief Youth Suicide Prevention Interventions.” Suicide and Life-Threatening Behavior 31:41–61.

Thompson, Elaine Adams, Leona L. Eggert, Brooke P. Randell, and Kenneth C. Pike. 2001. “Evaluation of Indicated Suicide Risk Prevention Approaches for Potential High School Dropouts.” American Journal of Public Health 91:742–52.

Following are CrimeSolutions-rated programs that are related to this practice:

Mentoring for Youth Development

This practice provides youth with a positive and consistent adult or older youth relationship to promote healthy youth development and social functioning and to reduce risk factors. The practice is rated Effective in reducing delinquency and improving educational outcomes; Promising in improving psychological outcomes and cognitive functioning; and Ineffective in reducing substance use.

Evidence Ratings for Outcomes

	Crime & Delinquency - Multiple crime/offense types
	Education - Multiple education outcomes
	Mental Health & Behavioral Health - Psychological functioning
	Mental Health & Behavioral Health - Cognitive functioning
	Mental Health & Behavioral Health - Social functioning
	Drugs & Substance Abuse - Multiple substances

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?