Treffer: Characterizing facilitators of and barriers to suicide prevention program development and use: An exploratory study.

Parental history of a suicide attempt increases children's risk for suicidal behavior. This study examined parental perceptions of and willingness to engage in suicide prevention programs for children whose parents have a history of attempting suicide. Semistructured qualitative interviews were conducted with nine parents who had a history of suicide attempt. Parents described three key elements they perceived to be necessary for this type of suicide prevention program: (a) parental involvement and education, (b) child education and counseling, and (c) timeliness of intervention. Parents also identified three barriers that could hinder program participation: (a) fear, stigma, and embarrassment; (b) finances, insurance, time, and transportation; and (c) lack of education. Incorporating these key components within suicide prevention programs as well as addressing identified barriers may increase familial participation and help reduce suicide risk in youth with a parental history of suicide attempt. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Characterizing Facilitators of and Barriers to Suicide Prevention Program Development and Use: An Exploratory Study

<cn> <bold>By: Cassandra L. Hartman</bold>
> Nationwide Children’s Hospital, Columbus, Ohio, United States
> <bold>Carol A. Wygant</bold>
> Nationwide Children’s Hospital, Columbus, Ohio, United States
> <bold>Arielle H. Sheftall</bold>
> Department of Psychiatry, University of Rochester Medical Center
> <bold>Alice A. Gaughan</bold>
> Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University
> <bold>Amanda J. Thompson</bold>
> Nationwide Children’s Hospital, Columbus, Ohio, United States
> <bold>Ann Scheck McAlearney</bold>
> Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University
> Department of Family and Community Medicine, College of Medicine, The Ohio State University </cn>

<bold>Acknowledgement: </bold>Arin M. Connell served as action editor.Data will be made available upon reasonable request. This study was not preregistered. Arielle H. Sheftall receives research grant funding from the National Institute of Mental Health, National Institutes of Health (Grant IP50MH27476-01A1 subproject ID 7957).Cassandra L. Hartman played a lead role in project administration, resources, and writing–original draft, a supporting role in conceptualization and supervision, and an equal role in data curation, investigation, and methodology. Carol A. Wygant played a supporting role in data curation, project administration, and writing–review and editing and an equal role in investigation. Arielle H. Sheftall played a lead role in conceptualization and funding acquisition and a supporting role in supervision and writing–review and editing. Alice A. Gaughan played a lead role in formal analysis and a supporting role in writing–review and editing. Amanda J. Thompson played a supporting role in resources, supervision, and writing–review and editing. Ann Scheck McAlearney played a lead role in writing–review and editing and a supporting role in formal analysis, methodology, and resources.

In 2021, suicide was ranked as the third leading cause of death in the United States for youth aged 5–17 years in the United States (Centers for Disease Control and Prevention & National Center for Injury Prevention and Control, 2022). Rates of youth suicide attempts (SA) for all age groups have increased since 2007 (Centers for Disease Control and Prevention, 2021). The strongest predictors of youth SA and suicides are previous suicidal thoughts and behaviors (STB)—which include suicidal ideation, suicidal planning like securing lethal means, or a history of prior SA (Lewinsohn et al., 1994). Notably, there is an elevated risk for STB among children with a parental history of SA. Children with a parental history of SA are four to six times more likely to engage in STBs at earlier ages compared with children without a parental history of SA (Brent et al., 2002, 2003; Melhem et al., 2007; Ortin-Peralta et al., 2023). These children are also at increased risk for co-occurring suicidal planning and self-harm behaviors (Geulayov et al., 2014).

Throughout development, children can be repeatedly exposed to parental SA. Notably, exposure to parental SA at a younger age (0–1 years) compared with at an older age (6–12 years) was associated with increased risk for youth SA (Ranning et al., 2022). Furthermore, among 16- to 17-year-olds, children with maternal SA history are three to four times more likely to attempt suicide than children without a parental history of SA (Geulayov et al., 2014). In the same study, children with paternal SA history were almost two times more likely to attempt suicide by ages 16–17 than children without a parental history of SA (Geulayov et al., 2014).

A child’s role in discussions about their parent’s STB and their understanding of their parent’s mental health can vary (Cerel et al., 2016; Ranning et al., 2022). Although some children will learn of their parent’s STB, one study found that more than half of children with a parent who attempted suicide did not know about their parent’s history (Cerel et al., 2016). Furthermore, general stigma toward suicide among parents with a history of STB has been associated with more negative attitudes toward help-seeking behaviors for their children (Burke et al., 2023). Parents who have experienced STB can likely benefit from additional support for recognizing and preventing suicidal behavior in their children as they play an important role in shaping and supporting their children’s mental health (Gould et al., 2003; Hickey et al., 2019; Krysinska et al., 2022). While families’ avoidance of openly discussing suicide is known (Sheehan et al., 2017), less is known about parents’ willingness to engage with children on the topic of familial suicide risk or with specialized suicide preventions for families at risk of suicide (Frey & Cerel, 2015). Thus, an important first step is to contextualize what parents generally find supportive in their efforts to protect their children at all ages against risks for STB.

While early intervention and prevention efforts for adolescent STB are important, very little is known about what prevention resources would be most beneficial for youth with a parental history of SA. Similarly, little is known about the perceptions and willingness of parents with a history of SA to engage in suicide prevention programs for their youth. There are studies focused on supporting bereaved children who have lost a caregiver to suicide (Journot-Reverbel et al., 2017; Pfeffer et al., 2002); however, interventions addressing suicide prevention for children with a parental history of SA—a high-risk population—are lacking. To improve our understanding about how suicide prevention programs could be developed and tailored to support youth with a parental history of SA, this study investigated the perceptions of parents with a history of SA about suicide prevention programs for their children.

Method

>

We conducted an exploratory qualitative interview study to learn from parents who had a history of SA and had children aged 5–17 years. Parents were asked about their perceptions of suicide prevention intervention programs for their youth and their willingness to participate. We included a wide age range for children because research on this topic is very limited and youth with a parental history of SA are of all ages. We report how we determined our sample size, all data exclusions (if any), all manipulations, and all measures in the study.

<h31 id="fam-39-7-899-d391e196">Study Participants</h31>

Parents were recruited from a major metropolitan children’s hospital and were eligible for participation based on having a SA history and having a child aged 5–17 years who had received behavioral health services at the hospital within 12 months of the study start date. A medical record review identified families with parents meeting the criteria for participation (i.e., the patient’s medical record noted a history of SA for one biological parent), and 559 parents were contacted for participation in this study. Exclusion criteria included the inability of the parent to speak/read English and the inability to provide informed consent. Eligible parents were mailed information about the study. Of the 559 parents contacted, 14 expressed interest in participating, 12 were screened and found eligible, and nine agreed to participate. Parents were sent a confirmation of their study appointment time and a reminder the day before the interview. Transportation and all costs associated with study participation were covered by the research team.

<h31 id="fam-39-7-899-d391e200">Data Collection</h31>

Study team members conducted one-on-one interviews with parents between March and June 2023. Interviewers used a semistructured interview format, following a guide that included questions about suicide prevention programs as well as about barriers to and facilitators of participation in suicide prevention programs. Interviewers were research staff trained to conduct interviews by an experienced team of qualitative researchers. Interviewers asked parents with open-ended questions and follow-up probes as needed on the following topics: parent’s mental health treatment, child’s mental health treatment, and perspectives about suicide prevention programs, stigma, mental health, and suicidal behavior. Sample questions for each topic are presented in Table 1.
>
><anchor name="tbl1"></anchor>

All interviews took place in private observation rooms and lasted between 1.5 and 2 hr. Interviews were audio recorded, transcribed verbatim, and then de-identified. Participants were provided breaks during the study visit as needed and received payment for participation. This study was approved by the hospital’s institutional review board, and written informed consent was obtained from all participants. Interviews were conducted until we reached saturation in data collection around the themes we report.

<h31 id="fam-39-7-899-d391e210">Procedures for Minimizing Risks</h31>

Prior to conducting interviews, interviewers were trained to work with individuals who have a history of SA. A safety protocol was implemented that included offering to contact a clinician from crisis services, who would conduct a risk assessment and determine the current level of risk. The call allowed parents to address immediate safety concerns if they described current suicidal ideation and/or any other significant ongoing psychiatric symptoms during the study visit. Participants were also provided with a list of resources they could use to seek help at the conclusion of the interview.

<h31 id="fam-39-7-899-d391e214">Analysis</h31>

The study team coded and analyzed all interview transcripts using deductive dominant thematic analysis (Armat et al., 2018; Vaismoradi et al., 2013). Using this approach enabled the team to categorize the data based on question domains from the interview guide as well as explore emergent themes. One study team member coded all transcripts, which ensured consistent application of codes to all the data. The lead qualitative investigator (ASM) oversaw the coding process by holding regular meetings to discuss coding decisions and the application of emergent codes. This constant comparative approach also allowed for comparison of themes across interviews including the characterization of themes around the development and implementation of suicide prevention programs. The team used ATLAS.ti software (ATLAS.ti Scientific Software Development, Berlin, Germany) to support their qualitative coding and analysis process. Data will be made available upon reasonable request. This study was not preregistered.

Results

>

Study participants were 27–58 years of age (M = 44 years) and had children aged 5–17 years (M = 12 years). Additional details about participant demographics are presented in Table 2.
>
><anchor name="tbl2"></anchor>

<h31 id="fam-39-7-899-d391e236">Parent Perspectives About Suicide Prevention Programs</h31>

Across interviews, participants described three elements of suicide prevention programs they perceived to be particularly important: (a) parental involvement/parental education, (b) education and counseling for the child, and (c) timely intervention. Additionally, participants noted three potential barriers to their child’s participation in suicide prevention programs: (a) fear, stigma, and embarrassment; (b) finances, time, and transportation; and (c) lack of education. These themes are related to both facilitators of and barriers to the development and use of suicide prevention programs. Further discussion is presented below, with additional representative quotations from participants shown in Tables 3 and 4.
>
><anchor name="tbl3"></anchor>
>
><anchor name="tbl4"></anchor>

<h31 id="fam-39-7-899-d391e248">Perceptions About Important Elements of Suicide Prevention Programs</h31>

Participants in all interviews discussed the importance of parental involvement in suicide prevention programs that included a focus on parental education. As one participant explained: “I mean, parents always should be involved with everything. I mean, because they need educated as well as their child.” Another participant echoed this theme, also suggesting the importance of considering the needs of parents and children both separately and together:<blockquote>I think that at first, you may need to do some intervention with the parents separately, because they need to be educated and they also need to be given time to process what they’re being told and to understand the best ways to respond to the information. But then I think that that needs to be brought together with the child because like I said, I think the child needs to understand that their parent is on their team and is trying to accomplish the same goals that they are, in the sense of like keeping them alive.</blockquote>

A second theme focused specifically on the need for education and counseling for the children. As one parent shared,<blockquote>I think it’s important because they’re going to tell. I mean, my daughter is pretty communicative. But I feel like there are times where there are things that she’s not ready to tell me. And I’m okay with her telling someone else that will give her good advice.</blockquote>Another parent explained the benefits their child received from counseling:<blockquote>I think it’s great. I definitely think it can open up the floor for a child to get something out that maybe they didn’t want to say in front of their parents or somebody else. They have that sense of like, confidentiality. His emotional control since we’ve started the counseling has increased a lot. He’s able to identify feelings and he’s able to sit down and do the breathing to calm himself down before he freaks out.</blockquote>

Third, the importance of making suicide prevention both readily available and open to any age was emphasized. One participant noted about their child: “She’s only 11, but she’s having these thoughts, so I mean, earlier is better.” Another participant who expressed concern about their own history with an SA insisted: “get them counseling as soon as possible, even if, even if they’ve never mentioned anything about suicide attempts before.”

<h31 id="fam-39-7-899-d391e266">Potential Barriers to Suicide Prevention Program Participation</h31>

Participants discussed three factors they perceived may create challenges for participating in suicide prevention programs. First, feelings of fear, embarrassment, and concern about stigma were reported by all participants. As one described: “It’s something that either a lot of people don’t want to admit, don’t want to face for some parents, or they’re aware of and are scared.” Another parent commented about mental health stigma in the community by sharing: “I just think that like you’re still, there’s still a bit of a stigma about being weak or having something wrong with you if you have mental health concerns.”

The second theme reported by participants concerning potential barriers was around resources. This theme included both direct mentions of finances and insurance limitations and the barriers of time and transportation. For instance, one participant explained: “There’s financial barriers. I mean, what parent, some parents can’t take the day off work, and take their kid to see somebody.” Similarly, another participant commented: “Gotta be cost-effective. That’s, I mean, because, let’s be honest, if you’re in a lower demographic, it’s harder to find, especially if you’re, you know, your parent works, three jobs to put food on the table.”

The third barrier category involved a lack of education about suicide prevention. This theme was clear in comments directly noting the need for education, such as one participant’s reflection: “A potential barrier that can prevent a parent is just their own lack of knowledge and education around the subject, so it’s difficult for them to engage when they just don’t have the knowledge.” However, this barrier was also reflected in comments suggesting a lack of understanding of STB overall. As one interviewee commented: “It would never happen to my child. To that, happened to me, but that would never happen to my child.”

Discussion

>

The purpose of this study was to understand how parents with a history of SA perceive suicide prevention programs for their children as well as learn about their willingness to engage in such programs. We identified three elements of suicide prevention programs that these parents considered key, as well as three major barriers to program participation. Notably, some of the key elements may have the potential to reduce the reported barriers.

First, parental involvement and education were noted to be important, consistent with findings about mental health and suicide literacy (Jorm et al., 1997). Prior research has found that parents’ knowledge and beliefs about mental health conditions and suicide and the ability to recognize, manage, and prevent mental health conditions and suicide are critical to suicide prevention (Jorm et al., 1997). As parents with low mental health and suicide literacy may not know what signs and symptoms their children may exhibit that increase the child’s risk for STB, involvement and education of these parents may be crucial. Developing suicide prevention programs that educate parents on mental health and suicide may also decrease the identified barriers of fear, stigma, and embarrassment. Previous research supports the importance of this educational component of an intervention (e.g., Moskos et al., 2007). Furthermore, Sayal et al. (2010) found that parents who associated mental health with less stigma and embarrassment were more likely to seek mental health and/or suicide services for their child. Well-designed suicide prevention programs that include parental education may therefore increase parental help-seeking behaviors while also reducing stigma.

Second, child education and counseling were emphasized as an important suicide prevention program element. In related literature, Robinson et al. (2018) found that promising suicide prevention intervention programs included education for adolescents on mental wellness and used skills-based trainings (e.g., strengthening coping skills, emotional awareness). For instance, Youth Aware of Mental Health (Wasserman et al., 2012) and the Signs of Suicide (Aseltine & DeMartino, 2004) are suicide prevention programs that promote open discussion of mental health and risk factors for suicide. Both Youth Aware of Mental Health and Signs of Suicide have been shown to reduce risk, supporting the concept that child education and counseling are important elements of suicide prevention programs.

Third, participants identified timeliness of the intervention as a key characteristic of suicide prevention programs. In practice, suicide prevention programs can be categorized in three groups, based on targeted population: universal, selective, or indicated. Universal suicide prevention programs target everyone, selective programs target those at increased risk for STB, and indicated programs target those at high risk for suicide or those who are already exhibiting signs of STB (Goldsmith et al., 2002). There are several universal suicide prevention programs that have shown high efficacy at reducing STB (Robinson et al., 2018). At the same time, Calear et al. (2016) found that the most effective suicide prevention programs target a specific population. Future research may need to focus on developing suicide prevention programs that target different populations and emphasize the timeliness of the intervention so that it occurs before a child engages in STB.

Study participants also identified resource challenges including cost, insurance, time, and transportation as potential barriers to engaging in suicide prevention programs. In prior research, Michael and Ramtekkar (2022) similarly found transportation to be a barrier to engagement in suicide prevention programs, especially for those residing in rural communities. One promising option that may be able to help reduce these identified barriers is online suicide prevention programs. Web-based interventions have been found to have positive short-term effects on adolescents’ mental health (Välimäki et al., 2017) and have specifically been shown to reduce suicidal ideation (Witt et al., 2017). Furthermore, as accessibility has been noted as an appealing feature of online programs (Lai et al., 2014), offering such programs online may be an approach that can reduce the barriers of both timing and transportation.

Finally, our finding about cost as a barrier to suicide prevention participation is consistent with information from the World Health Organization (2018), which reported that financial considerations such as budgets for implementing suicide prevention programs were a hindrance. Crepeau-Hobson and Estes (2019) found that removing financial barriers increased access to and participation in mental health treatment, thereby reducing STB. Creating a free program for all youth at all ages who have a parental history of SA may increase the likelihood of participation for this group of families.

<h31 id="fam-39-7-899-d391e336">Study Limitations</h31>

Limitations to this study include the small sample size and lack of diversity in gender, race, and ethnicity. Nonetheless, we were able to achieve saturation in our findings, suggesting that these results may resonate with others in this population. As suicide affects individuals across race and ethnicity, socioeconomic status, sexual orientation, and so forth, it will be important to include perspectives from varied populations to further improve our understanding of what can encourage broad participation in suicide prevention programs. Future research with additional groups of parents with varying demographic characteristics is also needed. Studies that investigate the perspectives of children and adolescents about suicide prevention programs would also be helpful to inform future suicide prevention program design. Due to the limited number of children included in this pilot, we were unable to assess differences in perceptions of parents of younger children versus parents of older children. These potential differences can be considered in future studies.

<h31 id="fam-39-7-899-d391e340">Conclusion</h31>

Children whose parents have a history of SA have an increased risk for STB. Suicide prevention programs for these children should incorporate factors such as parental involvement and education as well as child counseling and education that our study participants reported were important elements of such programs. In addition, barriers to participation in suicide prevention programs such as fear, stigma and embarrassment, cost, time and transportation, and lack of education should be addressed. Considering these factors as well as program features (e.g., online offerings) will be important elements of suicide prevention programs that can be designed and implemented to reduce the risk of STB in this vulnerable population of children.

References

<anchor name="c38"></anchor>

Armat, M. R., Assarroudi, A., Rad, M., Sharifi, H., & Heydari, A. (2018). Inductive and deductive: Ambiguous labels in qualitative content analysis. The Qualitative Report, 23(1), 219–221. 10.46743/2160-3715/2018.2872

<anchor name="c2"></anchor>

Aseltine, R. H., Jr., & DeMartino, R. (2004). An outcome evaluation of the SOS suicide prevention program. American Journal of Public Health, 94(3), 446–451. 10.2105/AJPH.94.3.446

<anchor name="c4"></anchor>

Brent, D. A., Oquendo, M., Birmaher, B., Greenhill, L., Kolko, D., Stanley, B., Zelazny, J., Brodsky, B., Bridge, J., Ellis, S., Salazar, J. O., & Mann, J. J. (2002). Familial pathways to early-onset suicide attempt: Risk for suicidal behavior in offspring of mood-disordered suicide attempters. Archives of General Psychiatry, 59(9), 801–807. 10.1001/archpsyc.59.9.801

<anchor name="c5"></anchor>

Brent, D. A., Oquendo, M., Birmaher, B., Greenhill, L., Kolko, D., Stanley, B., Zelazny, J., Brodsky, B., Firinciogullari, S., Ellis, S. P., & Mann, J. J. (2003). Peripubertal suicide attempts in offspring of suicide attempters with siblings concordant for suicidal behavior. The American Journal of Psychiatry, 160(8), 1486–1493. 10.1176/appi.ajp.160.8.1486

<anchor name="c7"></anchor>

Burke, C. T., Calear, A. L., Cruwys, T., & Batterham, P. J. (2023). Are parents the key? How parental suicide stigma and suicide literacy affect help-seeking attitudes and intentions for their child. Journal of Youth and Adolescence, 52(11), 2417–2429. 10.1007/s10964-023-01841-3

<anchor name="c8"></anchor>

Calear, A. L., Christensen, H., Freeman, A., Fenton, K., Busby Grant, J., van Spijker, B., & Donker, T. (2016). A systematic review of psychosocial suicide prevention interventions for youth. European Child & Adolescent Psychiatry, 25(5), 467–482. 10.1007/s00787-015-0783-4

<anchor name="c35"></anchor>

Centers for Disease Control and Prevention. (2021). Web-Based Injury Statistics Query and Reporting System (WISQARS) [online]: Leading causes of death visualization tool. <a href="https://wisqars.cdc.gov/lcd/" target="_blank">https://wisqars.cdc.gov/lcd/</a>

<anchor name="c36"></anchor>

Centers for Disease Control and Prevention & National Center for Injury Prevention and Control. (2022). Web-Based Injury Statistics Query and Reporting System (WISQARS). <a href="https://www.wisqars.cdc.gov" target="_blank">https://www.wisqars.cdc.gov</a>

<anchor name="c10"></anchor>

Cerel, J., Frey, L. M., Maple, M., & Kinner, D. G. (2016). Parents with suicidal behavior: Parenting is not always protective. Journal of Child and Family Studies, 25(7), 2327–2336. 10.1007/s10826-016-0377-x

<anchor name="c11"></anchor>

Crepeau-Hobson, F., & Estes, J. (2019). Removing barriers to treatment: Evaluation of a youth suicide prevention program. Journal of Youth Development, 14(3), 146–159. 10.5195/jyd.2019.731

<anchor name="c12"></anchor>

Frey, L. M., & Cerel, J. (2015). Risk for suicide and the role of family: A narrative review. Journal of Family Issues, 36(6), 716–736. 10.1177/0192513X13515885

<anchor name="c34"></anchor>

Geulayov, G., Metcalfe, C., Heron, J., Kidger, J., & Gunnell, D. (2014). Parental suicide attempt and offspring self-harm and suicidal thoughts: Results from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Journal of the American Academy of Child & Adolescent Psychiatry, 53(5), 509–517. 10.1016/j.jaac.2013.12.022

<anchor name="c6"></anchor>

Goldsmith, S. K.,Pellmar, T. C.,Kleinman, A. M., & Bunney, W. E. (Eds.). (2002). Reducing suicide: A national imperative. National Academies Press.

<anchor name="c13"></anchor>

Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 42(4), 386–405. 10.1097/01.CHI.0000046821.95464.CF

<anchor name="c14"></anchor>

Hickey, K., Rossetti, J., & Musker, K. (2019). Concerns most important to parents after their child’s suicide attempt: A pilot study and collaboration with a rural mental health facility. Journal of Child and Adolescent Psychiatric Nursing, 32(2), 61–67. 10.1111/jcap.12234

<anchor name="c15"></anchor>

Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rodgers, B., & Pollitt, P. (1997). “Mental health literacy”: A survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166(4), 182–186. 10.5694/j.1326-5377.1997.tb140071.x

<anchor name="c16"></anchor>

Journot-Reverbel, K., Raynaud, J. P., Bui, E., & Revet, A. (2017). Support groups for children and adolescents bereaved by suicide: Lots of interventions, little evidence. Psychiatry Research, 250, 253–255. 10.1016/j.psychres.2017.01.077

<anchor name="c17"></anchor>

Krysinska, K., Andriessen, K., Ozols, I., Reifels, L., Robinson, J., & Pirkis, J. (2022). Effectiveness of psychosocial interventions for family members and other informal support persons of individuals who have made a suicide attempt. Crisis, 43(3), 245–260. 10.1027/0227-5910/a000776

<anchor name="c18"></anchor>

Lai, M. H., Maniam, T., Chan, L. F., & Ravindran, A. V. (2014). Caught in the web: A review of web-based suicide prevention. Journal of Medical Internet Research, 16(1), Article e30. 10.2196/jmir.2973

<anchor name="c19"></anchor>

Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1994). Psychosocial risk factors for future adolescent suicide attempts. Journal of Consulting and Clinical Psychology, 62(2), 297–305. 10.1037/0022-006X.62.2.297

<anchor name="c20"></anchor>

Melhem, N. M., Brent, D. A., Ziegler, M., Iyengar, S., Kolko, D., Oquendo, M., Birmaher, B., Burke, A., Zelazny, J., Stanley, B., & Mann, J. J. (2007). Familial pathways to early-onset suicidal behavior: Familial and individual antecedents of suicidal behavior. The American Journal of Psychiatry, 164(9), 1364–1370. 10.1176/appi.ajp.2007.06091522

<anchor name="c21"></anchor>

Michael, K. D., & Ramtekkar, U. (2022). Overcoming barriers to effective suicide prevention in rural communities. In J. P.Ackerman & L. M.Horowitz (Eds.), Youth suicide prevention and intervention: Best practices and policy implications (pp. 153–159). Springer Nature. 10.1007/978-3-031-06127-1_17

<anchor name="c22"></anchor>

Moskos, M. A., Olson, L., Halbern, S. R., & Gray, D. (2007). Utah youth suicide study: Barriers to mental health treatment for adolescents. Suicide and Life-Threatening Behavior, 37(2), 179–186. 10.1521/suli.2007.37.2.179

<anchor name="c24"></anchor>

Ortin-Peralta, A., Kerkelä, M., Veijola, J., Gissler, M., Sourander, A., & Duarte, C. S. (2023). Parental suicide attempts and offspring mental health problems in childhood and adolescence. Journal of Child Psychology and Psychiatry, 64(6), 886–894. 10.1111/jcpp.13743

<anchor name="c25"></anchor>

Pfeffer, C. R., Jiang, H., Kakuma, T., Hwang, J., & Metsch, M. (2002). Group intervention for children bereaved by the suicide of a relative. Journal of the American Academy of Child & Adolescent Psychiatry, 41(5), 505–513. 10.1097/00004583-200205000-00007

<anchor name="c26"></anchor>

Ranning, A., Uddin, M. J., Sørensen, H. J., Laursen, T. M., Thorup, A. A. E., Madsen, T., Nordentoft, M., & Erlangsen, A. (2022). Intergenerational transmission of suicide attempt in a cohort of 4.4 million children. Psychological Medicine, 52(14), 3202–3209. 10.1017/S0033291720005310

<anchor name="c27"></anchor>

Robinson, J., Calear, A. L., & Bailey, E. (2018). Suicide prevention in educational settings: A review. Australasian Psychiatry, 26(2), 132–140. 10.1177/1039856218759406

<anchor name="c28"></anchor>

Sayal, K., Tischler, V., Coope, C., Robotham, S., Ashworth, M., Day, C., Tylee, A., & Simonoff, E. (2010). Parental help-seeking in primary care for child and adolescent mental health concerns: Qualitative study. The British Journal of Psychiatry, 197(6), 476–481. 10.1192/bjp.bp.110.081448

<anchor name="c37"></anchor>

Sheehan, L. L., Corrigan, P. W., Al-Khouja, M. A. & the Stigma of Suicide Research Team. (2017). Stakeholder perspectives on the stigma of suicide attempt survivors. Crisis, 38(2), 73–81. 10.1027/0227-5910/A000413

<anchor name="c29"></anchor>

Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing Health Sciences, 15(3), 398–405. 10.1111/nhs.12048

<anchor name="c30"></anchor>

Välimäki, M., Anttila, K., Anttila, M., & Lahti, M. (2017). Web-based interventions supporting adolescents and young people with depressive symptoms: Systematic review and meta-analysis. JMIR mHealth and uHealth, 5(12), Article e180. 10.2196/mhealth.8624

<anchor name="c31"></anchor>

Wasserman, C., Hoven, C. W., Wasserman, D., Carli, V., Sarchiapone, M., Al-Halabí, S., Apter, A., Balazs, J., Bobes, J., Cosman, D., Farkas, L., Feldman, D., Fischer, G., Graber, N., Haring, C., Herta, D. C., Iosue, M., Kahn, J. P., Keeley, H., …Poštuvan, V. (2012). Suicide prevention for youth—A mental health awareness program: Lessons learned from the Saving and Empowering Young Lives in Europe (SEYLE) intervention study. BMC Public Health, 12(1), Article 776. 10.1186/1471-2458-12-776

<anchor name="c32"></anchor>

Witt, K., Spittal, M. J., Carter, G., Pirkis, J., Hetrick, S., Currier, D., Robinson, J., & Milner, A. (2017). Effectiveness of online and mobile telephone applications (‘apps’) for the self-management of suicidal ideation and self-harm: A systematic review and meta-analysis. BMC Psychiatry, 17(1), Article 297. 10.1186/s12888-017-1458-0

<anchor name="c33"></anchor>

World Health Organization. (2018). National suicide prevention strategies: Progress, examples and indicators. <a href="https://www.who.int/publications/i/item/national-suicide-prevention-strategies-progress-examples-and-indicators" target="_blank">https://www.who.int/publications/i/item/national-suicide-prevention-strategies-progress-examples-and-indicators</a>

Submitted: January 17, 2025 Revised: July 14, 2025 Accepted: July 15, 2025