Lock and Protect, Reducing Access to Adolescent Means of Suicide: A Feasibility Cohort Pilot Study

Ashley Blanchard, MD, MS
Joandalys Tejada, MPH
Emma Cornell, MPH
Joan Asarnow, PhD
Randy P. Auerbach, PhD
Peter Dayan, MD, MSc

Emergency department (ED) visits for adolescent suicidal ideation or attempts have doubled in recent decades. Providing lethal means counseling to guardians in EDs is a promising method to prevent suicide attempts and death in adolescents. Our multi-disciplinary clinical and investigative team has systematically developed Lock and Protect, a novel lethal means restriction decision aid for guardians presenting to EDs with their adolescent child. Lock and Protect is a web-based, decision aid, that uses a non-judgmental, self-directed approach to offer a range of options to reduce access to lethal means. We aimed to determine the acceptability and feasibility of implementing the Lock and Protect decision aid and the feasibility of conducting a future trial in the ED among parents whose adolescents are at risk of suicide.

We conducted a prospective cohort study of caregivers and adolescents. Caregivers received the Lock and Protect intervention during evaluation of their child in the ED. We included caregivers of adolescents ages 13-17 years-old presenting to the ED for suicidal ideation, suicide attempt, or non-suicidal self-injury. Though our study is not powered to determine effectiveness, our primary outcome assessed change in home access of medications and/or firearms at 2-weeks and 4-weeks after ED visit. Secondary outcomes included measures of decision quality, acceptability and behavioral intent. Decision quality is a fundamental element of the Ottawa Decision Support Framework, as a precursor to behavior change. We used standard descriptive statistics with appropriate distribution measures to summarize feasibility, acceptability, and behavior change.

Of 40 enrolled, caregivers were 52.5% Latine, 42.5% White, and 30% Black. Among caregivers, Lock and Protect was found to be respectful of their family values about medications (100%) and firearms (97.5%), with 92.5% of caregivers reporting that the length and amount of information in Lock and Protect was “just right.” All caregivers would recommend the tool to a friend or family member in a similar situation, and 93.3% found that the options presented were realistic. 97.5% of guardians found Lock and Protect to be useful for changing home access to lethal means. Caregivers used the tool for an average of 9.5 minutes and 100% of caregivers completed the tool. Follow up procedures were completed for 71% of caregivers and adolescents and 70.9% of caregivers increased safe storage of firearms or medications in their home.

Lock and Protect, a web-based lethal means counseling decision aid, is feasible to implement in the ED and acceptable to guardians of adolescents presenting to a single, urban ED for suicidal thoughts and behaviors.

1. Understand the acceptability and feasibility of a novel, web-based ED-based lethal-means counseling decision aid
2. Understand how a novel, web-based lethal means counseling decision aid might be integrated into ED-care of adolescents at increased risk for suicide.

Excess Risk of Self-Injury Associated with Autism Spectrum Disorder

Guohua Li, MD, DrPH
Stanford Chihuri
Ashley Blanchard, MD, MS
Carolyn DiGuiseppi

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent challenges in social interactions and restricted, repetitive patterns of behavior and interests. The reported prevalence of ASD in the United States has tripled in the past two decades. Recent studies indicate that ASD is associated with increased self-injurious behaviors. The purpose of this study is to assess the excess risk of self-injury associated with ASD.

Data from the 2016-2018 Nationwide Emergency Department Samples were analyzed to examine the epidemiologic patterns and excess risks of self-injury associated with ASD, and attention deficit/hyperactivity disorder (ADHD) or intellectual disability (ID). ED visits for self-injury were identified according to the ICD–10–CM external cause-of-injury matrix. Multivariable logistic regression modeling was used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (CI) of self-injury associated with ASD, and ADHD/ID.

The 2016-2018 NEDS recorded a total of 99,602,049 ED visits; of them, 2,488,066 (2.5%) were related to self-injury. Self-injury accounted for 3.6% of ED visits made by patients with a diagnosis of ASD, 5.8% of ED visits by patients with a diagnosis of ADHD, and 4.9% of ED visits by patients with a diagnosis of ID. Relative to patients without ASD, ADHD, and ID, the odds of self-injury increased 84% for patients with ASD but without ADHD or ID (aOR = 1.84; 95% CI: 1.78, 1.89), 189% for patients with ADHD/ID but without ASD (aOR = 2.89; 95% CI: 2.86, 2.93), and 178% for patients with ASD and ADHD or ID (aOR = 2.78; 95% CI: 2.63, 2.94). Poisoning was the leading mechanism of self-injury, accounting for 73.7% of self-injury-related ED visits.

Results of this study indicate that ASD is associated with a significantly increased risk of self-injury and that comorbid ADHD/ID can explain only part of the excess risk of self-injury in people with ASD.

1. Update on the recent trends of autism prevalence in the US.
2. Review recent research on injuries among people with autism.
3. Assess evidence regarding self-injury risk associated with autism and comorbidities.

What's Known, What’s New and What’s Needed in Injury Prevention

Lorrie Lynn, MA, CPSTI
Rohit P. Shenoi, MD
Keisha Fraser Doh, MD
Ashley Blanchard, MD, MS

This session will highlight the work of our esteemed colleagues in a myriad of injury prevention topics including firearms, drowning, sleep related injuries, suicide, and youth with autism spectrum disorder. The panelists will highlight new trends in epidemiology and intervention strategies. They will further identify gaps in their fields and describe potential solutions to improve future injury prevention efforts.

1. Describe existing disparities in drowning burden and access to drowning countermeasures.
2. Formulate an injury prevention framework to address pediatric drowning.
3. Understand existing burden of SUID, current trends and best practice recommendations.
4. Describe existing disparities in firearm injuries.
5. Formulate an injury prevention framework to address firearm injuries.
6. Understand the trends of injury among children with autism and their unique injury risk and available interventions.