The goal of this clinical trial is to test the I-CARE program in children who are in a medical hospital awaiting inpatient mental health treatment. The main questions it aims to answer are:

• Can the I-CARE program be used at the medical hospitals and do the patients and hospital staff like the program?
• Does the I-CARE program lower patients' emotional distress, thoughts about suicide or suicide attempts?

Patients will complete as many of the 7 I-CARE videos as possible during their stay at the medical hospital and fill out online surveys. There are workbook activities that go with each I-CARE video. A hospital staff member will help the patient do the videos and workbook activities.

The COVID-19 pandemic has contributed to a dramatic and unprecedented rise in pediatric mental health conditions, with rates of depression and anxiety doubling from pre-pandemic estimates. These increases exacerbate decades-long trends of increasing youth suicidality. Suicide is the second leading cause of death among adolescents; from 2007 to 2017 suicide deaths tripled in youth 10 to 14 years. Emergency departments (EDs) at acute care hospitals increasingly serve as portals of care for youth with suicidal ideation or attempt. When these youth are deemed to require psychiatric hospitalization, the demand for beds often exceeds supply, leading to psychiatric boarding. To address this gap, a multidisciplinary team including pediatricians, psychologists and patient partners developed a modular digital intervention and associated training materials to deliver evidence-based psychosocial skills to youth during boarding. This program, entitled I-CARE (Improving Care, Accelerating Recovery & Education), consists of 7 web-based animated videos and workbook exercises, facilitated by licensed nursing assistants who provide 1-on-1 safety supervision during boarding. Given that 1-on-1 safety supervision is the current standard of care at most hospitals, I-CARE requires minimal additional resources beyond those already available in these settings. The psychosocial skills included in I-CARE are grounded in cognitive behavioral therapy and were prioritized through a rigorous Delphi process evaluating their importance and feasibility to deliver during psychiatric boarding.

Aim 1:

Adapt and refine I-CARE training and implementation materials, taking into account variation in hospital resources and boarding locations while maintaining implementation fidelity.

Aim 2:

Using an open pilot/case series design, assess I-CARE feasibility and engagement of target mechanisms from the perspectives of youth, caregivers, and clinicians using a mixed-methods approach.

Aim 3:

Determine the preliminary effectiveness of I-CARE to reduce emotional distress and suicidal risk compared to usual care in youth experiencing boarding for suicidal ideation or attempt, and assess the effects of I-CARE on readiness for change, suicide-related coping, hope, and mental health treatment engagement.

Inclusion Criteria:

• Adolescents aged 12-17 years
• Ability to speak and complete surveys in English
• Presented to ED with suicidal ideation or attempt
• Awaiting psychiatric disposition
• Receiving one-on-one safety supervision
• Medically stable

Exclusion Criteria:

• Cognitive or developmental delays that preclude program participation based on clinical team assessment
• Diagnosis of psychosis
• Primary reason for hospitalization or ED visit is an eating disorder
• Parent/guardian not able to provide consent in English
• Admission or transfer for psychiatric care anticipated on the first day of potential enrollment
• Clinical team concern for patient or staff safety based upon active behavioral concerns
• In child protective custody/ward of the state

Data will be uploaded into the NIMH Data Archive (NDA).

Data will be collected from approximately 109 adolescents 12-17 years of age. Measures include:

1. Depression, Anxiety, and Stress Scale - Youth version (DASS-Y)
2. Harkavy-Asnis Suicide Scale (HASS) - Suicide Attempt module
3. Concise-Health Risk Tracking-Self Report (CHRT)
4. Efficacy to Cope with Suicidal Thoughts and Urges Scale
5. The Children's Hope Scale
6. My Thoughts about Therapy Expectancy Scale
7. Cunningham Treatment Engagement Readiness to Change Scale
8. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure for Youth
9. RCADS-25 for Youth

All data will be deposited to NDA starting 12 months after the award begins and will be deposited every six months thereafter following the usual NDA data submission dates.

All those with access to the NDA will have access to our data.