Andrew J. Barnes

Suicide and Self-Injury Among Children and Youth With Chronic Health Conditions

OBJECTIVE: Chronic conditions may be associated with suicide risk. This study aimed to specify the extent to which youth chronic conditions are at risk for suicidality and self-harm. METHODS: Logistic regression was used to estimate odds of self-harm, suicidal ideation, and suicide attempts in 10- to 19-year-olds with and without chronic physical and/or mental health conditions. RESULTS: Independent of race, socioeconomic status, absent parent, special education status, substance use, and emotional distress, youth with co-occurring chronic physical and mental conditions (n = 4099) had significantly higher odds of self-harm (odds ratio [OR]: 2.5 [99% confidence interval (CI): 2.3–2.8), suicidal ideation (OR: 2.5 [99% CI: 2.3–2.8), and suicide attempts (OR: 3.5 [99% CI: 3.1–3.9]) than healthy peers (n = 106 967), as did those with chronic mental conditions alone (n = 8752). Youth with chronic physical conditions alone (n = 12 554) were at slightly elevated risk for all 3 outcomes. Findings were similar among male and female youth, with a risk gradient by grade. CONCLUSIONS: Chronic physical conditions are associated with a slightly elevated risk for self-harm, suicidal thinking, and attempted suicide; chronic mental conditions are associated with an increased risk for all 3 outcomes. Co-occurring chronic physical and mental conditions are associated with an increased risk for self-harm and suicidal ideation that is similar to the risk in chronic mental conditions and with an attempted suicide risk in excess of that predicted by the chronic mental health conditions alone. Preventive interventions for these youth should be developed and evaluated.

Promoting healthy behaviors in pediatrics: Motivational interviewing

1. Andrew J. Barnes, MD, MPH* 2. Melanie A. Gold, DO† 1. *Assistant Professor, Developmental-Behavioral Pediatrics, University of Minnesota, Minneapolis, MN. 2. †Clinical Professor of Pediatrics, Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh Student Health Service, Pittsburgh, PA. * Abbreviations: MI: : motivational interviewing MINT: : Motivational Interviewing Network Trainers After completing this article, readers should be able to: 1. Describe the spirit and principles of motivational interviewing (MI). 2. Know indications for using MI in the pediatric setting. 3. Apply MI to support behavioral change in pediatric patients at all stages of development. Please read the following and watch the video clip (Fig 1). Figure 1. Most pediatric clinicians realize that well-intentioned clinical plans can sometimes fall flat or backfire. Everyday practice is rife with times when one might wonder about which prescriptions go unfilled, whether home safety advice is being “tuned out,” or whether families will return for recommended follow-up visits. In pediatrics, in which “the family is the patient,” ensuring positive changes in health behaviors is daunting, especially in the face of perceived barriers such as lack of time and reimbursement for counseling. The true obstacles to high-quality care often are interpersonal and can include how practitioners deal (or fail to deal) with their feelings of discouragement or discomfort when faced with particularly “resistant” patients. Integrating motivational interviewing (MI) into one’s practice can be a very satisfying way to overcome some of these barriers. MI allows the clinician to stay more connected in a therapeutic relationship with patients by helping them identify how, when, and what behaviors they can change to improve their own health. MI is a supportive counseling style that guides patients toward positive health-related behaviors by helping them resolve ambivalence toward changing. (1) MI seeks to enhance the self-efficacy of patients to facilitate these changes, helping patients move through the continuum of change proposed in the Transtheoretical Model of James Prochaska and Carlo DiClemente, progressing from not yet …

Documentation of Child Maltreatment in Electronic Health Records

International Classification of Diseases codes for child maltreatment can aid surveillance and research, but the extent to which they are used is not well established. We documented prevalence of the use of maltreatment-related codes, examined demographic characteristics of youth assigned these codes, and compared results with previous studies. Data were extracted from electronic health records of 0- to 21-year-olds assigned 1 of 15 maltreatment-related International Classification of Diseases, Ninth Revision, codes who had encounters in a large medical system over a 4-year period. Only 0.02% of approximately 2.5 million youth had a maltreatment-related code, replicating other studies. Results provide a dramatic contrast to much higher rates based on self-report or informant-report and referrals to Child Protective Services. Lack of documentation of maltreatment in electronic health records can lead to missed chances at early intervention, inadequate coordination of health care, insufficient allocation of resources to addressing problems related to maltreatment, and flawed public health data.

Attachment-based family therapy reduces suicidal ideation in adolescents.

ED FROM Diamond GS, Wintersteen MB, Brown GK, et al. Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2010;49:122–31. Correspondence to: Guy S Diamond, Center for Family Intervention Science, Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104, USA; diamond@email.chop.edu Source of funding: US Centers of Disease Control and Prevention. A table and references are published online only at http://ebmh.bmj.com Common clinical approaches to suicidal behavior in adolescents sorely lack evidence, including brief hospitalization, ‘contracts for safety’ and supportive counseling. Even ‘combined’ therapy (intensive medication management plus cognitive–behavioral psychotherapy), which has the strongest evidence for preventing mild suicidal ideation, does not seem to decrease suicide risk in severely depressed adolescents. Two existing ‘manualized’ treatments, Multisystemic Therapy and Social Support Teams, seem to hold promise in reducing suicidality in teens. Although neither has yet been rigorously tested in randomized control trials using intention-to-treat analyses, their effi cacy suggests that garnering and maintaining effective social support may indeed alleviate some forms of adolescent suicidality. Attachment-based family therapy reduces suicidal ideation in adolescents

Health-Care Utilization Patterns of Maltreated Youth

To examine in detail the health-care utilization patterns of maltreated children, we studied electronic health records (EHRs) of children assigned maltreatment-related codes in a large medical system. We compared youth with maltreatment-related diagnoses (N = 406) with those of well-matched youth (N = 406). Data were based on EHRs during a 4-year period from the University of Minnesotas Clinical Data Repository, which covers eight hospitals and over 40 clinics across Minnesota. A primary care provider (PCP) was assigned to over 80% of youth in both groups. As expected, however, the odds of not having a PCP were twice as high in the maltreated as in the comparison group. Also as expected, maltreated youth had higher rates of emergency department visits. We ruled out differences in age, gender, race, public insurance, duration in the medical system, type of specialty department, and clinic location as potential explanations for these differences. On the other hand, there were no significant differences between maltreated and comparison youth in hospitalizations, preventive visits, or office visits. Contrary to expectations, maltreated youth were not in the medical system for just a brief period of time and were not more likely to cancel or miss appointments. The current study adds to the research literature by providing more detailed information about the nature of health-care services used by children with maltreatment-related diagnoses.

Promoting Resilience by Improving Children's Sleep: Feasibility Among Families Living in Supportive Housing

Abstract: Background: Poverty has been linked to sleep disruption, which is in turn associated with health and behavior problems. Sleep disturbance may be a key mechanism by which poverty affects child development. Objective: To evaluate the feasibility, appeal, and promise of a brief sleep-promoting intervention for low-income families with 4- to 8-year-old children in site-based supportive housing. Methods: University researchers and community partners developed a sleep-promoting intervention (family workshop and bedtime relaxation routine) that was implemented at one supportive housing site. Multiple methods were used to assess feasibility and preliminary effectiveness in 11 participating families. Results: Intervention and research activities were acceptable to families, but adherence to daily sleep measures was low. Most parents reported high satisfaction, and data showed trends of improvement in children’s sleep, behavior, and executive function (EF). Conclusions: A brief sleep-promoting intervention for children in disadvantaged families showed feasibility and promise. Future studies are needed to test the efficacy of a refined version of this sleep intervention with families in similar situations, focusing on decreasing burden, tailoring interventions, and sustaining change.

Adverse Childhood Experiences and Weight Status among Adolescents

Objective To investigate the relationship between adverse childhood experiences (ACEs) and weight status among adolescents. Study design Data were drawn from the Minnesota Student Survey, a large (n = 105 759), statewide, anonymous survey of public school students in eighth, ninth, and eleventh grades. Self‐reported height and weight were used to calculate body mass index. Multinomial logistic regression was used to examine associations between self‐reported ACEs and weight status, controlling for key sociodemographic characteristics. Results ACEs were positively associated with weight status; adolescents with more ACEs were more likely to have overweight, obesity, and severe obesity than adolescents with no ACEs. Adolescents who reported an ACE were 1.2, 1.4, and 1.5 times as likely to have overweight, obesity, and severe obesity, respectively, compared with their peers with no ACEs. There was no relationship between ACEs and underweight. Conclusions The results of this large sample of adolescents with anonymous data support the hypothesis that ACEs and obesity are strongly associated. The directionality of this relationship needs to be understood. Moreover, these findings suggest that child health professionals may need to screen for ACEs as an important aspect of clinical weight management.

Emotional Health Among Youth Experiencing Family Homelessness

In 4594 children with family homelessness, elevated emotional health risks were mitigated by developmental assets but not to the same extent as for nonhomeless youth. BACKGROUND AND OBJECTIVES: Youth who are homeless with adult family members comprise 37% of the US homeless population, yet mental health among this group has not yet been well described. We aimed to compare the risk of suicidality, and factors that may protect against it, between family-homeless and nonhomeless youth. METHODS: We used cross-sectional data, representing 62 034 eighth- to 12th-graders, to estimate the adjusted odds ratio (aOR) of emotional distress, self-injury, suicidal ideation, and attempted suicide in the past 12 months for youth who experienced family homelessness in the past 12 months compared with housed youth, controlling for covariates. We then tested whether developmental assets moderated these outcomes. RESULTS: Four percent (n = 4594) of youth (mean age 14.9 years) were homeless with an adult family member. Among these, 29.1% (n = 1317; aOR: 2.52, 95% confidence interval [CI] 2.34–2.69) reported self-injury, 21% (n = 940; aOR: 2.30, 95% CI: 2.14–2.48) reported suicidal ideation, and 9.3% (n = 416; aOR: 3.24, 95% CI: 2.91–3.60) reported suicide attempts. Developmental assets decreased the odds of these outcomes for all youth but were less protective for homeless youth. CONCLUSIONS: Youth experiencing recent family homelessness are at higher risk of suicidality than their nonhomeless peers, suggesting homelessness itself as a marker of risk. Factors that protect emotional health are less impactful among youth experiencing recent family homelessness. Thus, interventions among homeless youth may need to address social determinants of health such as stable housing and adversity in addition to developmental assets.

Adolescent Connectedness with Parents Promotes Resilience among Homeless Youth

Youth who experience homelessness have worse health and well-being than housed youth. Internal assets, including social competency and positive self-identity, are factors that promote healthy development. This study compared internal assets between homeless and housed youth, and examined whether connectedness with parents moderates the association between homelessness and internal assets. Using data from a large population-based survey of middle- and high-school aged youth, we found that homelessness was associated with lower levels of internal assets. However, having high connectedness with a parent significantly predicted the strength of these assets, suggesting opportunities to promote health equity among homeless youth.

Integrating Pediatric Hypnosis with Complementary Modalities: Clinical Perspectives on Personalized Treatment

While pediatric integrative medicine (PIM) emphasizes an “evidence-based practice using multiple therapeutic modalities”; paradoxically, literature reviews examining the prevalence and/or efficacy of such mind–body approaches often address PIM modalities separately. Such contributions are relevant, yet documentation of how to deliver combined complementary approaches in children and youth are scarce. Nevertheless, integrative practitioners in clinical practice routinely mix approaches to meet the individual needs of each patient. Best practices are flexible, and include blending and augmenting services within the same session, and/or connecting modalities sequentially for an incremental effect, and/or referring to outside resources for additional interventions. Resonating with integrative medicine’s definition, this article’s goal is to demonstrate paradigms that “bring together complementary approaches in a coordinated way within clinical practice” by linking clinical hypnosis, the trail-blazer modality in PIM’s history, with mindfulness, biofeedback, acupuncture, and yoga. Following the consideration of the overlap of guided imagery with hypnosis and an abridged literature report, this clinical perspective considers the selection of modalities within a collaborative relationship with the child/teen and parents, emphasizing goodness-of-fit with patients’ contexts, e.g., symptoms, resources, interests, goals, and developmental stage. Case vignettes illustrate practical strategies for mixing approaches.