Ian Manion

Children's emotional and behavioral reactions following the disclosure of extrafamilial sexual abuse: Initial effects

Despite a dramatic increase of the empirical literature on child sexual abuse, very few investigations have examined the initial effects of extrafamilial sexual abuse (ESA). The present study evaluated the emotional and behavioral adjustment of 41 children (mean age 10 years, range 5.4 to 15.5 years) within the first 3 months following the disclosure of ESA. Childrens functioning was compared to that of a nonclinical comparison group of 43 children, matched on childs age, gender, and family constellation. Child functioning was assessed using a combination of child-report, primary caregiver-report (i.e., parent), and teacher-report measures. Results revealed that sexually abused children, in comparison to nonabused children, suffered deleterious and clinically significant effects. Standard multiple regressions found that the childrens perceptions of self-blame and guilt for the abuse and the extent of traumatization predicted their self-reported symptomatology of depression, social efficacy, and general and abuse-related fears. As well, childs gender predicted the level of general fearfulness. None of the other demographic or abuse-related variables were related to childrens functioning. These results underscore the need for multidimensional and multisource assessment of children who experience ESA, and point to the clinical importance of addressing the abuse-related attributions of these children.

Suicidal Children and Adolescents With First Emergency Room Presentations: Predictors of Six-Month Outcome

OBJECTIVE To examine risk of future documented suicide attempts and emergency room (ER) returns among children and adolescents with first suicidal ER presentations. METHOD A total of 548 consecutive ER presentations of suicidal 5- to 19-year-olds to a Canadian center over a 1-year period (1997-1998) were reviewed. Relative risk analyses were performed on 224 first-time patients (mean age 14.6+/-2.1) to determine the strength of associations between predictors and outcomes (ER return and suicide attempts). RESULTS At 6-month follow-up, 32.6% (n = 73) had returned to the ER, 24.1% (n = 54) had a documented suicide attempt, and 14.3% (n = 32) required psychiatric hospitalization. Predictors for both ER return and future documented suicide attempts included 15- to 19-year age range, past foster/group home placement, past mental health care, a suicide plan, reported mood symptoms, sobriety at ER visit, and general substance use. Child welfare guardianship and abuse history were also predictors of ER returns. CONCLUSIONS Clinicians should be aware of these risk factors when assessing and managing suicidal youths with first ER presentations.

Factors in the Psychological Adjustment of Homeless Adolescent Males: The Role of Coping Style

OBJECTIVE This cross-sectional study explored differences in and the association of self-reported coping style, negative life events, self-esteem, and perceived social support with the psychological adjustment (i.e., depressive symptoms, internalizing and externalizing behavior problems) of homeless and nonhomeless adolescent males. METHOD Data were collected from 100 youths accessing an emergency shelter and two comparison groups of nonhomeless youths: 70 youths accessing local community drop-in centers and 54 high school youths who had never accessed a shelter or drop-in. Data were collected from January 2000 to January 2001 in Ottawa. RESULTS Homeless youths reported a higher prevalence of family dysfunction, school difficulties, suicide attempts, legal problems, and substance use than nonhomeless youths. Homeless youths differed from nonhomeless youths for each outcome measure, reporting a greater use of the disengagement coping style, higher negative life events index, less perceived parental support, and higher levels of depressive symptoms and internalizing and externalizing behavior problems. Hierarchical regression analyses indicated that disengagement coping and self-worth accounted for significant amounts of variance in depressive symptomatology, and both internalizing and externalizing behavior problems in homeless youths. CONCLUSIONS Findings reflect the merit of considering coping style as a factor in the prevalence of psychological maladjustment among homeless youths.

A survey of behavior problems in children with epilepsy

Over a period of 3 consecutive months, a cross-sectional, descriptive survey was made of the frequency of behavior problems and needs, as reported by their caregivers, of 6- to 18-year-old epileptic children attending two neurology clinics, using the Child Behavior Checklist. Caregivers of 175 children were approached to take part in the study; 158 (90%) completed the Child Behavior Checklist. The mean age of the children was 11.3 (range, 6-18). t scores >70 were obtained for 15.9% of the group for total behavior, 12.7% of the group for internalized behavior and 11.4% of the group for externalized behavior. Compared with those with normal scores, children with elevated t scores were more likely to have learning difficulties and to require the use of more community services.

Pediatric Suicide-Related Presentations: A Systematic Review of Mental Health Care in the Emergency Department

STUDY OBJECTIVE We evaluate the effectiveness of interventions for pediatric patients with suicide-related emergency department (ED) visits. METHODS We searched of MEDLINE, EMBASE, the Cochrane Library, other electronic databases, references, and key journals/conference proceedings. We included experimental or quasiexperimental studies that evaluated psychosocial interventions for pediatric suicide-related ED visits. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy. Consensus was reached by conference; disagreements were adjudicated by a third reviewer. We calculated odds ratios, relative risks (RRs), or mean differences for each studys primary outcome, with 95% confidence intervals (CIs). Meta-analysis was deferred because of clinical heterogeneity in intervention, patient population, and outcome. RESULTS We included 7 randomized controlled trials and 3 quasiexperimental studies, grouping and reviewing them according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3). An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions (mean difference=2.6 sessions; 95% CI 0.05 to 5.15 sessions). Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge (RR=1.28; 95% CI 1.06 to 1.56). The 3 ED transition intervention studies reported (1) reduced risk of subsequent suicide after brief ED intervention and postdischarge contact (RR=0.10; 95% CI 0.03 to 0.41); (2) reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care (RR=0.41; 95% CI 0.28 to 0.60); and (3) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent (odds ratio=2.78; 95% CI 1.20 to 6.67). CONCLUSION Transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence. Use of similar interventions and outcome measures in future studies would enhance the ability to derive strong recommendations from the clinical evidence in this area.

Prospective Assessment of Cannabis Withdrawal in Adolescents With Cannabis Dependence: A Pilot Study

OBJECTIVE To prospectively identify and assess withdrawal symptoms in adolescents with cannabis dependence. METHOD Twenty-one adolescents ages 13 to 19 years voluntarily entering residential and day/outpatient substance abuse programs, with cannabis dependence as their only current substance of dependence, were assessed using the Teen-Addiction Severity Index, Substance Use Survey, Cannabis Withdrawal Scale, and the Structured Clinical Interview for DSM-IV Childhood Diagnoses Substance Use Disorders Module. Weekly assessments continued for 4 weeks. Thirteen youths attained a minimum of 2 weeks of abstinence. RESULTS Cannabis withdrawal symptoms were present in adolescents. Cannabis withdrawal was greatest in the first 2 weeks of abstinence with evidence that it continued well into week 3. Most withdrawal symptoms were endorsed with a high degree of frequency. Those symptoms endorsed with the greatest severity were restlessness, appetite change, and thoughts of and cravings for cannabis, with the highest ratings occurring in week 1. Over the course of the study, participants reported fewer symptoms with decreasing levels of severity. Youth ratings of overall severity of withdrawal were significantly and positively correlated with withdrawal symptoms of irritability (r = 0.56), depression (r = 0.56), twitches and shakes (r = 0.57), perspiring (r = 0.57), thoughts of (r = 0.86), and cravings for (r = 0.69) cannabis. CONCLUSIONS Findings support the presence of clinically significant cannabis withdrawal symptoms in adolescents with cannabis dependence seeking substance abuse treatment. This study also provides supporting evidence suggesting a vulnerability of adolescents to physiological cannabis dependence. The study supports the addition of cannabis withdrawal as a distinct entity for inclusion in DSM-V.

Identifying depressed and suicidal adolescents in a teen health clinic

PURPOSE This study examined the 6-month prevalence of depression and suicidal probability among new referrals to an adolescent health clinic. METHODS All subjects (n = 104) completed the Beck Depression Inventory (BDI) and the Suicide Probability Scale (SPS) prior to being seen by a physician and were categorized according to presenting problem (physical complaints only, psychological complaints only, and physical and psychological complaints combined). RESULTS Fifty-nine percent of the sample was depressed with 21% falling in the moderate range and 21% falling within the severe range of depression. Almost 23% of the sample demonstrated significant suicidal probability. The BDI and SPS were highly correlated (r = .73, p < .001) and 22% of the sample met criteria for both moderate to severe depression and suicidal probability. A significantly greater proportion of patients presenting with physical and psychological complaints combined (60%) met BDI criteria for depression than was found for the other two groups. Suicidal probability was most prevalent in patients presenting with psychological complaints only (26%) and moderate to severe depression and significant suicidal probability also coexisted to a greater extent within this group (26%). CONCLUSIONS Results suggest that depression and suicidal probability represent significant mental health problems within the adolescent clinic and the identification of high-risk individuals can be achieved through comprehensive screening practices.

Sex Differences in Childhood Sexual Abuse and Suicide-Related Behaviors

Child sexual abuse and suicide-related behaviors are associated, but it remains unclear if the strength of this association differs in boys and girls. In a systematic review of this association in children and youth, we identified 16 relevant studies, all cross-sectional surveys of students. The association is stronger in boys specific to suicide attempt(s). Adjustments for potential confounding variables explained some, but not all of this sex difference. While additional research would strengthen causal inferences, this sex difference may be influenced by the nature and timing of child sexual abuse as well as the sex of the perpetrator, which in turn shapes the disclosure of these events.

A youth suicide prevention plan for Canada: a systematic review of reviews

Objective: We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts. Methods: Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings. Results: No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%. Conclusions: Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Child maltreatment and onset of emergency department presentations for suicide-related behaviors

OBJECTIVES To determine whether the rates of a first presentation to the emergency department (ED) for suicide-related behavior (SRB) are higher among children/youth permanently removed from their parental home because of substantiated maltreatment than their peers. To describe the health care settings accessed by these children/youth before a first SRB presentation to help design preventive interventions. METHODS A population-based (retrospective) cohort of 12-17-year-olds in Ontario, Canada was established. Children/youth removed from their parental home because of the above noted maltreatment (n=4683) and their population-based peers (n=1,034,546) were individually linked to administrative health care records over time to ascertain health service use and subsequent ED presentations for SRB during follow-up. Person-time incidence rates were calculated and Cox regression models used to estimate adjusted hazard ratios (HR) and corresponding 95% confidence intervals (CI). RESULTS After controlling for demographic characteristics and prior health service use, maltreated children/youth were about five times more likely to have a first ED presentation for SRB compared to their peers, in both boys (HR: 5.13, 95% CI: 3.94, 6.68) and girls (HR: 5.36, 95% CI: 4.40, 6.54). CONCLUSIONS Children/youth permanently removed from their parental home because of substantiated child maltreatment are at an increased risk of a first presentation to the ED for SRB. The prevention of child maltreatment and its recurrence and the promotion of resilience after maltreatment has occurred are important avenues to study toward preventing ED SRB presentations in children/youth. Provider and system level linkages between care sectors may prevent the need for such presentations by providing ongoing environmental support.