Paula Cloutier

Nonsuicidal self-harm in youth: a population-based survey

Background: Nonsuicidal self-harm includes cutting, scratching, burning and minor overdosing. There have been few studies that have examined the rate of self-harm and mental-health correlates among community-based youth. We performed a population-based study to determine the prevalence of nonsuicidal self-harm, its mental-health correlates and help-seeking behaviour. Methods: We used data from the Victoria Healthy Youth Survey, a population-based longitudinal survey of youth aged 14–21 in Victoria, British Columbia. The survey included questions about the history, method, frequency, age of onset and help-seeking for nonsuicidal self-harm. Youth were interviewed between February and June 2005. Univariable group differences were analyzed using students t test for continuous data and χ2 for binary or categorical data. Multivariate analyses were conducted by use of multivariate analysis of variance and logistic regression. Results: Ninety-six of 568 (16.9%) youth indicated that they had ever harmed themselves. Self-injuries such as cutting, scratching and self-hitting were the most common forms of nonsuicidal self-harm (83.2%). The mean age of onset was 15.2 years. Of those who reported nonsuicidal self-harm, 56% had sought help for this behaviour. Participants who reported 5 or more symptoms (out of 6) in a given symptom category were more likely than those who reported less than 5 symptoms to report nonsuicidal self-harm for the following categories: depressive mood (odds ratio [OR] 2.18, confidence interval [CI] 1.28–3.7) and problems with regulation of attention, impulsivity and activity (OR 2.24, CI 1.33–3.76). Interpretation: We found a high lifetime prevalence of nonsuicidal self-harm. Many mental-health symptoms were associated with this behaviour, particularly those with depressive mood and attention-related problems. Just over half of youth reported seeking help for nonsuicidal self-harm. Clinicians who encounter youth should be vigilant to assess for this behaviour in youth who present with mental health issues.

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.

The HEADS-ED: A Rapid Mental Health Screening Tool for Pediatric Patients in the Emergency Department

BACKGROUND AND OBJECTIVE: The American Academy of Pediatrics called for action for improved screening of mental health issues in the emergency department (ED). We developed the rapid screening tool home, education, activities/peers, drugs/alcohol, suicidality, emotions/behavior, discharge resources (HEADS-ED), which is a modification of “HEADS,” a mnemonic widely used to obtain a psychosocial history in adolescents. The reliability and validity of the tool and its potential for use as a screening measure are presented. METHODS: ED patients presenting with mental health concerns from March 1 to May 30, 2011 were included. Crisis intervention workers completed the HEADS-ED and the Child and Adolescent Needs and Strengths-Mental Health tool (CANS MH) and patients completed the Children’s Depression Inventory (CDI). Interrater reliability was assessed by using a second HEADS-ED rater for 20% of the sample. RESULTS: A total of 313 patients were included, mean age was 14.3 (SD 2.63), and there were 182 females (58.1%). Interrater reliability was 0.785 (P < .001). Correlations were computed for each HEADS-ED category and items from the CANS MH and the CDI. Correlations ranged from r = 0.17, P < .05 to r = 0.89, P < .000. The HEADS-ED also predicted psychiatric consult and admission to inpatient psychiatry (sensitivity of 82% and a specificity of 87%; area under the receiver operator characteristic curve of 0.82, P < .01). CONCLUSIONS: The results provide evidence to support the psychometric properties of the HEADS-ED. The study shows promising results for use in ED decision-making for pediatric patients with mental health concerns.

Psychometric properties of the functions and addictive features scales of the Ottawa Self-Injury Inventory: a preliminary investigation using a university sample

Nonsuicidal self-injury (NSSI) is an issue primarily of concern in adolescents and young adults. Thus far, no single NSSI self-report measure offers a fully comprehensive assessment of NSSI, particularly including measurement of both its functions and potential addictive features. The Ottawa Self-Injury Inventory (OSI) permits simultaneous assessment of both these characteristics; the current study examined the psychometric properties of this measure in a sample of 149 young adults in a university student sample (82.6% girls, Mage = 19.43 years). Exploratory factor analyses revealed 4 functions factors (internal emotion regulation, social influence, external emotion regulation, and sensation seeking) and a single addictive features factor. Convergent evidence for the functions factor scores was demonstrated through significant correlations with an existing measure of NSSI functions and indicators of psychological well-being, risky behaviors, and context and frequency of NSSI behaviors. Convergent evidence was also shown for the addictive features scores, through associations with NSSI frequency, feeling relieved following NSSI, and inability to resist NSSI urges. Additional comment is made regarding the potential for addictive features of NSSI to be both negatively and positively reinforcing. Results show preliminary psychometric support for the OSI as a valid and reliable assessment tool to be used in both research and clinical contexts. The OSI can provide important information for case formulation and treatment planning, given the comprehensive and all-inclusive nature of its assessment capacities.

Establishing best practice in pediatric emergency mental health: a prospective study examining clinical characteristics.

Objectives: The objectives of this prospective study were to determine the demographic and clinical characteristics of children and youth presenting to the emergency department (ED) for mental health concerns through the use of a valid standardized assessment protocol. Methods: Children and adolescents, 8 to 17 years, who presented to an ED-based crisis intervention program during fiscal years 2005 to 2006, completed self-report measures of depression, anxiety, and behavior. Clinicians completed the childhood acuity of psychiatric illness based on their assessment. Results: The clinician ratings indicated that 93.1% of the sample had at least 1 risk behavior or clinical symptom in the moderate/severe range. Admittance rate for the sample was 17.9% (low-risk admissions, 5.8%; high-risk deflections, 9%). Significant differences were found in presentations by sex and age as follows: (1) female youths (12-17 years) were more likely than male youth to report clinically significant depressive symptoms and to present with suicidal ideation/gesture and self-injury. (2) Male youths (12-17 years) were more likely to present with aggression to people/objects than female youth. (3) Male children younger than 12 years were more likely to present with high activity level than female children. Self-report measures (depression, anxiety, and behavior) corelated with corresponding clinician ratings. Conclusions: This research, through the use of a multi-informant standardized assessment protocol, presents a comprehensive study of children and youth presenting to the ED with mental health issues. Identifying the clinical characteristics of this population is an important first step toward establishing best practice within an ED.

Mental health services for children and youth: a survey of physicians' knowledge, attitudes and use of telehealth services.

Summary Rural physicians in Ontario, whose practice included children, were surveyed on their awareness, attitudes and use of telemental health services for children and young people in their region. Of 95 rural physicians, 70 completed and returned the telehealth section of the survey (74% response rate). The survey comprised 14 questions. Only 27% of responders were aware of the available videoconferencing services. The proportion of physicians who reported having referred patients for the various mental health services through videoconferencing was 0–24%. The proportion of physicians who reported that they would refer patients through videoconferencing was 55–92%. Reduced travel time and care provided closer to home were seen as the primary benefits of referring patients to mental health services through videoconferencing. Unclear referral patterns and technology compromises were seen as limitations of referring patients to videoconferencing. Access to rural populations and improved access to patients were seen as benefits to practice, and undeveloped remuneration procedures as the primary limitation. Promotion may be important to successful implementation of telemental health services for children and young people.

Physician management of pediatric mental health patients in the emergency department: assessment, charting, and disposition

Objective The focus of this study was to describe the clinical data that pediatric emergentologists recorded and how they were used in the mental health (MH) care of patients. Methods A structured chart review was conducted for all MH presentations to a pediatric emergency department in 2007. Three research assistants extracted clinical chart data and completed the Child and Adolescent Needs and Strengths Tool. Results The clinical records of 495 children and youth were reviewed. Emergentologists referred 124 (25.4%) for a psychiatric consult, and 46 (37%) of these patients were admitted to either an inpatient psychiatric or eating-disorders unit. Psychosis, suicide risk, eating disturbance, anxiety, and resistance to treatment predicted admission to the psychiatric inpatient unit or the eating-disorders unit. Of the 365 patients discharged back to the community, the majority (n = 189, 51.8%) were referred back to their family physician. For 117 patients (32%), there was no discharge documentation in the medical chart. Age, parent present, currently on medication, currently receiving counseling, depression, anxiety, and adjustment to trauma predicted provision of charted recommendation. Conclusions This study revealed that the pediatric emergentologists’ charting of MH patients is inconsistent and incomplete. Although recorded clinical data predicted psychiatric consultation and disposition for these patients, missing data were evident in a significant number of records. The results of the study point to a need to develop a more uniform approach to the collection and recording of clinical data for MH patients.

Emotion dysregulation mediates the influence of relationship difficulties on non-suicidal self-injury behavior in young adults

This study examined associations between relationship difficulties with parents and peers and non-suicidal self-injury (NSSI). Particular emphasis was placed on examining mediating pathways through emotion dysregulation, as per commonly accepted theory. Participants were 1153 university students (905 females; Mage=19.35 years, S.D.=1.49); 79 of these participants had engaged in NSSI during the previous 6 months (63 females, Mage=19.35 years, S.D.=1.51). Participants completed questionnaires assessing NSSI, quality of relationships with parents and peers, and emotion dysregulation. Hierarchical logistic regressions suggest that the quality of parent-child relationships has a greater impact on the prediction of NSSI engagement than the quality of peer relationships. Results of a structural equation model showed that feelings of alienation in both parent and peer relationships had indirect effects on NSSI through deficits in emotion regulation (ER). Results suggest the importance of examining emotion dysregulation in association with NSSI, and that both parent and peer relationships are implicated in NSSI engagement through emotion regulation deficits. Important clinical implications regarding the need to acknowledge both emotion dysregulation and interpersonal difficulties when treating NSSI in young adults are discussed.

Evaluating crisis intervention services for youth within an emergency department : a view from within

An innovative crisis intervention programme was created at the Childrens Hospital of Eastern Ontario in Canada in order to provide emergency assessments for youth presenting with mental health crises. The current investigation presents an overview of the programme and examines the emergency staffs perception and satisfaction with it. Eighty-seven emergency department medical staff completed a survey. Overall, emergency department staff place high value on having access to emergency mental health services, are pleased with the quality of service and appreciate that the crisis intervention workers presence allows them to spend more time with other patients.

Preoccupied but not dismissing attachment states of mind are associated with nonsuicidal self-injury

In this investigation the factor structure of the Adult Attachment Interview was studied in a partially at-risk sample of 120 young adults. More specifically, 60 participants had engaged in nonsuicidal self-injury (NSSI; 53 females, M age = 20.38 years), and 60 were non-self-injuring controls matched by age and sex. Theoretically anticipated differential associations between preoccupied (but not dismissing) states of mind and NSSI were then examined. Exploratory factor analyses identified evidence for two weakly correlated state of mind dimensions (i.e., dismissing and preoccupied) consistently identified in factor analyses of normative-risk samples. As hypothesized, results further showed that preoccupied (but not dismissing) states of mind were associated with NSSI behavior. Findings support existing arguments suggesting that the regulatory strategy adults adopt when discussing attachment-related experiences with primary caregivers, particularly passive, angry, or unresolved discourse patterns, is uniquely correlated with NSSI.