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

Cross-Cultural Adaptation and Psychometric Validation of the Suicide Cognitions Scale-Revised (SCS-R) in Spanish Adolescents in Residential Care

The Suicide Cognitions Scale (SCS) has demonstrated considerable promise as a risk screening tool, although it has yet to be validated for use with adolescents or in Spanish-speaking populations. The aim of this study was to develop a Spanish version of the 16-item SCS-Revised (SCS-R) and to examine its psychometric properties in a sample of adolescents. Participants were 172 adolescents aged between 12 and 18 years (M = 15.32, SD = 1.57) and currently in residential care. They completed the Spanish SCS-R and a series of other psychological measures. The psychometric properties of the SCS-R were examined through factor analyses and testing of convergent/discriminant validity and construct validity. Factor analyses supported a bifactor structure, indicating that SCS-R items were primarily measuring a common underlying latent variable. SCS-R scores were positively correlated with multiple indicators of psychopathology and other suicide risk factors (e.g., depression, hopelessness) but negatively correlated with protective factors (e.g., believing that one's mental pain will eventually end). Importantly, SCS-R scores differentiated adolescents in residential care who had previously attempted suicide from those who had only thought about suicide. Scores also differentiated adolescents who had previously attempted suicide from those who had previously only engaged in non-suicidal self-injury. This constitutes further evidence that the SCS-R measures a construct that distinguishes suicidal thought from action and is specific to suicidal forms of self-harm. Overall, the results suggest that the Spanish SCS-R is a potentially useful tool for identifying adolescents at risk of attempting suicide in residential care.

Child maltreatment and youth suicide risk: A developmental conceptual model and implications for suicide prevention

Experiences of child abuse and neglect are risk factors for youth suicidal thoughts and behaviors. Accordingly, suicide risk may emerge as a developmental process that is heavily influenced by the rearing environment. We argue that a developmental, theoretical framework is needed to guide future research on child maltreatment and youth (i.e., adolescent and emerging adult) suicide, and to subsequently inform suicide prevention efforts. We propose a developmental model that integrates principles of developmental psychopathology and current theories of suicide to explain the association between child maltreatment and youth suicide risk. This model bears significant implications for future research on child maltreatment and youth suicide risk, and for suicide prevention efforts that target youth with child maltreatment experiences.

Leveraging Administrative Data to Better Understand and Address Child Maltreatment: A Scoping Review of Data Linkage Studies

BACKGROUND

This scoping review aimed to overview studies that used administrative data linkage in the context of child maltreatment to improve our understanding of the value that data linkage may confer for policy, practice, and research.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL, and ERIC electronic databases in June 2019 and May 2020 for studies that linked two or more datasets (at least one of which was administrative in nature) to study child maltreatment. We report findings with numerical and narrative summary.

RESULTS

We included 121 studies, mainly from the United States or Australia and published in the past decade. Data came primarily from social services and health sectors, and linkage processes and data quality were often not described in sufficient detail to align with current reporting guidelines. Most studies were descriptive in nature and research questions addressed fell under eight themes: descriptive epidemiology, risk factors, outcomes, intergenerational transmission, predictive modelling, intervention/service evaluation, multi-sector involvement, and methodological considerations/advancements.

CONCLUSIONS

Included studies demonstrated the wide variety of ways in which data linkage can contribute to the public health response to child maltreatment. However, how research using linked data can be translated into effective service development and monitoring, or targeting of interventions, is underexplored in terms of privacy protection, ethics and governance, data quality, and evidence of effectiveness.

The role of attachment to the foster parent with regard to suicidal risk among adult survivors of childhood maltreatment

BACKGROUND

Childhood maltreatment is associated with an increased risk of insecure/disorganized attachment and in turn with suicidal risk (SR). Out-of-family placement is aimed at interrupting child exposure to further abuse and at providing the necessary security for proper development via the establishment of an alternative attachment relationship. However, the actual protective role of this type of care is not clear given the high rates of SR among institutionalized or foster children.

OBJECTIVE

The aim of this study was to examine whether 1) attachment to the biological parents mediates the association between abuse and SR and 2) attachment to a foster parent (whether from a foster home or an institution) moderates the effect of attachment to biological parents on SR.

PARTICIPANTS

The sample consisted of 77 adults (52 female; 25 male; mean age: 26.6 years) who received out-of-home care during childhood.

METHOD

The Childhood Trauma Questionnaire and the Mini International Neuropsychiatric Interview (for SR) were used. The Attachment Multiple Model Interview was also administered to assess attachment to each biological parent and to the foster parent.

RESULTS

Results show that attachment (security and disorganization) to the biological mother mediates the link between abuse and SR and that attachment to the foster parent moderates the link between attachment to the biological mother and SR.

CONCLUSIONS

Findings point to the importance of interventions aimed at supporting the establishment of a secure attachment relationship between children in care and their foster parents.

Autism spectrum disorders as a risk factor for adolescent self-harm: a retrospective cohort study of 113,286 young people in the UK

BACKGROUND

Individuals with autism spectrum disorder (ASD) are at particularly high risk of suicide and suicide attempts. Presentation to a hospital with self-harm is one of the strongest risk factors for later suicide. We describe the use of a novel data linkage between routinely collected education data and child and adolescent mental health data to examine whether adolescents with ASD are at higher risk than the general population of presenting to emergency care with self-harm.

METHODS

A retrospective cohort study was conducted on the population aged 11-17 resident in four South London boroughs between January 2009 and March 2013, attending state secondary schools, identified in the National Pupil Database (NPD). Exposure data on ASD status were derived from the NPD. We used Cox regression to model time to first self-harm presentation to the Emergency Department (ED).

RESULTS

One thousand twenty adolescents presented to the ED with self-harm, and 763 matched to the NPD. The sample for analysis included 113,286 adolescents (2.2% with ASD). For boys only, there was an increased risk of self-harm associated with ASD (adjusted hazard ratio 2·79, 95% CI 1·40-5·57, P<0·01). Several other factors including school absence, exclusion from school and having been in foster care were also associated with a higher risk of self-harm.

CONCLUSIONS

This study provides evidence that ASD in boys, and other educational, social and clinical factors, are risk factors for emergency presentation with self-harm in adolescents. These findings are an important step in developing early recognition and prevention programmes.

Child maltreatment and emergency department visits: a longitudinal birth cohort study from infancy to early adulthood

BACKGROUND

Child maltreatment (CM) is a serious global public health issue, with documented impacts on health.

OBJECTIVE

To examine the association between different levels of CM concern, and Emergency Department (ED) visits from infancy to early adulthood.

PARTICIPANTS AND SETTING

Individuals born in Adelaide, South Australia from January 1986 to June 2017 (N = 443,754).

METHODS

Using linked administrative data, we examined frequency and adjusted rate ratios for all-cause and cause specific ED visits among individuals with varying levels of CM concern.

RESULTS

Cumulative mean ED visits to age 14.5 years were higher for individuals with any CM concern, ranging from 10.2 to 14.8, compared with 6.4 in persons with no recorded CM concern. Adjusted rate ratios for ED visits varied from 1.26 (95% CI: 1.23-1.30) to 1.54 (1.48-1.60) in children (birth to 12 years), 1.98 (CI: 1.92-2.04) to 4.34 (CI: 4.09-4.60) in adolescence and 2.22 (CI: 2.14-3.48) to 3.48 (3.27-3.72) in young adults, increasing with severity of maltreatment concerns. ED visits coded as self-harm or poisoning, injuries, substance use or mental illness were particularly high, with incidence rate ratios mostly 3 to 15 times for mental health/substance related visits and 1.5 to 3.2 for other accidents or injury for individuals with any CM concern versus none.

CONCLUSIONS

The high rate ratios for ED visits in children with CM concern, especially for self-harm, substance use and mental health during adolescence and adulthood highlights the enduring mental health needs of victims of child maltreatment, providing further impetus for prevention.

A Social-Emotional Learning Program for Suicide Prevention through Animal-Assisted Intervention

Simple Summary

Youth suicide is a global public health problem. According to data from the World Health Organization (WHO), suicide is the fourth leading cause of death in the age group between 15 and 29 years, after injuries due to traffic accidents, tuberculosis, and interpersonal violence. For this reason, the reduction of mortality by suicide is one of the WHO’s priority objectives. Here we describe a pilot study evaluating the OverCome-AAI program, a pioneering animal-assisted intervention for preventing suicidal behavior. After the intervention, the young people showed reductions in suicidal behavior and non-suicidal self-harm, as well as a greater predisposition to seek help. Mental pain was less intense, although no changes in symptoms of hopelessness or depression were found. The results of this pilot study suggest that the inclusion of specially prepared and trained animals can promote socio-emotional learning for preventing suicidal behavior in high-risk populations.

Abstract

The aim of the study was to carry out a pilot implementation and evaluation of the OverCome-AAI program, a pioneering program for the prevention of suicidal behavior through animal-assisted interventions for young people with high risk factors for suicidal behavior. The study sample consisted of 30 adolescents (11 boys and 19 girls) aged between 14 and 17 years (Mean age = 15.50, SD = 1.60) from the Basque Country (Northern Spain). After the intervention, subjects presented reductions in suicidal ideation, suicide plans, and non-suicidal self-harm, as well as a greater predisposition to seek help. A reduction in the intensity of mental pain was also found, although no differences were observed in indicators of hopelessness and depression. The preliminary results obtained in this pilot study suggest that the OverCome-AAI program may be effective in reducing suicidal behavior and non-suicidal self-harm in young people in residential care who present high risk factors for suicide.

Child maltreatment, suicidal ideation, and in-home firearm availability in the U.S.: findings from the longitudinal studies of child abuse and neglect

Suicide is the second leading cause of death among adolescents in the U.S., and risk factors include child maltreatment (CM), especially physical and emotional abuse, and in-home firearm availability ('availability'). However, research examining availability among adolescent populations at-risk for CM is limited. This study examines availability in this population, the association between CM and availability, and availability among adolescents experiencing suicidal ideation. A multivariable modified Poisson regression model assessed the relationship between CM by age 12 and availability at age 14 using data from the Longitudinal Studies of Child Abuse and Neglect (n = 1,354 families). Approximately 11.61% of adolescents reported availability, and physical abuse increased the risk of availability (aRR = 1.94; 95% CI [1.22, 3.08]). Over one-quarter (27.50%) of adolescents with suicidal ideation at age 16 reported availability. Child welfare-involved families are often referred to interventions. Future research and prevention efforts should explore augmentation of these programmes with firearm safe storage guidance.

Health Services Use by Children in the Welfare System Who Died by Suicide

OBJECTIVES

To examine characteristics and health service use patterns of suicide decedents with a history of child welfare system involvement to inform prevention strategies and reduce suicide in this vulnerable population.

METHODS

A retrospective matched case-control design (120 suicide decedents and 1200 matched controls) was implemented. Suicide decedents included youth aged 5 to 21 who died by suicide and had an open case in Ohio's Statewide Automated Child Welfare Information System between 2010 and 2017. Controls were matched to suicide decedents on sex, race, and ethnicity. Comparisons were analyzed by using conditional logistic regressions to control for matching between the suicide and control groups.

RESULTS

Youth in the child welfare system who died by suicide were significantly more likely to experience out-of-home placements and be diagnosed with mental and physical health conditions compared with controls. Suicide decedents were twice as likely to access mental health services in the 1 and 6 months before death, regardless of the health care setting. A significantly higher percentage of suicide decedents used physical health services 6 months before their death or index date. Emergency department visits for both physical and mental health conditions were significantly more likely to occur among suicide decedents.

CONCLUSIONS

Suicide decedents involved in the child welfare system were more likely to use both mental and physical health care services in the months before their death or index date. Findings suggest that youth involved in the child welfare system may benefit from suicide prevention strategies in health care settings.

Development and implementation of a pediatric adverse childhood experiences (ACEs) and other determinants of health questionnaire in the pediatric medical home: A pilot study

Adverse Childhood Experiences (ACEs) are associated with poor health outcomes, underlining the significance of early identification and intervention. Currently, there is no validated tool to screen for ACEs exposure in childhood. To fill this gap, we designed and implemented a pediatric ACEs questionnaire in an urban pediatric Primary Care Clinic. Questionnaire items were selected and modified based on literature review of existing childhood adversity tools. Children twelve years and under were screened via caregiver report, using the developed instrument. Cognitive interviews were conducted with caregivers, health providers, and clinic staff to assess item interpretation, clarity, and English/Spanish language equivalency. Using a rapid cycle assessment, information gained from the interviews were used to iteratively change the instrument. Additional questions assessed acceptability of screening within primary care and preferences around administration. Twenty-eight (28) caregivers were administered the questionnaire. Cognitive interviews conducted among caregivers and among 16 health providers and clinic staff resulted in the changes in wording and addition of examples in the items to increase face validity. In the final instrument, no new items were added; however, two items were merged and one item was split into three separate items. While there was a high level of acceptability of the overall questionnaire, some caregivers reported discomfort with the sexual abuse, separation from caregiver, and community violence items. Preference for methods of administration were split between tablet and paper formats. The final Pediatric ACE and other Determinants of Health Questionnaire is a 17-item instrument with high face validity and acceptability for use within primary care settings. Further evaluation on the reliability and construct validity of the instrument is being conducted prior to wide implementation in pediatric practice.

Examining the association between suicidal behaviors and referral for mental health services among children involved in the child welfare system in Ontario, Canada

Although various studies have investigated factors associated with mental health service utilization, few studies have examined factors associated with referral for mental health services among maltreated children. The objective of this study was to examine the association between suicidal thoughts and self-harming behavior and referral for mental health services among children involved in the Child Welfare System in Ontario, Canada. Data for this study were obtained from the Ontario Incidence Study of Reported Child Abuse and Neglect 2013. An estimate 57,798 child maltreatment investigations was analyzed using binary logistic regression with referral for mental health service as the outcome variable. Of the 57,798 cases, 4709 (8.1%), were referred for mental health services. More than seven out of ten maltreated children who engaged in self-harming behavior and two out of three maltreated children who expressed suicidal thoughts were not referred for mental health services. In the multivariate logistic regression model, children who expressed suicidal thoughts had 2.39 times higher odds of being referred for mental health services compared to children with no suicidal thoughts (AOR = 2.39, 99% C.I. 2.05-2.77) and children who engaged in self-harming behavior had 1.44 times higher odds of being referred for mental health services compared to children who did not engage in self-harming behavior (AOR = 1.44, 99% C.I. 1.24-1.67), both after controlling for child demographic characteristics, maltreatment characteristics, and child functioning concerns. Given that referral is the initial step towards mental health service utilization, it is important that child welfare workers receive the necessary training so as to carefully assess and refer children in care who expressed suicidal thoughts or engaged in self-harming behavior for appropriate mental health services. The paper discusses the results and their implications for child welfare policy and practice.

Youth self-report of child maltreatment in representative surveys: a systematic review

INTRODUCTION

This systematic review identified population-representative youth surveys containing questions on self-reported child maltreatment. Data quality and ethical issues pertinent to maltreatment data collection were also examined.

METHODS

A search was conducted of relevant online databases for articles published from January 2000 through March 2016 reporting on population-representative data measuring child maltreatment. Inclusion criteria were established a priori; two reviewers independently assessed articles to ensure that the criteria were met and to verify the accuracy of extracted information.

RESULTS

A total of 73 articles reporting on 71 surveys met the inclusion criteria. A variety of strategies to ensure accurate information and to mitigate survey participants' distress were reported.

CONCLUSION

The extent to which efforts have been undertaken to measure the prevalence of child maltreatment reflects its perceived importance across the world. Data on child maltreatment can be effectively collected from youth, although our knowledge of best practices related to ethics and data quality is incomplete.

Involuntary Psychiatric Holds in Preadolescent Children

INTRODUCTION

Little is known about the use of involuntary psychiatric holds in preadolescent children. The primary objective was to characterize patients under the age of 10 years on involuntary psychiatric holds.

METHODS

This was a two-year retrospective study from April 2013 - April 2015 in one urban pediatric emergency department (ED). Subjects were all children under the age of 10 years who were on an involuntary psychiatric hold at any point during their ED visit. We collected demographic data including age, gender, ethnicity and details about living situation, child protective services involvement and prior mental health treatment, as well as ED disposition.

RESULTS

There were 308 visits by 265 patients in a two-year period. Ninety percent of involuntary psychiatric holds were initiated in the prehospital setting. The following were common characteristics: male (75%), in custody of child protective services (23%), child protective services involvement (42%), and a prior psychiatric hospitalization (32%). Fifty-six percent of visits resulted in discharge from the ED, 42% in transfer to a psychiatric hospital and 1% in admission to the pediatric medical ward. Median length of stay was 4.7 hours for discharged patients and 11.7 hours for patients transferred to psychiatric hospitals.

CONCLUSION

To our knowledge, this study presents the first characterization of preadolescent children on involuntary psychiatric holds. Ideally, mental health screening and services could be initiated in children with similar high-risk characteristics before escalation results in placement of an involuntary psychiatric hold. Furthermore, given that many patients were discharged from the ED, the current pattern of utilization of involuntary psychiatric holds in young children should be reconsidered.

The Nurse-Family Partnership: evidence-based public health in response to child maltreatment

Too many Canadian children are exposed to child maltreatment-neglect, emotional maltreatment, exposure to intimate partner violence, and physical and sexual abuse. Retrospective data indicates that 32% of Canadian adults have experienced childhood abuse. There is evidence that child maltreatment is associated with a wide array of negative health consequences across the life span. These consequences expand across physical, mental, developmental and social domains to include suicide, substance abuse, anxiety, depression and physical health problems. Experts have asked for coordinated national leadership in protecting children from maltreatment. They also envision broadening the mandate for injury prevention to include not only physical injury but also emotional injury and harm.

Substantiated Reports of Child Maltreatment From the Canadian Incidence Study of Reported Child Abuse and Neglect 2008: Examining Child and Household Characteristics and Child Functional Impairment

OBJECTIVE

Identifying child and household characteristics that are associated with specific child maltreatment types and child functional impairment are important for informing prevention and intervention efforts. Our objectives were to examine the distribution of several child and household characteristics among substantiated child maltreatment types in Canada; to determine if a specific child maltreatment type relative to all other types was associated with increased odds of child functional impairment; and to determine which child and household characteristics were associated with child functional impairment.

METHOD

Data were from the Canadian Incidence Study of Reported Child Abuse and Neglect (collection 2008) from 112 child welfare sites across Canada (n = 6163 children).

RESULTS

Physical abuse, sexual abuse, and emotional maltreatment were highly prevalent among children aged 10 to 15 years. For single types of child maltreatment, the highest prevalence of single-parent homes (50.6%), social assistance (43.0%), running out of money regularly (30.7%), and unsafe housing (30.9%) were reported for substantiated cases of neglect. Being male, older age, living in a single-parent home, household running out of money, moving 2 or more times in the past year, and household overcrowding were associated with increased odds of child functional impairment.

CONCLUSIONS

More work is warranted to determine if providing particular resources for single-parent families, financial counselling, and facilitating adequate and stable housing for families with child maltreatment histories or at risk for child maltreatment could be effective for improving child functional outcomes.

The associations among childhood maltreatment, "male depression" and suicide risk in psychiatric patients

In the current cross-sectional study, we aimed to investigate the presence and severity of "male" depressive symptoms and suicidal behaviors in psychiatric patients with and without a history of child abuse and neglect, as measured by the Childhood Trauma Questionnaire (CTQ), as well as to explore the associations among childhood maltreatment, "male depression" and suicide risk. The sample consisted of 163 consecutively admitted adult inpatients (80 men; 83 women). The patients were administered the CTQ, Gotland Male Depression Scale (GMDS), and Suicidal History Self-Rating Screening Scale (SHSS). Those with a moderate-severe childhood maltreatment history were more likely to be female (p<0.05) and reported more "male depression" (p<0.001) and suicidal behaviors (p<0.01) as compared to those not having or having a minimal history of child abuse and neglect. In the multivariate analysis, only the minimization/denial scale of the CTQ (odds ratio=0.31; p<0.001) and "male depression" (odds ratio=1.83; p<0.05) were independently associated with moderate/severe history of child maltreatment. The findings suggest that exposure to abuse and neglect as a child may increase the risk of subsequent symptoms of "male depression", which has been associated with higher suicidal risk.

Intermittent Explosive Disorder and aversive parental care

Parental bonding has been shown to have lasting impacts on the psychological development of children. Despite a growing body of research examining trauma as it relates to Intermittent Explosive Disorder (IED), no prior research has examined the relationship between parental bonding and IED. Six hundred fifty eight subjects were studied and categorized into one of three groups: Normal Control (no history of current or lifetime Axis I or Axis II disorder), Psychiatric Control (current and/or lifetime Axis I and/or Axis II disorders without IED), and IED (met current and/or lifetime criteria for IED). Self-reported parental care was assessed using the Parental Bonding Inventory (PBI). PBI Care scores were lowest among IED subjects, which were lower than among Psychiatric Control subjects, which were lower than among Normal Control subjects. PBI Control scores were highest among IED and Psychiatric Control subjects, which were higher than among Normal Control subjects. The diagnostic group differences in PBI Care/PBI Control scores were not impacted by the number of Axis I/II diagnoses. The findings in this study expand the link between childhood trauma exposure, violent behavior, and IED. This is the first report of an association of IED with an aversive childhood parenting environment.

Time trends in suicide-related behaviours in girls and boys

OBJECTIVE

To examine the incidence and nature of emergency department (ED) presentations for nonfatal suicide-related behaviours (SRBs) over time, in boys and girls living in Ontario. We hypothesize declining rates (fiscal years [FYs] 2002/03 to 2006/07) ceased thereafter owing to renewed regulatory warnings against prescribing antidepressants and the economic recession.

METHOD

We graphed and tested differences in ED SRB incidence rates for FYs 2002/03 to 2010/11. We estimated rate ratios and 95% confidence intervals using negative binomial regression controlling for changes in the underlying population (age, community size, and neighbourhood income quintile). We examined the nature of the incident (index) presentations over time in terms of the method(s) used and events occurring before and after the index event.

RESULTS

ED SRB incidence rates decreased by 30% in boys and girls from FYs 2002/03 to 2006/07, but not thereafter. This trend was most evident in girls who self-poisoned and in girls' presentations to hospital with mental illness in the preceding year. Within a year of the index event, the proportion of girls with a repeat ED SRB presentation also declined by about one-third, but beyond FYs 2005/06 to 2009/10. However, the proportion admitted subsequent to the index event increased by about one-third. In boys, their patterns of presentations to hospital with mental illness and SRB repetition over time were similar to girls, but estimated with greater variability.

CONCLUSIONS

While the decline in ED SRB rates to FY 2006/07 is encouraging, the lack of decline thereafter and an increase in subsequent admissions merits ongoing monitoring and evaluation.

Suicidality among preadolescent maltreated children in foster care

This study sought to determine the prevalence of suicidal ideation, plans, and attempts among 515 preadolescent (aged 9-11 years) maltreated children who entered foster care within the prior year. Over a quarter (26.4%) of the children had a history of suicidality according to their own and/or their caregiver's report, 4.1% of whom were imminently suicidal. In bivariate analyses, children at higher risk of suicidality tended to be younger, non-Hispanic, abused, and to have experienced multiple types of maltreatment, more referrals to child welfare, more household transitions, and a longer length of time in foster care. There were no gender differences. Multiple regression analyses found physical abuse and chronicity of maltreatment to be the most robust predictors of suicidality. It is critically important that these high-risk children are screened for suicidality before adolescence and that caregivers and professionals are informed of their risk status so that they may implement mental health treatment, monitoring, and harm reduction measures.

Commentary on Canadian child maltreatment data

The issue of how to best collect child maltreatment data is a key concern within the Public Health Agency of Canada (PHAC). We argue that maltreatment data can be collected from children, adolescents, and parents with approaches that are accurate, methodologically robust, legal, and ethical. It has been done in other countries. First, we clarify ongoing child maltreatment data collection by the Canadian government and address PHAC initiatives to include child maltreatment questions in national contemporaneous surveys. Second, we identify examples of population-based studies with child, adolescent, and parent respondents. Third, we highlight some measurement considerations. Fourth, we address ethical considerations in conducting this type of research.

Pain and suicidality: insights from reward and addiction neuroscience

Suicidality is exceedingly prevalent in pain patients. Although the pathophysiology of this link remains unclear, it may be potentially related to the partial congruence of physical and emotional pain systems. The latter system's role in suicide is also conspicuous during setbacks and losses sustained in the context of social attachments. Here we propose a model based on the neural pathways mediating reward and anti-reward (i.e., allostatic adjustment to recurrent activation of the reward circuitry); both are relevant etiologic factors in pain, suicide and social attachments. A comprehensive literature search on neurobiology of pain and suicidality was performed. The collected articles were critically reviewed and relevant data were extracted and summarized within four key areas: (1) physical and emotional pain, (2) emotional pain and social attachments, (3) pain- and suicide-related alterations of the reward and anti-reward circuits as compared to addiction, which is the premier probe for dysfunction of these circuits and (4) mechanistically informed treatments of co-occurring pain and suicidality. Pain-, stress- and analgesic drugs-induced opponent and proponent states of the mesolimbic dopaminergic pathways may render reward and anti-reward systems vulnerable to sensitization, cross-sensitization and aberrant learning of contents and contexts associated with suicidal acts and behaviors. These findings suggest that pain patients exhibit alterations in the brain circuits mediating reward (depressed function) and anti-reward (sensitized function) that may affect their proclivity for suicide and support pain and suicidality classification among other "reward deficiency syndromes" and a new proposal for "enhanced anti-reward syndromes". We suggest that interventions aimed at restoring the balance between the reward and anti-reward networks in patients with chronic pain may help decreasing their suicide risk.

Sex differences in suicides among children and youth: the potential impact of help-seeking behaviour

OBJECTIVE

To describe sex differences in health service use among children and youth who died by suicide.

METHOD

This is a retrospective study of children and youth (aged 10 to 25 years) living in Ontario who died by suicide between April 1, 2003, and December 31, 2007. Coroner records were individually linked to outpatient physician visit, emergency department (ED) presentation, and inpatient stay administrative health care records for 724 people (192 girls and 532 boys). Only 77 (10.6%) were aged 10 to 15 years. The health services types used, number of contacts made, and the last contact were compared in boys and girls.

RESULTS

About 80% of subjects had contact with the health care system in the year before their death, typically to an outpatient physician and (or) the ED. However, not all were seen for mental health reasons. Girls had more outpatient physician and ED contact than boys and closer in time to their death. Further, girls were more likely than boys to have contact in more than one setting. Still, boys and girls did not differ in their use of an outpatient psychiatrist, some ED presentations, and in the nature and number of inpatient stays.

CONCLUSIONS

While most people were seen by an outpatient physician and (or) in the ED in the year before their death, not all received mental health care. Further research is needed to determine whether boys and girls who died by suicide differ from their peers in their health service use to guide preventive interventions.

Child maltreatment: promising approaches and new directions

PURPOSE OF REVIEW

This review summarizes the key articles in the field of child maltreatment, addressing abusive head trauma, physical abuse, sexual abuse, and global issues surrounding maltreatment. This topic is salient for both general pediatricians as well as specialists.

RECENT FINDINGS

Many articles this year focus on the importance of making an accurate diagnosis when considering child maltreatment, whether in the form of physical or sexual abuse. There is also a focus on understanding the epidemiology of abuse, as some data show a decrease in numbers, which is felt by many in the field to be a misleading impression.

SUMMARY

An appreciation of the scope of Child Abuse Pediatrics requires an understanding of physical abuse, sexual abuse, and neglect. The authors summarize notable advances in our understanding of these key areas in a review of the year's best literature.

Child maltreatment and repeat presentations to the emergency department for suicide-related behaviors

OBJECTIVES

To identify factors associated with repeat emergency department (ED) presentations for suicide-related behaviors (SRB) - hereafter referred to as repetition - among children/youth to aid secondary prevention initiatives. To compare rates of repetition in children/youth with substantiated maltreatment requiring removal from their parental home with their peers in the general population.

METHODS

A population-based (retrospective) cohort study was established for children/youth with a first ED SRB presentation at risk for repetition in the Province of Ontario, Canada between 1 January 2004 and 31 December 2008. Children/youth legally removed from their parental home because of substantiated maltreatment (n=179) and their population-based peers (n=6,305) were individually linked to administrative health care records over time to ascertain social, demographic, and clinical information and subsequent ED presentations for SRB during follow-up. These children/youth were described and their repetition-free probabilities over time compared. To identify factors associated with repetition we fit multivariable, recurrent event survival analysis models stratified by repetition and present unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Children/youth with substantiated maltreatment (as noted) were two times more likely to have repetition than their peers after adjustments for social, demographic, and clinical factors (conditional on prior ED SRB presentations). A number of these factors were independently associated with repetition. No one factor distinguished between having a first and second repetition nor was more strongly associated with repetition than another.

CONCLUSIONS

The risk of repetition is higher in children with substantiated maltreatment (as noted) than their peers. No one factor stood out as predictive of repetition. Implications for secondary prevention initiatives include a non-selective approach, sensitive to family difficulties and the need to better contextualize repetition and harness data linkages.

Understanding risk and protective factors for child maltreatment: the value of integrated, population-based data

In this article, we argue for expanded efforts to integrate administrative data systems as a "practical strategy" for developing a richer understanding of child abuse and neglect. Although the study of child maltreatment is often critiqued for being atheoretical, we believe that a more pressing concern is the absence of population-based and prospective epidemiological data that can be used to better understand the distribution and interacting nature of risk and protective factors for maltreatment. We begin by briefly addressing the relevance of empirical observations to etiological theories of child maltreatment. Although the latter is widely cited as critical to the development of effective prevention and intervention responses, less attention has been paid to the role of population-based data in the development of theories relevant to highly applied research questions such as those pertaining to child abuse and neglect. We then discuss how child protection data, in isolation, translates into a relatively narrow range of questions that can be asked and answered, with an inherently pathology-focused construction of risks and little attention paid to strengths or protective factors. We next turn to examples of recent findings--spanning multiple countries--emerging from information integrated across data systems, concluding by calling for expanded administrative data linkages in an effort to better understand and prevent child maltreatment.