[Non-suicidal self-injurious behaviors in adolescence Role of frontline practitioners]. / Comportements autodommageables sans intention suicidaire à l'adolescence. Rôle des intervenant-e-s en première ligne.

Non-suicidal self-injury (NSSI) is an increasing mental health issue among adolescents. General practitioners and pediatricians play a crucial role in detecting, evaluating, and managing these behaviors. This article aims to provide recommendations for the first line surrounding the young person, such as the appropriate stance to adopt and the use of a safety plan, for effectively managing NSSI patients. It takes into account the often-present interpersonal hypersensitivity in these patients and includes strategies for working with families and within a multidisciplinary network.

Les comportements autodommageables sans intention suicidaire (NSSI, non-suicidal self-injury) sont un problème de santé mentale en augmentation chez les adolescents. Les généralistes et pédiatres jouent un rôle crucial dans la détection, l'évaluation et la prise en charge de ces comportements. Cet article donne des recommandations, surtout pour les services non spécialisés, telles la posture à tenir et l'utilisation d'un plan de sécurité, pour une prise en charge appropriée des patients NSSI, en tenant compte de l'hypersensibilité interpersonnelle souvent présente chez ces patients, et en incluant des stratégies pour le travail avec les familles et en réseau.

Exploring General Practitioners' Management of Self-Harm in Young People: A Qualitative Study.

BACKGROUND: General practitioners (GPs) are key to the frontline assessment and treatment of young people after self-harm. Young people value GP-led self-harm care, but little is known about how GPs manage young people after self-harm. AIM: This study aimed to understand the approaches of GPs to self-harm in young people and explore their perspectives on ways they might help young people avoid repeat self-harm. METHODS: We conducted semi-structured interviews with GPs from the National Health Service in England in 2021. GPs were recruited from four geographically spread clinical research networks and a professional special interest group. Data were analysed using reflexive thematic analysis. The study's patient and public involvement and community of practice groups supported participant recruitment and data analysis. RESULTS: Fifteen interviews were undertaken with a mean age of participants being 41 years and a breadth of experience in practice ranging from 1 to 22 years. Four themes were generated: GPs' understanding of self-harm; approaches to managing self-harm; impact of COVID-19 on consultations about self-harm; and ways to avoid future self-harm. CONCLUSION: Negative attitudes towards self-harm within clinical settings are well documented, but GPs said they took self-harm seriously, listened to young people, sought specialist support when concerned and described appropriate ways to help young people avoid self-harm. GPs felt that relationship-based care is an important element of self-harm care but feared remote consultations for self-harm may impede on this. There is a need for brief GP-led interventions to reduce repeat self-harm in young people. PATIENT AND PUBLIC CONTRIBUTION: A study advisory group consisting of young people aged 16-25 years with personal experience of self-harm and parents and carers of young people who have self-harmed designed the recruitment poster of this study, informed its topic guide and contributed to its findings.

Randomised controlled trial of a psychotherapeutic intervention to improve quality of life and other outcomes in people who repeatedly self-harm: FReSH START study protocol.

BACKGROUND: Self-harm is a major public health challenge, and repeated self-harm is common in those attending hospital following an episode. Evidence suggests psychological interventions could help people who self-harm, but few definitive studies have assessed their clinical and cost-effectiveness. Repeated self-harm is associated with poor quality of life, depression, suicide and increased health service costs which justify the development of psychotherapeutic interventions tailored for people with repeated self-harm. METHODS: FReSH START is a multicentre individually 1:1 randomised controlled trial evaluating the clinical and cost-effectiveness of standard care plus psychological therapy or standard care alone for adults (≥ 18 years) presenting at an emergency department (ED) with repeated self-harm. Recruiting 630 participants, it includes an internal pilot, economic evaluation and process evaluation. The intervention will be delivered by mental health staff working in acute settings, with experience of assessing and managing risk in people presenting to emergency services with self-harm. Staff will be trained and supervised to deliver one of three specially adapted therapies: psychodynamic interpersonal therapy, cognitive behavioural therapy or acceptance and commitment therapy. Participants allocated to the intervention will receive one of the adapted therapies according to therapist allocation for up to 6 months via 12 weekly, one to one, 45-50-min sessions. The primary outcome is quality of life measured by the Clinical Outcomes in Routine Evaluation Outcome Measure at 12 months post-randomisation. Secondary outcomes include suicidal intent, depression and cost-effectiveness. Data are collected using hospital attendance records and online/postal/telephone questionnaires at 6 and 12 months post-randomisation, with resource use additionally collected at 3 and 9 months. DISCUSSION: This protocol outlines a randomised controlled trial to investigate whether modified therapies are cost-effective and improve quality of life for people who repeatedly self-harm. Few interventions are proven to be deliverable in the NHS for this population. This study is strengthened by the involvement of qualified mental health workers experienced in managing risk as therapists. TRIAL REGISTRATION: Registered on August 03, 2021. IRAS number: 297939. ISRCTN: https://doi.org/10.1186/ISRCTN73357210 . REC reference: 21/EE/0145. SPONSOR: University of Leeds.

An Umbrella Review of Cognitive Behavioural and Dialectical Behavioural Therapies to Treat Self-Harm and Suicidal Behaviour in Adolescents.

BACKGROUND: The incidence of self-harm and suicidal behaviour in adolescents is increasing. Considering the great impact in this population, an actualization of the evidence of those psychological treatment's excellence for suicidal behaviour. Thus, the aim of this paper is to compile the available evidence on the effectiveness of cognitive behavioural therapy and dialectical behavioural therapy in preventing self-harm and suicidal behaviour in adolescents. METHODS: A umbrella review was carried out, different databases (PubMed, CINAHL, Cochrane Library, Psyinfo, Embase, Web of Science, Scopus and Google Scholar) were consulted. The 16-item measurement tool to assess systematic reviews-2 (AMSTAR-2) were performed by two independent reviewers and any discrepancies were resolved by consensus. The Rayyan-Qatar Computing Research Institute was used for the screening process. RESULTS: Nine systematic reviews were included. Cognitive Behavioural Therapy appears to reduce the incidence of suicide-related events compared with treatment as usual, compared to usual treatment (which usually consists of drugs and talk therapy) especially when combined with fluoxetine. Dialectical behavioural therapy seems to be associated with a reduction in suicidal ideation and self-harm. CONCLUSIONS: Although the results found show results with high heterogeneity. The evidence on cognitive behavioural therapy and dialectical behavioural therapy for suicide prevention, self-harm and suicide ideation in adolescents seems to show positive results. Considering, the special population and great impact, further research is needed and comparable studies should be sought that allow to set up robust recommendations.

A Systematic Review of the Use, Acceptability, Perceived Effectiveness and Effectiveness of Self-Help Toolkits.

Self-harming behaviours can include cutting the skin, ligaturing and taking overdoses. These actions can result in infection, blood loss, or even death. A young person's risk of dying by suicide increases if they engage in self-harm. Self-help empowers people to utilise different coping strategies and implement life changes without reliance on a clinical intervention, "helping people to help themselves". Self-help toolkits contain a variety of items that are selected by the person to help them manage the urge to self-harm. The items included sensory objects, distractions, prompts to seek help and creative prompts such as colouring books and pens and personal items that trigger positive memories. AMED, EMBASE, APA Psycinfo and MEDLINE were searched with no language restriction or date restriction. Of the 368 studies screened, 13 met the inclusion criteria. The studies were mainly small scale or case studies pertaining to the use of self-help toolkits or similar. They described the need for a flexible and/or individualised approach to self-help toolkits. Abstracts and studies were screened separately by two members of the research team for inclusion. Qualitative data was analysed using Grounded Theory. Nine themes were identified: Creativity, Hope, Social contact/help seeking, calming/relaxing, sensory items, reflection, distractions, therapeutic prompts and emotional release. Self-efficacy and self-awareness were the two main mechanisms identified. Self-help toolkits were found to be acceptable and helpful, but the limited evidence base means their efficacy for reducing self-harm episodes has not been established.

Fundamentals of Nonsuicidal Self-Injury in Pediatric Patients.

Nonsuicidal self-injury (NSSI) is deliberate self-inflicted injury to one's own body without suicidal intent. There is a high prevalence of NSSI among adolescents, especially in adolescents with history of adverse childhood events and intense reactive emotions. Pediatricians are commonly the first point of contact for adolescents and preadolescents with mental health concerns, and knowledge of how to elicit and respond to reports of NSSI are critical in identifying, supporting, and making appropriate referrals to behavioral health providers. Appropriate referrals include a psychiatric assessment by a child and adolescent psychiatrist and licensed therapist. Therapy targets NSSI by identifying the function of the behavior for the patient and finding ways to obtain that function safely using coping skills. Pediatricians should consider their role in setting the tone for families to engage in productive mental health treatment, with the goal of having the adolescent and caregiver work collaboratively to use healthy coping skills. [Pediatr Ann. 2024;53(8):e280-e282.].

Prefrontal cortex engagement during an fMRI task of emotion regulation as a potential predictor of treatment response in borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a severe mental illness, with high rates of co-morbid depression and suicidality. Despite the importance of optimizing treatment in BPD, little is known about how neural processes relate to individual treatment response. This study examines how baseline regional brain blood oxygen level dependent (BOLD) activation during a functional magnetic resonance imaging (fMRI) task of emotion regulation is related to treatment response following a six-month randomized clinical trial of Dialectical Behavior Therapy (DBT) or Selective Serotonin Reuptake Inhibitor (SSRI) treatment. METHODS: Unmedicated females with BPD (N = 37), with recent suicidal behavior or self-injury, underwent an fMRI task in which negative personal memories were presented and they were asked to distance (i.e., downregulate their emotional response) or immerse (i.e., experience emotions freely). Patients were then randomized to DBT (N = 16) or SSRI (N = 21) treatment, with baseline and post-treatment depression and BPD severity assessed. RESULTS: BOLD activity in prefrontal cortex, anterior cingulate, and insula was associated with distancing. Baseline BOLD during distancing in dorsolateral, ventrolateral, and orbital prefrontal cortex (dlPFC, vlPFC, OFC) differentially predicted depression response across treatment groups, with higher activity predicting better response in the SSRI group, and lower activity predicting better response in the DBT group. LIMITATIONS: All female samples. DISCUSSION: Findings indicate that greater prefrontal engagement during emotion regulation may predict more antidepressant benefit from SSRIs, whereas lower engagement may predict better response to DBT. These results suggest different mechanisms of action for SSRI and DBT treatment, and this may allow fMRI to guide individualized treatment selection.

Evaluation of dialectical behavior therapy for adolescents in routine clinical practice: a pre-post study.

BACKGROUND: Self-harm and suicidal ideation are prevalent among adolescents, cause physical and psychosocial disability, and have potentially life-threatening consequences. Dialectical behavioral therapy for Adolescents (DBT-A) is an evidence-based intervention for reducing self-harm. However, few studies have investigated the effectiveness of DBT-A when delivered in routine clinical practice. METHODS: A follow-up cohort study, based on data from a quality assessment register of DBT-A in child and adolescent mental health services including seven outpatient clinics. Inclusion criteria were ongoing or a history of self-harming behavior the last 6 months; current suicidal behavior; at least 3 criteria of DSM-IV Borderline personality disorder (BPD), or at least the self-destruction criterion of DSM-IV BPD, in addition to minimum 2 subthreshold criteria; and fluency in Norwegian. Participants received 20 weeks of DBT-A consisting of multifamily skills training groups and individual therapy sessions. Outcomes from 41 participants included frequency of self-harm, suicide attempts and hospitalizations caused by self-harm or suicide attempts, assessed pre-, during, and post-treatment by self-report and reviews of the patient's medical records. Suicidal ideation, urge to self-harm and perceived feelings of happiness and sadness were assessed by the patients' diary cards at week 1, 5, 10, 15 and 20 of the treatment program. RESULTS: Participants attended an average of 17.9 (SD = 4.7) individual sessions, 14.7 (SD = 3.4) group-based skills training sessions and 4.6 (SD = 4.1) brief intersession telephone consultations. Moderate to large within-group effect sizes (ES) were found in self-harm from pre-treatment to 1-5 weeks (d = 0.64), 6-10 weeks (d = 0.84), 11-15 weeks (d = 0.99), 16-20 weeks (d = 1.26) and post-treatment (d = 1.68). Nine participants were admitted to hospitalization during DBT-A, whereas five had attempted suicide, but no suicides were completed. No statistically significant changes were found in suicidal ideation, urge to self-harm or perceived feelings of happiness or sadness from pre to post treatment. CONCLUSION: The findings of the current study are promising as the participants reported considerably reduced self-harm behavior after DBT-A treatment in a child and adolescent mental health outpatient setting.

Healthcare practitioners' views of self-harm management practices in older adults in Ireland: A qualitative study.

OBJECTIVES: To explore healthcare practitioners' views on management practices of self-harm in older adults. METHODS: Semi-structured interviews were conducted with healthcare practitioners, including consultant psychiatrists, general practitioners, clinical psychologists, psychotherapists, clinical nurse specialists and social workers. Purposeful sampling was used to recruit participants in the Republic of Ireland ensuring diverse perspectives of healthcare practitioners were included. Healthcare practitioners were recruited advertising via professional and clinical research networks, social media, and snowballing methods. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis. RESULTS: We conducted interviews with 20 healthcare practitioners from April to July 2023. Three main themes were generated: first, a perceived greater risk of suicide, and increased awareness of complexity in older adults' self-harm presentations. Second, integrated care as an avenue for improving the management of self-harm in older adults. Third, the importance of safety planning in risk assessments of older adults. CONCLUSIONS: Healthcare practitioners viewed self-harm in older adults as complex, challenging, and associated with high suicide risk, approaching patients with care and caution. The need for integrated support and improved collaboration between relevant healthcare practitioners was identified. Suggestions were made for primary care having a lead role in identifying and managing older adults after self-harm. Increased mental health promotion and awareness of mental health and self-harm in this age group would help address current stigma and shame.

Early specialised treatment for bipolar disorder: Long-term follow-up from the early intervention in affective disorders (EIA) randomised controlled trial.

BACKGROUND: It is unclear whether treatment early after onset in bipolar disorder may improve the long-term illness course. The early intervention in affective disorders (EIA) randomised controlled trial found that 2-years treatment in a specialised mood disorder clinic combining evidence-based pharmacological treatment with group psychoeducation improved clinical outcomes compared with standard treatment in patients with bipolar disorder discharged after their 1st, 2nd, or 3rd hospital admission. We aimed to assess the 16 years long-term outcomes after randomisation of the participants in the EIA trial. METHODS: Data were obtained by linking nation-wide Danish population-based registers. All 158 participants of the EIA trial (Trial Registration Number NCT00253071) were followed from time of randomisation (2005-2009) to end of study (31 December 2021). The primary outcome was risk of psychiatric readmission. Secondary outcomes were total admissions and costs, medication use, intentional self-harm or suicide attempt or suicide, and socio-economic measures. RESULTS: The absolute mean risk of psychiatric readmission was 49.3% in the intervention group and 59.8% in the control group, with no statistically significant difference between the groups (b = -0.10, 95% CI: -0.26 to 0.047, p = 0.18). Compared with the control group, patients in the intervention group had numerically fewer total admission days (mean (SD) 44 (77) versus 62 (109)), lower total cost of psychiatric hospital admissions and hospital-based outpatient visits (mean (SD) 22,001 (36793) euros versus 29,822 (52671) euros) and higher use of lithium and antipsychotics, but the differences were not statistically significant. Fewer patients in the intervention group had an event of intentional self-harm or suicide attempt or suicide during follow-up (OR 0.25, 95% CI: 0.15-0.40, p < 0.001) compared with the control group and more patients in the intervention group used antiepileptics (OR 2.21, 95% CI: 1.08-4.60, p = 0.031). CONCLUSION: Analyses of very long-term outcomes of the EIA trial may potentially indicate a beneficial effect of the intervention at the long term but were likely underpowered to detect a more subtle effect and for most outcomes the differences between groups were not statistically significant.

Brief admission by self-referral as an add-on to usual care for individuals with self-harm at risk of suicide: cost-effectiveness and 4-year health-economic consequences after a Swedish randomized controlled trial.

BACKGROUND: Brief Admission by self-referral (BA) is a crisis-management intervention standardized for individuals with self-harm at risk of suicide. We analyzed its health-economic consequences. MATERIALS AND METHODS: BA plus treatment as usual (TAU) was compared with TAU alone in a 12-month randomized controlled trial with 117 participants regarding costs for hospital admissions, coercive measures, emergency care and health outcomes (quality-adjusted life years; QALYs). Participants were followed from 12 months before baseline to up to five years after. RESULTS: Over one year BA was associated with a mean annual cost reduction of 4800 or incremental cost of 4600 euros, depending on bed occupancy assumption. Cost-savings were greatest for individuals with >180 admission days in the year before baseline. In terms of health outcomes BA was associated with a QALY gain of 0.078. Uncertainty analyses indicated a significant QALY gain and ambiguity in costs, resulting in BA either dominating TAU or costing 59 000 euros per gained QALY. CONCLUSION: BA is likely to produce QALY gains for individuals living with self-harm and suicidality. Cost-effectiveness depends on targeting high-need individuals and comparable bed utilization between BA and other psychiatric admissions. Future research should elaborate the explanatory factors for individual variations in the usage and benefit of BA.

The role of emotion dysregulation and interpersonal dysfunction in nonsuicidal self-injury during dialectical behavior therapy for borderline personality disorder.

Dialectical Behaviour Therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD), with findings demonstrating improvements in various BPD features and related behaviours, such as nonsuicidal self-injury (NSSI). Theory and research suggest that reductions in emotion dysregulation and interpersonal dysfunction could account for at least some of the reduction in NSSI observed during the course of DBT. The current research investigated: 1) the trajectory of changes in emotion dysregulation, interpersonal dysfunction, and NSSI over the course of DBT, and 2) whether changes in emotion dysregulation mediate the relationship between changes in interpersonal dysfunction and changes in NSSI over treatment. One hundred and twenty individuals with BPD enrolled in a multi-site randomized-clinical trial were assessed at five timepoints over 12 months of standard DBT. Results indicated that interpersonal dysfunction and NSSI decreased over the course of DBT. Emotion dysregulation decreased in a quadratic manner such that most of the gains in emotion dysregulation occurred in earlier phases of DBT. Although changes in interpersonal dysfunction predicted changes in emotion dysregulation, changes in emotion dysregulation did not mediate the relationship between changes in interpersonal dysfunction and changes in NSSI.

Brief admission by self-referral for individuals with self-harm and suicidal ideation: a qualitative study based on focus groups exploring relatives' experiences.

PURPOSE: Brief Admission by self-referral (BA) is a standardized crisis-management intervention for individuals with self-harm and risk for suicide. This study explored relatives' experiences of BA. Relatives' perspectives may contribute to an increased understanding of the effects of BA given the relatives' role as support and informal caregivers as well as being co-sufferers. METHODS: Fourteen relatives to adults with access to BA within one Swedish region participated in focus groups analysed with reflexive thematic analysis. RESULTS: We generated themes evolving around three meaning-based concepts: access (A low threshold to a safe back-up is crucial and obstacles may easily break faith), independence (Trust in their ability with care and respect), and recovery (The rest and relational recovery we all get are needed and invaluable). CONCLUSIONS: BA brings considerable value to users and relatives, by supporting them to take care of themselves and each other. Communication and involvement of relatives may enhance users' ability to overcome obstacles to accessing BA. Implementation and adherence may be strengthened by supervision of BA staff and education of emergency care staff. Resources are needed to improve access. Mapping hurdles to BA, support through peers and targeted psychoeducation may improve recovery for BA users and their relatives.

A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series.

BACKGROUND: Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y). METHODS: A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure. RESULTS: The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low. CONCLUSIONS: The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

The Mental Health Toll of the COVID-19 Pandemic on Adolescents Receiving Inpatient Psychiatric Treatment.

Objective: During the COVID-19 pandemic, the prevalence of depression and anxiety among children and adolescents significantly increased, along with the number of visits to emergency departments due to suicidality and/or suicide attempts. Relatedly, health care workers experienced significant burnout and symptoms of anxiety, depression, and posttraumatic stress disorder during this time. However, the corresponding impact on psychiatric inpatient treatment has not yet been researched. We hypothesized that during the pandemic, adolescents hospitalized in an acute care psychiatric inpatient unit had increased incidents of suicide attempts and nonsuicidal self-injurious behaviors and of aggressive behaviors toward others, resulting in greater use of constant observation and restraints. Method: This study was a retrospective chart review based on electronic medical record data examining use of restraints and constant observation one year before the pandemic (March 2019 to February 2020) and 1 year following the onset of the pandemic (March 2020 to February 2021) in an acute-care adolescent (12 to 17 years old) psychiatric inpatient unit. Results: There were 571 admissions during the year before the pandemic and 500 admissions during the pandemic. The number of patients who were restrained (χ2 = 7.86, p = 0.005), number of patients who were placed on constant observation (χ2 = 13.41, p < 0.001), and number of constant observation orders per patient (χ2 = 91.90, p < 0.001) were all significantly greater during the pandemic. Conclusion: Psychiatrically hospitalized adolescents during the pandemic received more intensive interventions such as restraints and constant observation. Severe patient psychopathology and staff shortages, as well as limitations of and decreases to the dialectical behavior therapy program, may have been the contributing factor.

Editorial: How Can We Best Support Suicidal Youth? New Evidence for Dialectical Behavior Therapy and Different Forms of Self-Harm.

Establishing effective treatments for youth at risk of suicide is one of the most pressing and important tasks within child and adolescent psychiatry. Self-harm, which includes suicide attempt (SA), nonsuicidal self-injury (NSSI), and nonsuicidal self-poisoning, is one of the strongest predictors of suicide.1 Youth who engage in self-harm or experience mental health crisis are becoming more and more common, at increasingly younger ages, and so confidence in treatments to successfully reduce self-harm and prevent relapse and recurrence is crucial.2 However, the evidence base for such treatments is severely lacking despite some progress in the field.3-5 Dialectical behavior therapy (DBT) is the most established treatment option, but even so, the evidence comes from just a handful of studies and primarily focuses on the ability of DBT to reduce the repetition of self-harm. Whether DBT is successful in supporting young people along their recovery journey and is equally effective at treating different forms of self-harm are yet to be properly explored.

Should psychotherapists conduct visual assessments of nonsuicidal self-injury wounds?

Beneficence and nonmaleficence are key ethical principles toward which psychotherapists consistently strive. When patients engage in nonsuicidal self-injury (NSSI) during the course of psychotherapy, therapists may feel responsible for visually assessing the severity of the NSSI wound in order to benefit their patients and keep them from harm. However, there are no guidelines for conducting these visual assessments, and there is no research exploring their effects on patients. This article considers the ethical implications of visually examining NSSI wounds; discusses psychotherapist scope of practice and competence; draws attention to relevant ethical standards; underscores risk management, liability, and standard of care; and addresses the risk of suicide or accidental death resulting from NSSI. It also provides ethical guidance for conducting effective verbal assessments of NSSI wounds and offers suggestions for navigating complex clinical situations, such as when patients routinely and spontaneously show their therapists their wounds and how psychotherapists should handle assessments and interventions related to NSSI scars. It ends with implications for training and therapeutic practice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Examination of clinical variables affecting resurgence: A reanalysis of 46 applications.

Despite the efficacy of behavioral interventions, resurgence of challenging behavior (e.g., aggression, self-injury) following successful treatment can still occur. Applied work has focused on identifying treatment-related variables thought to affect the occurrence and magnitude of resurgence. The current study describes the relation between several variables (i.e., phase duration, response rates in baseline and treatment, obtained rates of reinforcement, downshift in reinforcement step size) and resurgence in a retrospective consecutive controlled case series of 46 treatment applications for challenging behavior conducted in an inpatient setting. Only the downshift in reinforcement (e.g., schedule-thinning) step size was correlated with the magnitude of resurgence. These results are consistent with recent findings suggesting that treatment duration and other factors have inconsistent effects on resurgence of challenging behavior.