Near-Fatal Self-Harm Among Canadian Adolescents.

OBJECTIVE: To evaluate the clinical features of Canadian adolescents admitted to the intensive care unit (ICU) for medically serious self-harm. METHODS: 2700 Canadian paediatricians were surveyed monthly over two years (January 2017 to December 2018) through the Canadian Paediatric Surveillance Program to ascertain data from eligible cases. RESULTS: Ninety-three cases (73 female; age 15.2 ± 1.5) met the case definition. Four provinces reported the majority of cases: Quebec (n = 27), Ontario (n = 26), Alberta (n = 21), and British Columbia (n = 8). There were 10 deaths, 9 by hanging. Overdose and hanging were the most frequently reported methods of self-harm (74.2% and 19.4%, respectively). Overdose was more common in females (80.8% females vs. 50% males; χ2 = 7.8 (1), p = .005), whereas hanging was more common in males (35% males vs. 15.1% females, χ2 = 3.9 (1), p = .04). More females than males had a past psychiatric diagnosis (79% vs. 58%; χ2 = 4.1 (1), p = .06), a previous suicide attempt (55.9% vs. 29.4%, χ2 = 3.8 (1), p = .05), and prior use of mental health service (69.7% vs. 27.8%, χ2 = 10.4 (1), p = .001). Family conflict was the most commonly identified precipitating factor (43%) of self-harm. CONCLUSIONS: Among Canadian adolescents admitted to the ICU with medically serious self-harm, females demonstrate a higher rate of suicide attempts and prior mental health care engagement, whereas males are more likely to die by suicide. These findings are consistent with data from other adolescent samples, as well as data from working-age and older adults. Therefore, a sex-specific approach to suicide prevention is warranted as part of a national suicide prevention strategy; family conflict may be a specific target for suicide prevention interventions among adolescents.

What's the harm in asking? A systematic review and meta-analysis on the risks of asking about suicide-related behaviors and self-harm with quality appraisal.

Research emphasizes the importance of asking about suicidality. Unfortunately, misperceptions of harm remain which can compromise clinical care, research, and public health surveillance efforts. Our objective was to evaluate the empirical evidence on whether and how asking about suicide related behaviors (SRB), such as suicidal ideation and suicide attempts, and non-suicidal self-injury (NSSI) results in harmful outcomes. We reviewed and rated seventeen studies and conducted a systematic review and random-effects meta-analysis on eight studies comparing those asked vs. not asked on immediate and later SRB, NSSI, and psychological distress (PD). Forest plots demonstrated no statistically significant effects of asking on SRB, NSSI, or PD. Eight RCTs provided the strongest evidence and demonstrated either low or unclear risk of bias, and the remaining cohort studies were of low to moderate quality. With the current available evidence, we found no harmful outcomes of asking, however more RCTs with a low risk of bias are required to firmly conclude that asking through self-report and interview methods does not further exacerbate distress, SRB and NSSI compared to those not asked.

Injury hospitalizations in Canada 2018/19. / Hospitalisations pour blessure au Canada en 2018-2019.

National injury hospitalization statistics are essential for understanding the burden and pattern of injuries. This paper used the Discharge Abstract Database to analyse injury hospitalizations in Canada (excluding Quebec) for fiscal year 2018/19. The results show that unintentional injuries were the eighth leading cause of hospitalization compared to all other diseases and conditions. For unintentional injury-related hospitalizations, in rank order, the leading causes were falls, suffocation, motor vehicle traffic crashes, poisonings, struck by/against, and fire/hot object/smoke. However, the rankings were different across age groups.

National injury hospitalization statistics are essential for understanding the burden and pattern of injuries, including nonfatal events, in Canada and informing prevention strategies. In fiscal year 2018/19, unintentional injuries were the eighth leading cause of hospitalizations overall compared to all other diseases and conditions. They were ranked ninth or higher among causes of hospitalization for every age group except less than 1 year olds. Falls were the leading cause of hospitalization in every age group for unintentional injury-related hospitalizations.

Les statistiques nationales sur les hospitalisations pour blessure permettent de comprendre le fardeau et le profil des blessures, en particulier les incidents non mortels, afin d'orienter les stratégies de prévention au Canada. Pour l'exercice 2018-2019, les blessures non intentionnelles occupent le huitième rang des principales causes d'hospitalisation pour l'ensemble des maladies et affections. Ce type de blessure se classe au neuvième rang ou à un rang supérieur en tant que principale cause d'hospitalisation pour tous les groupes d'âge sauf les enfants de moins d'un an. Les chutes sont la principale cause d'hospitalisation pour blessure non intentionnelle, tous groupes d'âge confondus.

Sentinel surveillance of child maltreatment cases presenting to Canadian emergency departments.

BACKGROUND: The Canadian Hospitals Injury Reporting Prevention Program (CHIRPP) is a sentinel surveillance program that collects and analyzes data on injuries and poisonings of people presenting to emergency departments (EDs) at 11 pediatric and eight general hospitals (currently) across Canada. To date, CHIRPP is an understudied source of child maltreatment (CM) surveillance data. This study: (1) describes CM cases identified in the CHIRPP database between1997/98 to 2010/11; (2) assesses the level of CM case capture over the 14-year period and; (3) uses content analysis to identify additional information captured in text fields. METHODS: We reviewed cases of children under 16 whose injuries were reported as resulting from CM from 1997/98 to 2010/11. A time trend analysis of cases to assess capture was conducted and content analysis was applied to develop a codebook to assess information from text fields in CHIRPP. The frequency of types of CM and other variables identified from text fields were calculated. Finally, the frequency of types of CM were presented by age and gender. RESULTS: A total of 2200 CM cases were identified. There was a significant decrease in the capture of CM cases between 1999 and 2005. Physical abuse was the most prevalent type (57%), followed by sexual assault (31%), unspecified maltreatment (7%), injury as the result of exposure to family violence (3%) and neglect (2%). Text fields provided additional information including perpetrator characteristics, the use of drugs and/or alcohol during the injury event, information regarding the involvement of non-health care professionals, whether maltreatment occurred during a visitation period with a parent and, whether the child was removed from their home. CONCLUSIONS: The findings from this initial study indicate that CHIRPP could be a complimentary source of CM data. As an injury surveillance system, physical abuse and sexual assault were better captured than other types of CM. Text field data provided unique information on a number of additional details surrounding the injury event, including risk factors.

At-a-glance - 2015 injury deaths in Canada. / Aperçu - Décès attribuables à des blessures au Canada en 2015.

Injuries continue to be a public health concern in Canada. National injury death data are essential for understanding the magnitude and pattern of injuries. This paper used the Vital Statistics - Death database to examine deaths associated with injuries in 2015. Injuries were ranked against causes of death, and more in-depth analysis of injury categories was conducted by sex and age. Unintentional injuries were the 6th leading causes of death overall, with different ranking by sex. Among unintentional injury deaths, leading causes included falls, poisonings, motor vehicle traffic collisions, and suffocation, which varied by age group.

Ongoing reporting of national injury death data is essential for understanding the trend and burden of injuries at the national level in Canada. In 2015, unintentional injuries were the 6th leading cause of death overall and the leading cause for those aged 1­34. Suicide ranked as the 2nd leading cause of death for 15­34-year-olds. Falls, poisonings and motor vehicle traffic collisions are the top three leading causes among unintentional injury deaths.

Pour comprendre les tendances et évaluer le fardeau en matière de blessures à l'échelle du Canada, il faut disposer de données nationales régulièrement mises à jour sur les décès attribuables aux blessures. En 2015, les blessures non intentionnelles ont constitué la sixième cause de décès en général et la principale cause de décès entre 1 et 34 ans. Le suicide a été la deuxième cause de décès chez les 15 à 34 ans. Les chutes, les empoisonnements et les accidents de la route ont constitué les trois principales causes de décès attribuables à des blessures non intentionnelles.

Self-Inflicted Injury-Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP-SI): a new surveillance tool for detecting self-inflicted injury events in emergency departments.

OBJECTIVES: To assess the performance of the Canadian Hospitals Injury Reporting and Prevention Program's newly developed self-harm surveillance tool (CHIRPP-SI) designed to improve emergency department (ED) hospital surveillance of youth self-inflicted injury (SI). METHODS: This was a prospective, single-centre cohort study from February 2015 to September 2015. Eligible participants were aged 6-17.99 years and presented to the ED with a primary mental health complaint. The frequency of SI cases was extracted from three data sources (CHIRPP-SI, medical chart, and the National Ambulatory Care Reporting System Metadata (NACRS)). Cohen's kappa statistic was used to examine the level of agreement between data sources. RESULTS: Of the 250 participants who received a medical chart review, 70 completed the CHIRPP-SI. Of those who did not complete the CHIRPP-SI, 86% (n = 154) reported no SI related to their presentation, 12% (n = 22) declined to participate without specifying self-injury status, and 2% (n = 4) were unable to be interviewed prior to discharge. The three sources of surveillance data varied considerably; the medical chart captured the highest frequency of individuals reporting SI related to their ED visit (33.6%), followed by the CHIRPP-SI (28.0%), and the NACRS database (8.4%). The CHIRPP-SI captured the method of SI and the place of occurrence in 100% of individuals, and the bodily location harmed in 98.6% of individuals. CONCLUSIONS: Study findings highlight the disparity between different sources of data, in relation to the capture of paediatric SI, presenting to hospital EDs. If greater details of SI events are to be identified, surveillance tools such as the CHIRPP-SI should be considered.

Emergency Department Presentations and Youth Suicide: A Case-Control Study.

OBJECTIVE: We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care. METHOD: This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases ( n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS: Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: 'other' injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, 'undetermined' injuries and poisonings in both sexes (aORs > 5), 'unintentional' poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days. CONCLUSIONS: The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.

Regional Variations in Suicide and Undetermined Death Rates among Adolescents across Canada.

OBJECTIVE: Trends in rates of adolescent suicide and undetermined deaths in Canada from 1981 to 2012 were examined, focusing specifically on variations between Canadian regions. Exploratory hypotheses were formulated for regional variability in adolescent suicide rates over time in Canada. METHODS: A descriptive time trend analysis using public domain vital statistics data was performed. All deaths from 1981 to 2012 among 15 to 19 year olds coded as suicides or undetermined intent according to the International Classification of Diseases, 9th and 10th Revisions were included. RESULTS: While there was an overall stability in adolescent suicide and undetermined death rates across Canada, regional analyses showed that Quebec experienced a 7.6% annual reduction between 2001 and 2012 while the Prairies and Atlantic provinces experienced significant annual increases since 2001. Ontario and British Columbia have had non-significant fluctuations since 2001. The trends remained similar overall when excluding undetermined deaths from the analyses. CONCLUSIONS: Variations in adolescent suicide trends across provinces were found. Factors such as provincial suicide action and prevention legislation contributing to these variations remain to be studied, but these regional differences point towards the need for better consistency of suicide prevention strategies across the country.

OBJECTIF: Les tendances des taux de suicide adolescent et des décès indéterminés au Canada de 1981 à 2012 ont été examinées, en mettant spécialement l'accent sur les variations entre les régions canadiennes. Des hypothèses exploratoires ont été formulées pour la variabilité régionale des taux de suicide adolescent avec le temps au Canada. MÉTHODES: Une analyse descriptive de l'évolution dans le temps utilisant les données des statistiques vitales du domaine public a été menée. Tous les décès de 1981 à 2012 chez les 15 à 19 ans codés comme suicides ou de cause indéterminée selon la Classification internationale des maladies, 9e et 10e révisions, étaient inclus. RÉSULTATS: Même s'il y avait une stabilité générale des taux de suicide adolescent et des décès indéterminés au Canada, les analyses régionales montraient que le Québec a connu une diminution annuelle de 7,6 % entre 2001 et 2012 alors que les Prairies et les provinces de l'Atlantique ont enregistré des hausses annuelles significatives depuis 2001. L'Ontario et la Colombie-Britannique ont eu des fluctuations non significatives depuis 2001. Les tendances sont demeurées semblables généralement en excluant les décès indéterminés des analyses. CONCLUSIONS: Des variations des tendances du suicide adolescent entre les provinces ont été constatées. Les facteurs contribuant à ces variations demeurent à étudier, comme les plans d'action et les mesures législatives provinciales de prévention du suicide. Ces différences régionales indiquent le besoin d'une meilleure cohésion des stratégies de prévention du suicide dans tout le pays.

Les soins médicaux de jeunes hommes et de jeunes femmes qui décèdent par suicide.

OBJECTIVE: Prior year medical care was compared among youth dying by suicide to their peers. Effect modification of these associations by age or place of residency (rural versus larger community sizes) was examined in a large, medically insured population. METHOD: This population-based case control study used data from the Office of the Chief Coroner in Ontario, Canada, linked to health care administrative data to examine associations between medical care for mental health or other reasons (versus no medical care) and suicide. Decedents ( n = 1203 males and n = 454 females) were youth (aged 10 to 25 years) who died by suicide in Ontario between April 2003 and March 2014, inclusive. Peers of the same ages were frequency matched to decedents on sex and place of residency. Logistic regression was used to calculate odds ratios and 95% confidence intervals and to test effect modification. RESULTS: Associations with mental health care were stronger in decedents than peers with a gradation of care (i.e., outpatient only, emergency department [ED], inpatient care) in both sexes. However, these associations were weaker among youth living in rural communities. Furthermore, older males (aged 18 to 25 years) were less likely than younger males (aged 10 to 17 years) to access the ED (ambulatory care only). This decrease was observed in rural and larger communities alongside no increase in medical care for other reasons. CONCLUSIONS: Geographical and age-related barriers to mental health care exist for youth who die by suicide. Preventive efforts can address these barriers, intervening early and integrating services, including the ED.

Antecedents and sex/gender differences in youth suicidal behavior.

Suicide is the second leading cause of death in youth globally; however, there is uncertainty about how best to intervene. Suicide rates are typically higher in males than females, while the converse is true for suicide attempts. We review this "gender paradox" in youth, and in particular, the age-dependency of these sex/gender differences and the developmental mechanisms that may explain them. Epidemiologic, genetic, neurodevelopmental and psychopathological research have identified suicidal behaviour risks arising from genetic vulnerabilities and sex/gender differences in early adverse environments, neurodevelopment, mental disorder and their complex interconnections. Further, evolving sex-/gender-defined social expectations and norms have been thought to influence suicide risk. In particular, how youth perceive and cope with threats and losses (including conforming to others' or one's own expectations of sex/gender identity) and adapt to pain (through substance use and help-seeking behaviours). Taken together, considering brain plasticity over the lifespan, these proposed antecedents to youth suicide highlight the importance of interventions that alter early environment(s) (e.g., childhood maltreatment) and/or one's ability to adapt to them. Further, such interventions may have more enduring protective effects, for the individual and for future generations, if implemented in youth.

Time trends in medically serious suicide-related behaviours in boys and girls.

OBJECTIVE: To determine whether emergency department (ED) presentations for suicide-related behaviours (SRBs) in boys and girls were identified as more clinically acute in the ED in the period after the regulatory warnings against prescribing antidepressants and during the global economic recession, and to characterize the medical severity of SRBs among boys and girls to aid surveillance activities. METHOD: Among Ontario boys and girls (aged 12 to 17 years) presenting to the ED with an incident (index) ED SRB event between fiscal years (FYs) 2002 to 2010, we compared the number of high (compared with lower) acuity events in FYs 2005 to 2010 to those in FYs 2002 to 2004. We described the SRB method by its acuity and tested the linearity of varying trends in the SRB method in boys and girls. RESULTS: In both boys and girls, high acuity events were 50% greater after FY 2004 than before, regardless of subsequent admission, and most common among boys and girls who self-poisoned. In girls, opposing linear trends before and after FY 2004 were observed in the proportion of self-poisonings and cut (or) pierce SRB methods. Throughout the study period, there was a linear decline in the proportion of boys presenting to the ED with other methods. CONCLUSIONS: The previously reported increase in hospital admissions after the warnings and during the recession is unlikely artifactual. An equivalent increase in high acuity events was also evident among those not subsequently admitted. The reasons for varying responses in boys and girls by SRB method warrant further study.

Canada-wide effect of regulatory warnings on antidepressant prescribing and suicide rates in boys and girls.

OBJECTIVE: To examine the impact of the Health Canada regulatory warnings regarding antidepressant (AD) prescribing on suicide rates in boys and girls under the age of 18 and aged 18 to 19 years in Canada between 2004 and 2009. We hypothesized that an increase in suicide rates would be specific to girls, reflecting higher AD prescribing rates in girls than boys. METHOD: We graphed and tested the difference between Canada-wide suicide rates before and after the regulatory warning periods (either from 1995 to 2006 or from 1995 to 2009) in boys and girls under the age of 18 or aged 18 to 19 years. For comparison with prior studies, we estimated rate ratios and 95% confidence intervals using either Poisson regression or negative binomial regression. RESULTS: There was no statistically significant increase in suicide rates in girls under the age of 18, or aged 18 to 19 years in response to the AD regulatory warnings. In boys under the age of 18 or aged 18 to 19 years, suicide rates declined after 2003. CONCLUSIONS: We did not find increased rates of suicide after the AD regulatory warnings in boys or girls under the age of 18 or aged 18 to 19 years in Canada-wide rates. However, this does not rule out the possibility that such an effect occurred in some jurisdictions in girls and (or) the regulatory warnings prevented the trend toward declining suicide rates. Factors influencing the downward trend in boys merit further attention.

Objectif : Examiner l'effet des mises en garde de Santé Canada concernant la prescription d'antidépresseurs (AD) et les taux de suicide des filles et garçons de moins de 18 ans et de 18 à 19 ans au Canada entre 2004 et 2009. Nous avons émis l'hypothèse qu'une augmentation des taux de suicide serait propre aux filles, reflétant des taux de prescription d'AD plus élevés chez les filles que chez les garçons. Méthode : Nous avons établi des graphiques et testé la différence entre les taux de suicide pancanadiens avant et après les périodes de mise en garde réglementaires (soit de 1995 à 2006 ou de 1995 à 2009) chez les filles et garçons de moins de 18 ans ou de 18 à 19 ans. Pour comparer avec les études précédentes, nous avons estimé les rapports de cotes et les intervalles de confiance à 95 % à l'aide de la régression de Poisson ou de la régression négative binomiale. Résultats : Il n'y avait pas d'augmentation statistiquement significative des taux de suicide chez les filles de moins de 18 ans, ou de 18 à 19 ans, en réponse aux mises en garde réglementaires contre les AD. Chez les garçons de moins de 18 ans ou de 18 à 19 ans, les taux de suicide ont diminué après 2003. Conclusions : Nous n'avons pas observé de taux de suicide accrus après les mises en garde réglementaires contre les AD chez les filles ou les garçons de moins de 18 ans ou de 18 à 19 ans dans les taux pancanadiens. Cependant, cela n'élimine pas la possibilité qu'un tel effet se soit produit dans certaines administrations chez les filles et (ou) que les mises en garde réglementaires aient nui à la tendance à la baisse des taux de suicide. Les facteurs influençant la tendance à la baisse chez les garçons méritent d'être davantage étudiés.

Suicide among children and adolescents in Canada: trends and sex differences, 1980-2008.

BACKGROUND: Suicide is the second leading cause of death for young Canadians (10-19 years of age)--a disturbing trend that has shown little improvement in recent years. Our objective was to examine suicide trends among Canadian children and adolescents. METHODS: We conducted a retrospective analysis of standardized suicide rates using Statistics Canada mortality data for the period spanning from 1980 to 2008. We analyzed the data by sex and by suicide method over time for two age groups: 10-14 year olds (children) and 15-19 year olds (adolescents). We quantified annual trends by calculating the average annual percent change (AAPC). RESULTS: We found an average annual decrease of 1.0% (95% confidence interval [CI] -1.5 to -0.4) in the suicide rate for children and adolescents, but stratification by age and sex showed significant variation. We saw an increase in suicide by suffocation among female children (AAPC = 8.1%, 95% CI 6.0 to 10.4) and adolescents (AAPC = 8.0%, 95% CI 6.2 to 9.8). In addition, we noted a decrease in suicides involving poisoning and firearms during the study period. INTERPRETATION: Our results show that suicide rates in Canada are increasing among female children and adolescents and decreasing among male children and adolescents. Limiting access to lethal means has some potential to mitigate risk. However, suffocation, which has become the predominant method for committing suicide for these age groups, is not amenable to this type of primary prevention.

Playground equipment injuries at home versus those in public settings: differences in severity.

The objective of the present research was to compare the severity of playground-related injuries in backyards of home with those occurring in public settings. This case-control study used emergency-based surveillance data from Canada regarding children, 3-11 years old, who were injured after falling from playground equipment (PGE). Cases were those whose injuries occurred at home (backyards), and controls were those whose injuries occurred in parks, schools or daycare centres. Of the 39,730 subjects selected, 84% happened in public and 16% at home. Children falling from a home PGE had greater odds of severe injuries (OR=1.30; 95% CI 1.23 to 1.37) and fractures (OR=1.47; 95% CI 1.39 to 1.55) than those from public PGE. Children aged 3-5 years falling off slides at home, compared to slides in public settings, had the greatest odds of severe injuries (OR=1.72; 95% CI 1.41 to 2.09) and fractures (OR=2.17; 95% CI 1.79 to 2.64.) When setting up PGE at home, parents should be diligent in using proper landing surfaces, such as those found in public playgrounds.