Predictors of substance use disorder treatment initiation and engagement among adolescents enrolled in Medicaid.

Background: Adolescents with substance use disorders (SUD) should receive timely access to treatment to improve lifelong outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement in treatment (IET) performance measure was intended to promote quality improvement for patients with SUD. Yet, few studies have assessed predictors of measure performance among adolescents or other engagement in mental health services, which is critical to understanding disparities in treatment quality or opportunities for targeted improvement strategies. The present study reports the rates and predictors of IET among adolescents with SUD, as well as receipt of any mental health services. Methods: The sample included adolescents enrolled in Medicaid in 14 states who had a qualifying diagnosis for SUD (2009-2013) and met HEDIS IET performance measure eligibility criteria. Three outcomes were assessed, including initiation of SUD treatment within 14 days of qualifying diagnosis, engagement in SUD treatment (2 or more encounters) within 30 days of initiation, and receipt of any mental health services (1 or more encounters) within 30 days of initiation. Logistic regression was used to identify demographic and clinical characteristics associated with outcomes. Results: Among 20,602 adolescents who met eligibility criteria, 49.5% initiated SUD treatment, 48.5% engaged in SUD treatment, and 70% received any mental health service. Adolescents with higher levels of clinical need (e.g., medical complexity, mental health comorbidity, and multiple SUD diagnoses) had significantly higher odds of initiating, but lower odds of engaging in treatment or receiving any mental health service. Conclusions: To increase the delivery of SUD treatment, efforts should target adolescents with co-occurring mental health needs, many of whom are receiving mental health services after SUD diagnosis. Integrating addiction and mental health services could address these missed opportunities.

Self-reported Symptoms of Anxiety Predict Positive Suicide Risk Screening in Adolescents Presenting to the Emergency Department.

OBJECTIVE: The objective of this study was to assess whether patient-reported anxiety symptoms are associated with suicide risk in pediatric emergency department (ED) patients. An additional objective was to examine differences between patients presenting for medical/surgical or psychiatric complaints. METHODS: Pediatric patients aged 10 to 21 years were recruited from 3 pediatric EDs. Participants completed self-report questionnaires assessing for suicidal ideation and behavior, in addition to questions of interest about recent feelings of unbearable anxiety and depression. Adjusted odds ratios were calculated to assess the relationship between endorsement of recent anxiety and screening positive for suicide risk. RESULTS: Data were analyzed from 522 participants, including 344 presenting with medical/surgical chief complaints and 178 presenting with psychiatric complaints. Overall, 28.9% of participants screened positive for suicide risk, 29.9% endorsed recent feelings of anxiety, and 24.3% endorsed recent feelings of depression. Patients who self-reported recent anxiety symptoms were 5 times more likely to screen positive for suicide risk (adjusted odds ratios = 5.18, 95% confidence interval = 3.06-8.76). Analysis of the 344 medical/surgical patients revealed that this subsample was also 5 times more likely to screen positive for suicide risk if they endorsed recent anxiety (adjusted odds ratios = 4.87, 95% confidence interval = 2.09-11.36). CONCLUSIONS: Self-reported suicidal ideation and feelings of unbearable anxiety are prevalent among patients presenting to pediatric EDs. Patients who self-report recent feelings of unbearable anxiety are significantly more likely to screen positive for suicide risk, regardless of whether their presenting complaint is medical/surgical or psychiatric in nature.

Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis.

OBJECTIVE: The objective of this study was to provide a systematic review and meta-analysis to quantify prognosis and identify factors associated with variations in reported mortality estimates among infants who were born at 22 weeks of gestation and provided proactive treatment (resuscitation and intensive care). DATA SOURCES: PubMed, Scopus, and Web of Science databases, with no language restrictions, were searched for articles published from January 2000 to February 2020. STUDY ELIGIBILITY CRITERIA: Reports on live-born infants who were delivered at 22 weeks of gestation and provided proactive care were included. The primary outcome was survival to hospital discharge; secondary outcomes included survival without major morbidity and survival without neurodevelopmental impairment. Because we expected differences across studies in the definitions for various morbidities, multiple definitions for composite outcomes of major morbidities were prespecified. Neurodevelopmental impairment was based on Bayley Scales of Infant Development II or III. Data extractions were performed independently, and outcomes agreed on a priori. STUDY APPRAISAL AND SYNTHESIS METHODS: Methodological quality was assessed using the Quality in Prognostic Studies tool. An adapted version of the Grading of Recommendations Assessment, Development and Evaluation approach for prognostic studies was used to evaluate confidence in overall estimates. Outcomes were assessed as prevalence and 95% confidence intervals. Variabilities across studies attributable to heterogeneity were estimated with the I2 statistic; publication bias was assessed with the Luis Furuya-Kanamori index. Data were pooled using the inverse variance heterogeneity model. RESULTS: Literature searches returned 21,952 articles, with 2034 considered in full; 31 studies of 2226 infants who were delivered at 22 weeks of gestation and provided proactive neonatal treatment were included. No articles were excluded for study design or risk of bias. The pooled prevalence of survival was 29.0% (95% confidence interval, 17.2-41.6; 31 studies, 2226 infants; I2=79.4%; Luis Furuya-Kanamori index=0.04). Survival among infants born to mothers receiving antenatal corticosteroids was twice the survival of infants born to mothers not receiving antenatal corticosteroids (39.0% vs 19.5%; P<.01). The overall prevalence of survival without major morbidity, using a definition that includes any bronchopulmonary dysplasia, was 11.0% (95% confidence interval, 8.0-14.3; 10 studies, 374 infants; I2=0%; Luis Furuya-Kanamori index=3.02). The overall rate of survival without moderate or severe impairment was 37.0% (95% confidence interval, 14.6-61.5; 5 studies, 39 infants; I2=45%; Luis Furuya-Kanamori index=-0.15). Based on the year of publication, survival rates increased between 2000 and 2020 (slope of the regression line=0.09; standard error=0.03; P<.01). Studies were highly diverse with regard to interventions and outcomes reported. CONCLUSION: The reported survival rates varied greatly among studies and were likely influenced by combining observational data from disparate sources, lack of individual patient-level data, and bias in the component studies from which the data were drawn. Therefore, pooled results should be interpreted with caution. To answer fundamental questions beyond the breadth of available data, multicenter, multidisciplinary collaborations, including alignment of important outcomes by stakeholders, are needed.

Discrepancies in Physician and Coroner Findings in Cases of Fatal Suspected Physical Child Abuse.

OBJECTIVES: As mandated reporters of suspected abuse, physicians must consider abuse when a child dies unexpectedly. Subsequently, a coroner or medical examiner determines the manner of death (MOD) and cause of death (COD). Accurate diagnoses and determinations are important for social safety and justice. This study described discrepancies between physicians' and coroners' findings in cases of fatal suspected physical child abuse. METHODS: This study was a single-institution, retrospective review. All children 6 years or younger who died in a pediatric emergency department from October 2006 to January 2013 with a coroner report were included in this study. Coroner reports, MODs, and CODs were reviewed. Skeletal survey results were compared with coroners' findings. RESULTS: One hundred twenty-nine children were included. The MODs included the following: undetermined, 63 (49%); accident, 32 (25%); natural, 31 (24%); and homicide, 3 (2%). Thirty-three (26%) of the 129 patients had abuse suspected at the time of death in the emergency department; in this subset, MODs were as follows: undetermined, 16 (48%); accident, 8 (24%); natural, 6 (18%); and homicide, 3 (9%). Sudden infant death syndrome or sudden unexpected death was the most common COD in all children (68, 55%). Skeletal surveys were positive in 12 children with 29 fractures identified; 8 (28%) of the 29 fractures were corroborated on autopsy findings. Of the 12 children with positive skeletal survey findings, only 1 was ruled a homicide. CONCLUSIONS: We found discrepancies between coroner determination of homicide and abuse suspected by physicians, especially among children with fractures. Improved communication between agencies in cases of fatal child abuse is needed.

Validation of the Ask Suicide-Screening Questions for Adult Medical Inpatients: A Brief Tool for All Ages.

BACKGROUND: Few brief suicide risk screening instruments are validated for use in both adult and pediatric medical populations. Using the pediatric Ask Suicide-Screening Questions (ASQ) development study as a model, this study aimed to determine whether the ASQ is a valid suicide risk-screening instrument for use among adults medical patients, as well as to evaluate a set of other potential screening questions for use in adults. METHODS: Adult patients hospitalized on inpatient medical/surgical units from 4 hospitals were recruited to participate in a cross-sectional instrument-validation study. The 4-item ASQ and other candidate items were compared against the 25-item, previously validated Adult Suicidal Ideation Questionnaire as the criterion standard. RESULTS: A total of 727 adult medical inpatients completed the screening process. Compared with the Adult Suicidal Ideation Questionnaire, the ASQ performed best among the full set of candidate items, demonstrating strong psychometric properties, with a sensitivity of 100% (95% confidence interval = 90%-100%), a specificity of 89% (95% confidence interval = 86%-91%), and a negative predictive value of 100% (95% confidence interval = 99%-100%). A total of 4.8% (35/727) of the participants screened positive for suicide risk based on the standard criterion Adult Suicidal Ideation Questionnaire. CONCLUSIONS: The ASQ is a valid and brief suicide risk-screening tool for use among adults. Screening medical/surgical inpatients for suicide risk can be performed effectively for both adult and pediatric patients using this brief, primary screener.

Emotion Regulation in Elementary School-Aged Children with a Maternal History of Suicidal Behavior: A Pilot Study.

Parental history of suicidal behavior is associated with an increased risk of early onset suicidal behavior in their offspring. The objective of this pilot study was to compare clinical characteristics, temperament, and emotion regulation in children, aged 6-9 years, with (PH+) and without (PH-) a maternal history of suicidal behavior to determine which factors could be markers of early vulnerability. At baseline, PH+ children, compared to PH- children, demonstrated more difficulties with temperament, emotion regulation, and experienced more life events in the year prior to their baseline appointment. At study follow-ups, however, no differences were found between PH+ and PH- children. Results suggest there are some signals of early vulnerability present in children with a maternal history of suicidal behavior and recruitment/retention of this group of youth is feasible.

Predicting 3-month risk for adolescent suicide attempts among pediatric emergency department patients.

BACKGROUND: The incidence of adolescent suicide is rising in the United States, yet we have limited information regarding short-term prediction of suicide attempts. Our aim was to identify predictors of suicide attempts within 3-months of an emergency department (ED) visit. METHODS: Adolescents, ages 12-17, seeking health care at 13 pediatric EDs (Pediatric Emergency Care Applied Research Network) and one Indian Health Service Hospital in the United States were consecutively recruited. Among 10,664 approached patients, 6,448 (60%) were enrolled and completed a suicide risk survey. A subset of participants (n = 2,897) was assigned to a 3-month telephone follow-up, and 2,104 participants completed this follow-up (73% retention). Our primary outcome was a suicide attempt between the ED visit and 3-month follow-up. RESULTS: One hundred four adolescents (4.9%) made a suicide attempt between enrollment and 3-month follow-up. A large number of baseline predictors of suicide attempt were identified in bivariate analyses. The final multivariable model for the full sample included the presence of suicidal ideation during the past week, lifetime severity of suicidal ideation, lifetime history of suicidal behavior, and school connectedness. For the subgroup of adolescents who did not report recent suicidal ideation at baseline, the final model included only lifetime severity of suicidal ideation and social connectedness. Among males, the final model included only lifetime severity of suicidal ideation and past week suicidal ideation. For females, the final model included past week suicidal ideation, lifetime severity of suicidal ideation, number of past-year nonsuicidal self-injury (NSSI) incidents, and social connectedness. CONCLUSIONS: Results indicate that the key risk factors for adolescent suicide attempts differ for subgroups of adolescents defined by sex and whether or not they report recent suicidal thoughts. Results also point to the importance of school and social connectedness as protective factors against suicide attempts.

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.

Innovations in Practice: Intensive crisis intervention for adolescent suicidal ideation and behavior - an open trial.

BACKGROUND: Adolescent suicide is a major public health concern worldwide. However, evidence regarding the effectiveness of interventions targeting youth suicide risk is limited. The purpose of this study was to assess the feasibility, acceptability, and clinical outcomes of Intensive Crisis Intervention (ICI), a cognitive-behavioral, family-centered treatment that provides an alternative to longer inpatient care. METHOD: Intensive Crisis Intervention was piloted over a two-year period with 50 adolescents (Mage  = 15.1 years; 86% Female; 78% Caucasian) admitted to an intensive crisis stabilization unit presenting with suicidal ideation and/or attempts. Data were collected at admission, 30 days, and 3 months post-admission to evaluate changes in suicidal ideation and functioning over time. RESULTS: Follow-up data were provided by 88% of study participants. At 3 months, the mean Suicidal Ideation Questionnaire-Junior score improved 34.2 points relative to baseline (effect size of 2.2, p < .0001). Significant improvements in functioning, high rates of consumer satisfaction and readiness for care transition upon discharge were also reported. CONCLUSION: Study findings set the stage for a larger, randomized controlled trial to examine the efficacy of ICI in targeting suicidal ideation and behavior in adolescents.

Mental Health after Unintentional Injury in a Pediatric Managed-Medicaid Population.

OBJECTIVES: The purpose of this study was to compare the rates of mental health diagnoses and psychotropic prescriptions pre- and posthospitalization for injury in a managed-Medicaid population. We hypothesized that children have increased rates of mental health diagnoses and psychotropic prescriptions after injury. STUDY DESIGN: We investigated children (n = 2208) ≤18 years of age treated at a pediatric trauma center from 2005 to 2015 who were enrolled in a managed-Medicaid program at hospital admission and for at least 1 healthcare visit in the preceding year. We used Poisson regression models to estimate rates of mental health diagnoses and psychotropic prescriptions that occurred in the 12 months pre- and postinjury. RESULTS: The rate of mental health diagnoses preinjury was 95.9 per 1000 person-years, which increased to 156.7 per 1000 postinjury (rate ratio [RR] 1.63, 95% CI 1.39-1.92). Children ages 0-4 years with burns were more likely to have mental health diagnoses postinjury (race and ethnicity adjusted RR [aRR] 8.56, 95% CI 3.30-22.2). Children with head injuries were also more likely to have mental health diagnoses postinjury: ages 0-4 years (aRR 3.87, 95% CI 1.31-11.5); ages 5-9 (aRR 3.11, 95% CI 1.27-7.59); ages 10-14 (aRR 2.17, 95% CI 1.27-3.73); and ages 15-18 (aRR 5.37, 95% CI 2.12-13.6). The rate of psychotropic prescriptions preinjury was 121.7 per 1000 person-years and increased to 310.9 per 1000 postinjury (RR 2.55, 95% CI 2.26-2.89). CONCLUSIONS: We identified increased mental health diagnoses and psychotropic prescriptions in children following hospitalization for injury.

Mapping suicide mortality in Ohio: A spatial epidemiological analysis of suicide clusters and area level correlates.

Previous studies have investigated spatial patterning and associations of area characteristics with suicide rates in Western and Asian countries, but few have been conducted in the United States. This ecological study aims to identify high-risk clusters of suicide in Ohio and assess area level correlates of these clusters. We estimated spatially smoothed standardized mortality ratios (SMR) using Bayesian conditional autoregressive models (CAR) for the period 2004 to 2013. Spatial and spatio-temporal scan statistics were used to detect high-risk clusters of suicide at the census tract level (N=2952). Logistic regression models were used to examine the association between area level correlates and suicide clusters. Nine statistically significant (p<0.05) high-risk spatial clusters and two space-time clusters were identified. We also identified several significant spatial clusters by method of suicide. The risk of suicide was up to 2.1 times higher in high-risk clusters than in areas outside of the clusters (relative risks ranged from 1.22 to 2.14 (p<0.01)). In the multivariate model, factors strongly associated with area suicide rates were socio-economic deprivation and lower provider densities. Efforts to reduce poverty and improve access to health and mental health medical services on the community level represent potentially important suicide prevention strategies.

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.

Bullying and Suicide Risk Among Pediatric Emergency Department Patients.

OBJECTIVES: This study aimed to describe the association between recent bullying victimization and risk of suicide among pediatric emergency department (ED) patients. METHODS: Patients presenting to 1 of 3 different urban pediatric EDs with either medical/surgical or psychiatric chief complaints completed structured interviews as part of a study to develop a suicide risk screening instrument, the Ask Suicide-Screening Questions. Seventeen candidate items and the criterion reference Suicidal Ideation Questionnaire were administered to patients ages 10 to 21 years. Bullying victimization was assessed by a single candidate item ("In the past few weeks, have you been bullied or picked on so much that you felt like you couldn't stand it anymore?"). RESULTS: A total of 524 patients completed the interview (34.4% psychiatric chief complaints; 56.9% female; 50.4% white, non-Hispanic; mean [SD] age, 15.2 [2.6] years). Sixty patients (11.5%) reported recent bullying victimization, and of these, 33 (55.0%) screened positive for suicide risk on the Ask Suicide-Screening Questions or the previously validated Suicidal Ideation Questionnaire. After controlling for demographic and clinical variables, including a history of depression and drug use, the odds of screening positive for suicide risk were significantly greater in patients who reported recent bullying victimization (adjusted odds ratio, 3.19; 95% confidence interval, 1.66-6.11). After stratification by chief complaint, this association persisted for medical/surgical patients but not for psychiatric patients. CONCLUSIONS: Recent bullying victimization was associated with increased odds of screening positive for elevated suicide risk among pediatric ED patients presenting with medical/surgical complaints. Understanding this important correlate of suicide risk in pediatric ED patients may help inform ED-based suicide prevention interventions.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews.

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

Sleep problems and suicide attempts among adolescents: a case-control study.

This study used a case-control design to compare sleep disturbances in 40 adolescents who attempted suicide with 40 never-suicidal adolescents. Using hierarchical logistic regression analyses, we found that self-reported nighttime awakenings were significantly associated with attempted suicide, after controlling for antidepressant use, antipsychotic use, affective problems, and being bullied. In a separate regression analysis, the parent-reported total sleep problems score also predicted suicide attempt status, controlling for key covariates. No associations were found between suicide attempts and other distinct sleep problems, including falling asleep at bedtime, sleeping a lot during the day, trouble waking up in the morning, sleep duration, and parent-reported nightmares. Clinicians should be aware of sleep problems as potential risk factors for suicide attempts for adolescents.

Quality of care for Medicaid-enrolled youth with bipolar disorders.

This study examined conformance to clinical practice guidelines for children and adolescents with bipolar disorders and identified patient and provider factors associated with guideline concordant care. Administrative records were examined for 4,047 Medicaid covered youth aged 5-18 years with new episodes of bipolar disorder during 2006-2010. Main outcome measures included 5 claims-based quality of care measures reflecting national treatment guidelines. Measures addressed appropriate pharmacotherapy, therapeutic drug monitoring, and psychosocial treatment. The results indicated that current treatment practices for youth diagnosed with bipolar disorder typically fall short of recommended practice guidelines. Although the majority of affected youth are treated with recommended first-line pharmacotherapy, only a minority receive therapeutic drug monitoring and/or psychotherapy of recommended duration, underscoring the need for quality improvement initiatives.

Neuroimaging and Neurological Outcomes in Perinatal Arterial Ischemic Stroke: A Systematic Review and Meta-Analysis.

BACKGROUND: Prediction of outcomes in perinatal arterial ischemic stroke (PAIS) is challenging. We performed a systematic review and meta-analysis to determine whether infarct characteristics can predict outcomes in PAIS. METHODS: A systematic search was conducted using five databases in January 2023. Studies were included if the sample included children with neonatal or presumed PAIS; if infarct size, location, or laterality was indicated; and if at least one motor, cognitive, or language outcome was reported. The level of evidence and risk of bias were evaluated using the Risk of Bias in Non-Randomized Studies of Interventions tool. Meta-analyses were conducted comparing infarct size or location with neurological outcomes when at least three studies could be analyzed. RESULTS: Eighteen full-text articles were included in a systematic review with nine included in meta-analysis. Meta-analyses revealed that small strokes were associated with a lower risk of cerebral palsy/hemiplegia compared with large strokes (risk ratio [RR] = 0.263, P = 0.001) and a lower risk of epilepsy (RR = 0.182, P < 0.001). Middle cerebral artery (MCA) infarcts were not associated with a significantly different risk of cerebral palsy/hemiplegia compared with non-MCA strokes (RR = 1.220, P = 0.337). Bilateral infarcts were associated with a 48% risk of cerebral palsy/hemiplegia, a 26% risk of epilepsy, and a 58% risk of cognitive impairment. CONCLUSIONS: Larger stroke size was associated with worse outcomes across multiple domains. Widely heterogeneous reporting of infarct characteristics and outcomes limits the comparison of studies and the analysis of outcomes. More consistent reporting of infarct characteristics and outcomes will be important to advance research in this field.

Alterations in performance and discriminating power of the death/suicide implicit association test across the lifespan.

The Death/Suicide Implicit Association Test (d/s-IAT) has differentiated individuals with prior and prospective suicide attempts in previous studies, however, age effects on test results remains to be explored. A three-site study compared performance on the d/s-IAT among participants aged 16-80 years with depression and prior suicide attempt (n = 82), with depression and no attempts (n = 80), and healthy controls (n = 86). Outcome measures included the standard difference (D) score, median reaction times, and error rates. Higher D scores represent a stronger association between death/suicide and self, while lower scores represent a stronger association between life and self. The D scores differed significantly among groups overall. Participants with depression exhibited higher scores compared to healthy controls, but there was no difference between participants with and without prior suicide attempts(F[2,242]=8.76, p<.001). Response times for participants with prior attempts differed significantly from other groups, with no significant differences in error rates. The D score was significantly affected by age (ß =-0.007, t = 3.65, p<.001), with slowing of response times in older ages. Results suggest reaction time d/s-IAT D scores may not distinguish implicit thinking about suicide as response times slow with age, but slowed response times may be sensitive to suicide risk potentially indicating basic information processing deficits.

Identifying Subgroups of Youth Suicide Decedents Based on Clinical Profiles of Psychiatric and Medical Diagnoses: A Latent Class Analysis.

PURPOSE: To identify risk subgroups of youth suicide decedents using demographic and clinical psychiatric and medical diagnostic profiles to inform tailored youth suicide prevention efforts. METHODS: This study linked Ohio Medicaid and death certificate data for Medicaid enrolled youth aged 8-25 years who died by suicide between January 1, 2010, and December 31, 2020 (N = 511). Latent class analysis was used to identify distinct clinical risk subgroups. RESULTS: Three latent classes were identified. Internalizing problems were common across all classes, but especially prevalent in class 1, the High Internalizing + Multiple Comorbidities group (n = 152, 30%). A prior history of suicidal behavior was confined to class 1 decedents, who were otherwise characterized by substance misuse, and multiple psychiatric and medical comorbidities. Class 2 decedents, the Internalizing + Externalizing group (n = 176, 34%), were more often younger, male, Black, and unlikely to have a history of substance misuse. Decedents in class 3, the Internalizing + Substance Misuse group (n = 183, 36%), were more often older and likely to have a history of substance misuse, but unlikely to exhibit other externalizing problems. DISCUSSION: Internalizing psychopathology is particularly common among youth who die by suicide, with comorbid externalizing psychopathology, substance misuse, and medical problems contributing to youth suicide risk. Because less than a third of youth who die by suicide have a prior history of recognized suicidal thinking or behavior, universal screening for youth suicide risk should be considered, particularly in younger children, and efforts to integrate suicide prevention in traditional health care settings should be prioritized.