Prevalence and Characteristics of Self-Harm in Adolescents: Meta-Analyses of Community-Based Studies 1990-2015.

OBJECTIVE: To provide meta-analytic estimates of self-harm from all community-based studies of adolescents from 1990 through 2015, estimates of suicidal risk, and characteristics including age profile, frequency, types, seeking help, and reasons. METHOD: Databases, bibliographies, and the internet were searched for cross-sectional and cohort studies of 12- to 18-year-olds. Meta-analytic estimates of the prevalence and characteristics of self-harm, risk of suicidal behaviors, and rates comparing different methods were calculated. RESULTS: One hundred seventy-two datasets reporting self-harm in 597,548 participants from 41 countries were included. Overall lifetime prevalence was 16.9% (95% CI 15.1-18.9), with rates increasing to 2015. Girls were more likely to self-harm (risk ratio 1.72, 95% CI 1.57-1.88). The mean age of starting self-harm was 13 years, with 47% reporting only 1 or 2 episodes and cutting being the most common type (45%). The most frequent reason was relief from thoughts or feelings. Slightly more than half sought help, but for most this was from a friend. Suicidal ideation (risk ratio 4.97) and attempts (risk ratio 9.14) were significantly higher in adolescents who self-harmed, but this was higher with more frequent self-harm. Methodologic factors also were associated with higher rates of self-harm. CONCLUSION: Interventions that can lower suicidal risk should be made available to adolescents who self-harm frequently as soon as possible. Preventative interventions that help adolescents deal with negative feelings should be instituted at the onset of puberty. Because friends are frequently asked for support, interventions also should be developed for peer groups.

Externalizing and attentional behaviors in children of depressed mothers treated with a selective serotonin reuptake inhibitor antidepressant during pregnancy.

OBJECTIVE: To evaluate attentional and activity behaviors in 4-year-olds following prenatal selective serotonin reuptake inhibitor (SSRI) exposure. DESIGN: Prospective cohort design. SETTING: Tertiary care center. PARTICIPANTS: Twenty-two 4-year-olds with prolonged prenatal SSRI medication exposure and 14 children without prenatal exposure. MAIN EXPOSURE: Prenatal SSRI exposure. MAIN OUTCOME MEASURES: Group differences in externalizing behaviors (according to the Child Behavior Checklist) and direct observations of child attention, activity, and impulsiveness in a laboratory setting using the procedure by Crowell and colleagues were compared, including measures of the duration of prenatal SSRI exposure, umbilical cord drug levels, a history of poor neonatal adaptation, and maternal mood. RESULTS: Externalizing behaviors did not differ between groups. Maternal depression and anxiety at the 4-year follow-up were associated with increased reports of externalizing behaviors. Increased externalizing behaviors were associated with increased umbilical cord drug levels (F(1,34) = 6.3; P = .02), but when controlling for maternal depressed mood at the 4-year follow-up, such levels only accounted for 11.2% of the behavioral outcomes (P>.05). On direct observation, the persistence score for child behavior was significantly lower in the exposed group. Increased aggressiveness scores were associated with a history of poor neonatal adaptation, even when parental report of stress was added to the model (F(1,34) = 4.0; P = .03); however, neither parental report of stress nor poor neonatal adaptation were significant (both P = .09), suggesting that both are important, if not unique, predictors of child behavior. CONCLUSIONS: These findings suggest that the best predictors of externalizing behaviors at age 4 years are current maternal mood and parental stress, regardless of prenatal depressed mood and SSRI treatment during pregnancy. It remains uncertain whether poor neonatal adaptation can be excluded as a possible predictor of externalizing behaviors.

Internalizing behaviors in 4-year-old children exposed in utero to psychotropic medications.

OBJECTIVE: Internalizing behaviors in children between 4 and 5 years of age who had been prenatally exposed to psychotropic medications were investigated. The authors had previously reported the effects of prenatal medication exposure in this same cohort when they were newborns and infants at 3 and 8 months of age. METHOD: Parental/teacher reports and a clinical measure of mother and child interactions were used to assess levels of internalizing behaviors (e.g., depression, anxiety, withdrawal). Outcomes were compared between children with prenatal selective serotonin reuptake inhibitor (SSRI) exposure (N=22) and nonexposed children of healthy, nondepressed, nonmedicated mothers (N=14). Measures of maternal mood were obtained. Ordered logistic regressions, independent-sample t tests, and univariate ANOVAs were used to compare outcomes between groups. Pearson correlations were used to determine associations between maternal mood and child behaviors. RESULTS: Levels of internalizing behaviors did not differ significantly between children with prenatal psychotropic medication exposure and those not exposed. However, as symptoms of maternal anxiety and depression increased, so did reported internalizing behaviors in their children. CONCLUSIONS: Prenatal exposure to psychotropic medications was not associated with increased reports of internalizing behaviors at 4 years of age, whereas impaired maternal mood did have an identified impact on child behavior. Further study of complex associations between maternal psychiatric disorders, prenatal SSRI exposure, and childhood internalizing behaviors is required to understand if the child outcome is affected by the illness, medications, or a combination of both.

The impact of treatment intervention on parenting stress in postpartum depressed mothers: a prospective study.

The aim of this study was to evaluate whether treatment intervention for postpartum depression impacted maternal parenting stress levels. Twenty-three mothers referred for postpartum mood and anxiety disorder to an outpatient program were included in the study. Statistically and clinically significant decreases in levels of parenting stress were evident at the end of the treatment. Subjects' perceptions of their parenting characteristics were found to be a major contributor to stress levels. In addition to monitoring of depressive symptoms, routine assessment of maternal parenting qualities is recommended to ensure healthy child outcomes.

The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial.

BACKGROUND: Approximately 10% to 16% of women experience a major depressive episode after childbirth. A significant proportion of these women also suffer from comorbid anxiety disorders. The purpose of this study was to evaluate whether the addition of cognitive-behavioral therapy (CBT) to standard antidepressant therapy offers additional benefits in the treatment of post-partum depression with comorbid anxiety disorders. METHOD: Thirty-five women referred to a tertiary care hospital outpatient program with a DSM-IV diagnosis of postpartum depression with comorbid anxiety disorder were randomly assigned to 1 of 2 treatment groups-paroxetine-only monotherapy group (N = 16) or paroxetine plus 12 sessions of CBT combination therapy group (N = 19)-for a 12-week trial. Progress was monitored by a psychiatrist blinded to treatment group, using the Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety, Yale-Brown Obsessive Compulsive Scale, Clinical Global Impressions scale, and Edinburgh Postnatal Depression Scale. Data were analyzed using 2-tailed statistical tests at an alpha level of.05. The study was conducted from April 1, 2002, to June 30, 2003. RESULTS: Both treatment groups showed a highly significant improvement (p <.01) in mood and anxiety symptoms. Groups did not differ significantly in week of recovery, dose of paroxetine at remission, or measures of depression, anxiety, and obsessive-compulsive symptoms at outcome. CONCLUSION: Antidepressant monotherapy and combination therapy with antidepressants and CBT were both efficacious in reducing depression and anxiety symptoms. However, in this sample of acutely depressed/anxious postpartum women, there were no additional benefits from combining the 2 treatment modalities. Further research into the efficacy of combination therapy in the treatment of moderate-to-severe depression with comorbid disorders in postpartum women is recommended.

Affect Expression and Self-Regulation Capacities of Infants Exposed in utero to Psychotropics.

This study explored the affect expression and self-regulation capacities of 8-month-old infants exposed in utero to psychotropic medications. This was a continuation of our previous study conducted on the same cohort when the infants were 3 months old. Psychotropics implicated included selective serotonin reuptake inhibitors (SSRIs), and a benzodiazepine derivative anxiolytic (clonazepam). The three comparison groups were: control (n = 23; infants not exposed to psychotropics in utero), SSRI-alone (n = 22; infants exposed to SSRIs only and having mothers who had a primary diagnosis of depressive disorder without having comorbid anxiety disorder), and SSRI+ group (n = 15; infants gestationally exposed to SSRIs and clonazepam and having mothers that had both clinical depression and anxiety disorder). Using the Parent-Child Early Relational Assessment Scale, infants were assessed in a dyadic context during free play and a structured task. There were significant differences in psychotropic exposed and non-exposed dyads regarding infant negative affect management. There were significant associations between the SSRI+ group of mothers and infant negative affect. This group of mothers also showed significant associations with infants' averting and avoiding behaviors in both play situations. The SSRI-alone group was similar to the control group and showed variable associations with infant's positive, negative, and sober moods unlike the SSRI+ group. There were no differences in infants' capacity for self-regulation in psychotropic exposed and non-exposed groups. Increased awareness of these vulnerable subgroups (SSRI-alone and SSRI+) is needed, in order to safeguard these dyads through better support systems and improved management.

The role of pharmacotherapy in the management of self-regulation difficulties in young children.

OBJECTIVE: To review adjunctive pharmacotherapeutic options in the management of self-regulation difficulties in young children. METHODS: Review of available literature and clinical experience pertaining to use of psychiatric medications in preschool aged children (under age 6). RESULTS: Relatively few medications are approved for use in preschool aged children. Pharmacotherapy in this age group may include melatonin for sleep disorders, psychostimulants for Attention Deficit/Hyperactivity Disorder (ADHD), selective serotonin reuptake inhibitors (SSRI), second-generation antipsychotics, mood stabilizers and alpha-agonists. Medication efficacy and adverse effects in this age group are poorly characterized and limited by lack of age-appropriate monitoring scales and published clinical experience. CONCLUSION: As an adjunctive measure, pharmacotherapy is sometimes warranted in young children who are unable to self-regulate their physiological, emotional and behavioural responses.

Aggression during early years - infancy and preschool.

INTRODUCTION: This review explores the meaning and origins of aggression in early years. Eight pathways to aggression with origins in early childhood are suggested. These include: the contribution of individual factors; the effects of disturbed family dynamics; parental characteristics and parenting practices; the impact of exposure to violence and the influence of attachment relationships. Other influences such as: aggression relating to psychiatric/medical syndromes; the influence of neurodevelopment pathways and psychodynamic explanations, such as aggressive behavior in relation to mothers' reflective capacity are also discussed. CONCLUSION: While several routes to aggression have been proposed, no single factor is sufficient to explain the development of aggressive behavior. Longitudinal studies are sorely needed to observe aggressive behavior in children and to monitor their developmental trajectories.

Relation between prenatal maternal mood and anxiety and neonatal health.

OBJECTIVE: To examine the relation between the mood and anxiety of pregnant, psychiatrically treated women and neonatal health outcomes after birth. METHOD: We prospectively assessed 46 women treated with psychotropic medications for anxiety and depression during pregnancy. We compared measures of maternal mental health with infant outcomes, in particular, the outcomes of infants with symptoms of poor neonatal adaptation. RESULTS: The mothers of babies who demonstrated poor neonatal adaptation reported higher levels of anxiety and depression at study entry than did the mothers of healthy babies. This relation was not related to the presence or absence of treatment with clonazepam, an anxiolytic used to treat symptoms of anxiety. Further, increased psychiatric comorbidity in the mother was associated with a greater likelihood of transient symptoms in the newborn. CONCLUSIONS: Despite psychiatric treatment, the intensity and degree of comorbid symptoms appear to be related to poor transient neonatal health outcome. Our data suggest that, in addition to the impact of pharmacologic factors, maternal psychiatric status influences infant outcomes.