Suicide and Self-Harm in Adolescents During the COVID-19 Pandemic: A U.S. Virtual Pediatric Systems, LLC, Database Study of PICU Admissions, 2016-2021.

OBJECTIVES: To characterize the epidemiology of suicide and self-harm among adolescents admitted to PICUs during the first 2 years of the COVID-19 pandemic in the United States. DESIGN: Descriptive analysis of a large, multicenter, quality-controlled database (Virtual Pediatric Systems [VPS]), and of a national public health dataset (U.S. Centers for Disease Control and Prevention web-based Wide-ranging ONline Data for Epidemiology Research [CDC WONDER]). SETTING: The 69 PICUs participating in the VPS database that contributed data for the entire the study period, January 1, 2016, to December 31, 2021. PATIENTS: Adolescents older than 12 years to younger than 18 years old admitted to a participating PICU during the study period with a diagnosis involving self-harm or a suicide attempt (VPS sample), or adolescent suicide deaths over the same period (CDC WONDER sample). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 10,239 suicide deaths and 7,692 PICU admissions for self-harm, including 5,414 admissions in the pre-pandemic period (Q1-2016 to Q1-2020) and 2,278 in the pandemic period (Q2-2020 to Q4-2021). Compared with the pre-pandemic period, there was no increase in the median (interquartile range) number of suicide deaths per quarter (429 [399-453] vs. 416 [390-482]) or PICU admissions for self-harm per quarter (315 [289-353] vs. 310 [286-387]) during the pandemic period, respectively. There was an increase in the ratio of self-harm PICU admissions to all-cause PICU admissions per quarter during the pandemic (1.98 [1.43-2.12]) compared with the pre-pandemic period per quarter (1.59 [1.46-1.74]). We also observed a significant decrease in all-cause PICU admissions per quarter early in the pandemic compared with the pre-pandemic period (16,026 [13,721-16,297] vs. 19,607 [18,371-20,581]). CONCLUSIONS: The number of suicide deaths and PICU admissions per quarter for self-harm remained relatively constant during the pandemic, while the number of all-cause PICU admissions per quarter decreased compared with the pre-pandemic period. The resultant higher ratio of self-harm admissions to all-cause PICU admissions may have contributed to the perception that more adolescents required critical care for mental health-related conditions early in the pandemic.

Youth mental health-related presentations at a quaternary centre: Who comes, What are their needs, and Can we meet their needs.

Background: Mental health issues are increasingly prevalent across Canada, reflected in rising presentations to emergency departments. To effectively address the needs of children and youth seeking mental health-related care in the emergency department and to judiciously use scarce mental health-related resources, we need to better identify the specific areas of psychosocial needs and accessibility of associated services. Objective: To describe the types and severity of paediatric mental health-related presentations evaluated at a quaternary paediatric emergency department, and to explore the accessibility of community mental health-related resources. Methods: We conducted a retrospective cohort study of children and youth presenting to a quaternary paediatric emergency department who were assessed using HEARTSMAP, a validated mental health assessment and management tool. We reported the proportion who sought care for a psychiatric, social, or youth health-related mental health complaint. We contacted community mental health-related resources for their estimated wait times to determine accessibility. Results: Of 1,530 paediatric emergency presentations, 98.8% of patients had psychiatric issues (40.1% were severe), 78.0% of patients had social issues (17.1% were severe), and 71.5% had youth health issues (18.1% were severe). We contacted 123 community mental health-related resources. Community youth health and social services were somewhat accessible, with 50.0% and 38.7%, respectively, able to intake youth within a week of referral. Community psychiatric programs were least accessible, with 59.3% having wait times greater than 1 month. Conclusions: Many psychiatric concerns presenting in paediatric emergency departments have complex psychosocial challenges requiring non-psychiatric support. A need exists for improved accessibility to community psychiatric programs.

Utility of MyHEARTSMAP in Youth Presenting to the Emergency Department with Mental Health Concerns.

OBJECTIVES: To evaluate the utility of a digital psychological self-assessment tool, MyHEARTSMAP (scores on 10 sections: home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources), in youth presenting to the pediatric emergency department (ED) with a mental health concern. STUDY DESIGN: We conducted a prospective cohort study in 2 tertiary care pediatric EDs from December 2017 to October 2019. Youth 10-17 years old triaged for a mental health concern were screened and enrolled to complete MyHEARTSMAP on a mobile device. A clinician blinded to the MyHEARTSMAP assessment conducted their own assessment which was used as the reference standard. Utility was quantified as the sensitivity and specificity of MyHEARTSMAP in detecting psychiatric, social, youth health, and functional concerns. RESULTS: Among 379 eligible youth, 351 were approached and 233 (66.4%) families were enrolled. Sensitivity for youth MyHEARTSMAP self-assessments ranged from 87.4% in the youth health domain to 99.5% in the psychiatric domain for identifying any concern, and 33.3% in the social domain to 74.6% in the psychiatric domain for severe concerns. Specificity ranged from 66.7% in the psychiatric domain to 98.2% in the youth health domain for no or only mild concerns. CONCLUSIONS: Youth and guardian MyHEARTSMAP assessments are sensitive for detecting psychosocial concerns requiring follow-up beyond pediatric ED evaluation. Specificity for no or only mild concerns was high in the nonpsychiatric domains.

Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department.

OBJECTIVES: To evaluate the utility of universal psychosocial screening in the emergency department (ED) using MyHEARTSMAP, a digital self-assessment and management guiding tool. STUDY DESIGN: We conducted a cohort study of youth 10-17 years of age with nonmental health related presentations at 2 pediatric EDs. On randomly selected shifts (December 2017-February 2019), participants completed their psychosocial self-assessments using MyHEARTSMAP on a mobile device, then underwent a standardized clinical mental health assessment (criterion standard). We reported the sensitivity and specificity of respondents' self-assessment, against a clinician's standard emergency psychosocial assessment, and the frequency of psychosocial issues and recommended mental health resources identified by screening. RESULTS: We approached 1432 eligible youth, among which 795 youth consented to participate (55.5%). Youth and guardians' sensitivity at self-identifying psychiatric concerns was 92.7% (95% CI 89.1, 95.4%) and 93.1% (95% CI 89.5, 95.8%), respectively. In cases where clinicians had determined to be no psychiatric issues, 98.5% (95% CI 96.7, 99.4%) of youth and 98.9% (95% CI 97.3, 99.7%) of guardians identified the youth as having no or only mild issues. Screening identified 36.4% of youth as having issues in at least 1 psychosocial domain which warranted further follow-up. CONCLUSIONS: Psychosocial screening in EDs using MyHEARTSMAP can reliably be conducted using the MyHEARTSMAP self-assessment tool and over one-third of screened youth identified issues which can be directed to further care.

Provincial dissemination of HEARTSMAP, an emergency department psychosocial assessment and disposition decision tool for children and youth.

BACKGROUND: This article describes the provincial dissemination of HEARTSMAP, an evidence-based emergency department (ED) psychosocial assessment and disposition decision tool for clinician use with children and youth. METHODS: HEARTSMAP was disseminated in partnership with local, child and youth mental health teams, as part of a quality improvement initiative implemented in British Columbia EDs. The target audience of education sessions were clinicians working in ED settings responsible for paediatric psychosocial assessments. We used the RE-AIM framework to evaluate the reach, effectiveness, adoption, implementation, and maintenance of HEARTSMAP dissemination, analyzing data from session evaluation forms and online tool data. RESULTS: Education sessions reached 475 attendees, in 52 of 95 British Columbia EDs. HEARTSMAP training was well received by clinicians with 96% describing effective content including increased comfort in conducting paediatric psychosocial assessments and confidence in disposition planning after training. Clinicians identified unclear processes and lack of local resources as the main barriers to implementation. One-third of the attendees expressed willingness to use the tool, and 27% of registered clinicians have used the tool postimplementation. CONCLUSIONS: Our approach reached and effectively trained clinicians from over half of the province's EDs to use HEARTSMAP for emergency paediatric psychosocial assessments. For some, this provided greater comfort and confidence for these assessments and the following disposition decisions. This evaluation provides valuable insights on training clinicians to use a paediatric mental health tool within diverse ED settings and emphasized the need for ongoing support and institutional engagement to facilitate local, infrastructural, and operational processes for adoption and maintenance, postdissemination.

Trends in Pediatric Emergency Department Utilization for Mental Health-Related Visits.

OBJECTIVE: To describe trends in utilization of pediatric emergency department (PED) resources by patients with mental health concerns over the past 11 [corrected] years at a tertiary care hospital. STUDY DESIGN: We conducted a retrospective cohort study of tertiary PED visits from 2002 [corrected] to 2012. All visits with chief complaint or discharge diagnosis related to mental health were included. Variables analyzed included number and acuity of mental health-related visits, length of stay, waiting time, admission rate, and return visits, relative to non-mental health [corrected] PED visits. Descriptive statistics were used to summarize the results. RESULTS: We observed a 47% increase in the number of mental health presentations compared with a 27.5% [corrected] increase in the number of total visits to the PED over the study period. Return visits represented a significant proportion of all mental health-related visits (32.2% [corrected] yearly). The proportion of mental health visits triaged to a high acuity level has decreased whereas the proportion of visits triaged to the mid-acuity level has increased. Length of stay for psychiatric patients was significantly longer than for visits to the PED in general. We also observed a 53.7% [corrected] increase in the number of mental health-related visits resulting in admission. CONCLUSION: Mental health-related visits represent a significant and growing burden for the emergency department at a tertiary care PED. These results highlight the need to reassess the allocation of health resources to optimize acute management, risk assessment, and linkage to mental health services upon disposition from the PED.

Commentary: School closures, the pandemic, and pediatric mental health: Scrutinizing the evidence.

The COVID-19 pandemic arrived with significant hardship. The secondary impacts of the pandemic and our response with respect to pediatric mental health has been a subject of significant discussion in the lay public, media, and decision-maker groups. The initiatives to control SARS-CoV-2 have become politicized. A narrative emerged early that strategies to mitigate the spread of the virus were harming children's mental health. Position statements from professional organizations in Canada have been used to support this claim. The aim of this commentary is to provide a reanalysis of some of the data and research methodology used to support these position statements. Some of the direct claims such as "online learning is harmful," should be supported by a strong evidence base with significant consensus that speaks directly to causality. We find that the quality of the studies and the heterogeneity of the results does not support the strength of the unequivocal claims made by these position statements. In a sample of the current literature examining the issue, we find that outcomes range from improvements to deteriorations. Earlier studies relying on cross-sectional surveys typically have shown stronger negative effects than longitudinal cohort studies, which often have also shown groups of children experiencing no changes to measured mental health characteristics or groups that have experienced improvements. We argue it is imperative that policymakers use the highest quality evidence in making the best decisions. We as professionals must avoid discussing only one side of heterogeneous evidence.

La pandémie de la COVID-19 est arrivée avec des difficultés importantes. Les effets secondaires de la pandémie et notre réponse à l'égard de la santé mentale pédiatrique ont constitué un sujet de discussion significatif dans le public profane, les médias et les groupes de décideurs. Les initiatives de contrôle du SRAS-CoV-2 sont devenues politisées. Une histoire a émergé tôt disant que les stratégies pour atténuer la propagation du virus nuisaient à la santé mentale des enfants. Des énoncés de position des organisations professionnelles du Canada ont été utilisés pour soutenir cette revendication. Le présent commentaire vise à offrir une ré-analyse de certaines données et méthodologies de recherche utilisées pour soutenir ces énoncés de position. Certaines revendications directes comme « l'apprentissage en ligne est nuisible ¼ devraient être appuyées par une forte base de données probantes et un consensus significatif qui s'adresse directement à la causalité. Nous croyons que la qualité des études et l'hétérogénéité des résultats ne soutiennent pas la force des revendications sans équivoque faites par ces énoncés de position. Dans un échantillon de la littérature actuelle qui examine la question, nous constatons que les résultats vont des améliorations aux détériorations. Des études précédentes s'appuyant sur des sondages transversaux ont typiquement montré des effets négatifs plus forts que les études de cohorte longitudinales, qui ont aussi souvent montré des groupes d'enfants qui ne connaissent aucun changement des caractéristiques mesurées de la santé mentale ou des groupes qui ont connu des améliorations. Nous défendons qu'il est impératif que les décideurs utilisent les données probantes de la plus grande qualité en prenant les meilleures décisions. Nous, comme professionnels, devons éviter de ne discuter que d'un côté des données probantes hétérogènes.

Evaluating the psychosocial status of BC children and youth during the COVID-19 pandemic: A MyHEARTSMAP cross-sectional study.

BACKGROUND: Understanding the psychosocial status of children and adolescents during the COVID-19 pandemic is vital to the appropriate and adequate allocation of social supports and mental health resources. This study evaluates the burden of mental health concerns and the impact of demographic factors while tracking mental health service recommendations to inform community service needs. METHODS: MyHEARTSMAP is a digital self-assessment mental health evaluation completed by children and their guardian throughout British Columbia between August 2020 to July 2021. Severity of mental health concerns was evaluated across psychiatric, social, functioning, and youth health domains. Proportional odds modelling evaluated the impact of demographic factors on severity. Recommendations for support services were provided based on the evaluation. RESULTS: We recruited 541 families who completed 424 psychosocial assessments on individual children. Some degree of difficulty across the psychiatric, social, or functional domains was reported for more than half of children and adolescents. Older youth and those not attending any formal school or education program were more likely to report greater psychiatric difficulty. Girls experienced greater social concerns, and children attending full-time school at-home were more likely to identify difficulty within the youth health domain but were not more likely to have psychiatric difficulties. Considerations to access community mental health service were triggered in the majority (74%) of cases. CONCLUSIONS: Psychosocial concerns are highly prevalent amongst children and adolescents during the COVID-19 pandemic. Based on identified needs of this cohort, additional community health supports are required, particularly for higher risk groups.

Surface-Dwelling Aquatic Insects in Low-Energy Freshwater Environments Are Highly Impacted by Oil Spills and the Surface Washing Agent Corexit EC9580A Used in Oil Spill Response.

Physical impacts of diluted bitumen (dilbit) and the application of surface washing agents (SWAs) in freshwater have not been characterized for aquatic invertebrates. These compounds are known to reduce surface tension in feather and fur microstructures of birds and mammals, and are thus likely to affect the buoyancy of surface-dwelling aquatic insects. We evaluated impacts of fresh dilbit and a SWA on water striders (Metrobates sp.), which are surface-dwelling organisms that rely on fine-hair microstructures to remain buoyant. We report nominal sheen thickness values that cause 50% immobility in 48 h as determined from exposure studies in outdoor tanks. A comparison of our data with those from historic oil spill volumes in Canada and the United States in the past 12 yr indicates that our reported nominal sheen thicknesses could have been reached or exceeded in 99% of historic spills when scaled to a small reference lake. The addition of Corexit EC9580A, a SWA approved for marine use in Canada, led to 100% immobility in striders within minutes, both in combination with oil and alone. Our study reveals an acute sensitivity to Corexit EC9580A and dilbit by surface-dwelling insects and may be driven by disruption of mechanisms of buoyancy. We highlight a need to evaluate physical impacts, typically excluded from standard toxicity testing, within the context of spill impact mitigation assessments. Environ Toxicol Chem 2021;40:1298-1307. © 2020 SETAC.

Using zooplankton metabarcoding to assess the efficacy of different techniques to clean-up an oil-spill in a boreal lake.

Regulators require adequate information to select best practices with less ecosystem impacts for remediation of freshwater ecosystems after oil spills. Zooplankton are valuable indicators of aquatic ecosystem health as they play pivotal roles in biochemical cycles while stabilizing food webs. Compared with morphological identification, metabarcoding holds promise for cost-effective, high-throughput, and benchmarkable biomonitoring of zooplankton communities. The objective of this study was to apply DNA and RNA metabarcoding of zooplankton for ecotoxicological assessment and compare it with traditional morphological identification in experimental shoreline enclosures in a boreal lake. These identification methods were also applied in context of assessing response of the zooplankton community exposed to simulated spills of diluted bitumen (dilbit), with experimental remediation practices (enhanced monitored natural recovery and shoreline cleaner application). Metabarcoding detected boreal zooplankton taxa up to the genus level, with a total of 24 shared genera, and while metabarcoding-based relative abundance served as an acceptable proxy for biomass inferred by morphological identification (ρ ≥ 0.52). Morphological identification determined zooplankton community composition changes due to treatments at 11 days post-spill (PERMANOVA, p = 0.0143) while metabarcoding methods indicated changes in zooplankton richness and communities at 38 days post-spill (T-test, p < 0.05; PERMANOVA, p ≤ 0.0429). Shoreline cleaner application overall seemed to have the largest impact on zooplankton communities relative to enhanced monitored natural recovery, regardless of zooplankton identification method. Both metabarcoding and morphological identification were able to discern the differences between the two experimental remediation practices. Metabarcoding of zooplankton could provide informative results for ecotoxicological assessment of the remediation practices of dilbit, advancing our knowledge of best practices for remediating oil-impacted aquatic ecosystems while serving to accelerate the assessment of at-risk freshwater ecosystems.

Simulating diluted bitumen spills in boreal lake limnocorrals - Part 1: Experimental design and responses of hydrocarbons, metals, and water quality parameters.

Large-scale, in-lake enclosures (limnocorrals) were used to simulate spills of diluted bitumen (dilbit) in a boreal lake. In this study we use these simulated spills, which covered a range of sizes (oil:water ratio) representative of the upper 25% of onshore crude oil spills in North America (2008-2019), to assess the fate of dilbit-derived hydrocarbons and metals as well as the impacts of the spills on standard water quality parameters. The systems were monitored over 70 days following the application of dilbit amounts ranging between 1.5 and 179.8 L into 10-m diameter, ~100 m3 limnocorrals. The concentration of total petroleum hydrocarbons (TPH) in the water column increased rapidly over the first two weeks reaching a plateau that ranged between 200 µg/L and 2200 µg/L for the lowest and highest treatment respectively. The concentration of total polycyclic aromatic compounds (PACs) also increased over the first two weeks, prior to a slow decrease until day 70. The maximum measured concentrations in the highest treatment were 2858 ng/L for the sum of all 46 quantified PACs, 2716 ng/L for alkylated PACs and 154 ng/L for the 16 EPA priority PAHs. The concentrations of PACs in the sediment increased continuously over the study in the three highest treatments with maximum observed concentrations of 189 ng/g for ΣPAC46, 169 ng/g for ΣPACalk. No significant treatment-related changes in the 16 EPA priority PAHs were observed in the sediment. Of the 25 metals quantified in the water column, only manganese, molybdenum, and vanadium displayed a significant treatment effect with increases of 280, 76 and 25% respectively in the total fraction. These results can help us understand and predict the fate of oil-derived contaminants following a spill and characterize the exposure of freshwater organisms living within them. These results should help inform the risk assessment of future dilbit transportation projects.

Outcome of pediatric emergency mental health visits: incidence and timing of suicide.

OBJECTIVES: To determine the incidence, risk, and timing of mortality (unnatural and natural causes) among youth seen in a pediatric emergency department (ED) for mental health concerns, compared with matched non-mental health ED controls. METHODS: This was a retrospective cohort study conducted at a quaternary pediatric ED in British Columbia. All visits for a mental health related condition between July 1st, 2005, and June 30th, 2015, were matched on age, sex, triage acuity, socioeconomic status, and year of visit to a non-mental health control visit. Mortality outcomes were obtained from vital statistics data through December 31st, 2016 (cumulative follow-up 74,390 person-years). RESULTS: Among all cases in our study, including 6,210 youth seen for mental health concerns and 6,210 matched controls, a total of 13 died of suicide (7.5/100,000 person-years) and 33 died of suicide or indeterminate causes (44/100,000 person-years). All-cause mortality was significantly lower among mental health presentations (121.3/100,000 v. 214.5/100,000 person-years; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.37-0.78). The median time from initial emergency visit to suicide was 5.2 years (interquartile range, 4.2-7.3). Among mental health related visits, risk of death by suicide or indeterminate cause was three-fold that of matched controls (HR, 3.05 95%CI, 1.37-6.77). CONCLUSIONS: While youth seeking emergency mental health care are at increased risk of death by unnatural causes, their overall mortality risk is lower than non-mental health controls. The protracted duration from initial presentation to suicide highlights the need for long-term surveillance and preventative care for youth seen in the ED for all mental health concerns.

A psychosocial assessment and management tool for children and youth in crisis.

OBJECTIVES: To evaluate the psychometric properties of HEARTSMAP, an emergency psychosocial assessment and management tool, and its impact on patient care and flow measures. METHODS: We conducted the study in two phases: first validating the tool using extracted information from a retrospective cohort, then evaluating implementation on a prospective cohort of youth presenting with mental health complaints to a tertiary Pediatric Emergency Department (PED). In phase 1, six PED clinicians applied HEARTSMAP to extracted narratives and we calculated inter-rater agreement for referral recommendations using Cohen's Kappa and the sensitivity and specificity for identifying youth requiring psychiatric consultation and hospitalization. In phase 2, PED clinicians prospectively used HEARTSMAP and we assessed the impact of the tool's implementation on patient-related outcomes and Emergency department (ED) flow measures. RESULTS: We found substantial agreement (κ=0.7) for cases requiring emergent psychiatric consultation and moderate agreement for cases requiring community urgent and non-urgent follow-up (κ=0.4 each). The sensitivity was 76% (95%CI: 63%, 90%) and specificity was 65% (95%CI: 55%, 71%) using retrospective cases. During pilot implementation, 62 patients received HEARTSMAP assessments: 46 (74%) of HEARTSMAP assessments triggered a recommendation for ED psychiatry assessment, 39 (63%) were evaluated by psychiatry and 13 (21%) were admitted. At follow-up, all patients with HEARTSMAP's triggered recommendations had accessed community resources. For those hospitalized for further psychiatric care at their index or return visit within 30 days, 100% were initially identified by HEARTSMAP at the index visit as requiring ED psychiatric consultation. CONCLUSIONS: HEARTSMAP has strong reliability, and when applied prospectively is a safe and effective management tool.

MyHEARTSMAP: development and evaluation of a psychosocial self-assessment tool, for and by youth.

BACKGROUND: Paediatric mental health-related visits to the emergency department are rising. However, few tools exist to identify concerns early and connect youth with appropriate mental healthcare. Our objective was to develop a digital youth psychosocial assessment and management tool (MyHEARTSMAP) and evaluate its inter-rater reliability when self-administered by a community-based sample of youth and parents. METHODS: We conducted a multiphasic, multimethod study. In phase 1, focus group sessions were used to inform tool development, through an iterative modification process. In phase 2, a cross-sectional study was conducted in two rounds of evaluation, where participants used MyHEARTSMAP to assess 25 fictional cases. RESULTS: MyHEARTSMAP displays good face and content validity, as supported by feedback from phase 1 focus groups with youth and parents (n=38). Among phase 2 participants (n=30), the tool showed moderate to excellent agreement across all psychosocial sections (κ=0.76-0.98). CONCLUSIONS: Our findings show that MyHEARTSMAP is an approachable and interpretable psychosocial assessment and management tool that can be reliably applied by a diverse community sample of youth and parents.