Youth, caregiver and healthcare professional perspectives on planning the implementation of a trauma-informed care programme: A qualitative study.

AIMS: To explore youth, caregiver and staff perspectives on their vision of trauma-informed care, and to identify and understand potential considerations for the implementation of a trauma-informed care programme in an inpatient mental health unit within a paediatric hospital. DESIGN AND METHODS: We applied the Interpretive Description approach, guided by complexity theory and the Implementation Roadmap, and used Applied Thematic Analysis methods. FINDINGS: Twenty-five individuals participated in individual or group interviews between March and June 2022, including 21 healthcare professionals, 3 youth and 1 caregiver. We identified two overarching themes. The first theme, 'Understanding and addressing the underlying reasons for distress', related to participants' understanding and vision of TIC in the current setting comprising: (a) 'Participants' understanding of TIC'; (b) 'Trauma screening and trauma processing within TIC'; (c) 'Taking "a more individualized approach"'; (d) 'Unit programming'; and (e) "Connecting to the community". The second theme, 'Factors that support or limit successful TIC implementation' comprises: (a) 'The need for a broad "cultural shift"'; (b) 'The physical environment on the unit'; and (c) 'Factors that may limit successful implementation'. CONCLUSION: We identified five key domains to consider within trauma-informed care implementation: (a) the centrality of engagement with youth, caregivers and staff in trauma-informed care delivery and implementation, (b) trauma-informed care core programme components, (c) factors that may support or limit success in implementing trauma-informed care within the mental health unit and (d) hospital-wide and (e) the importance of intersectoral collaboration (partnering with external organizations and sectors). IMPACT: When implementing TIC, there is an ongoing need to increase clarity regarding TIC interventions and implementation initiatives. Youth, caregiver and healthcare professional participants shared considerations important for planning the delivery and implementation of trauma-informed care in their setting. We identified five key domains to consider within trauma-informed care implementation: (a) the centrality of relational engagement, (b) trauma-informed care programme components, (c) factors that may support or limit successful implementation of trauma-informed care within the mental health unit and (d) hospital-wide and (e) the importance of intersectoral collaboration. Organizations wishing to implement trauma-informed care should consider ongoing engagement with all relevant knowledge user groups throughout the process. REPORTING METHOD: Standards for Reporting Qualitative Research (SRQR). PATIENT OR PUBLIC CONTRIBUTION: The local hospital research institute's Patient and Family Advisory Committee reviewed the draft study methods and provided feedback.

Building Resilience and Attachment in Vulnerable Adolescents: The Feasibility of a Virtually Delivered Group Intervention for Adolescents with Suicidal Ideation and Their Caregivers.

Background: The COVID-19 pandemic required many interventions to be conducted virtually. Building Resilience and Attachment in Vulnerable Adolescents (BRAVA) is a group intervention designed for adolescents and their caregivers to reduce adolescent suicidal ideation (SI). Objective: We aimed to adapt BRAVA for virtual delivery and evaluate its acceptability and feasibility. Methods: We conducted an 8-week pre-post trial between October and December 2020. Six adolescents and six primary caregivers were recruited from a pediatric hospital in Ontario, Canada. Families completed a virtual intake and exit assessment together and 6 weekly BRAVA group sessions separately. Satisfaction feedback was collected after each group session and during their exit, and clinical outcomes were collected at intake and exit. Weekly team meetings were conducted to gather clinician feedback. Results: The study uptake rate was 42.9% of eligible participants. There were no dropouts. Adolescent and caregiver attendance rates for group sessions were high (median = 6). Most youth (83.4%) and caregivers (66.7%) reported that the virtual process worked well. All caregivers (100%) agreed they would participate in a virtual group session again, compared with youth (50%). Providers approved of the virtual adaptation but identified potential improvements (e.g., manual content, safety procedures). Adolescent SI decreased significantly post-treatment (Mpre = 50.7, Mpost = 29.7, p = 0.002). Conclusions: Virtual delivery of BRAVA is acceptable and feasible and may help reduce SI in adolescents. Uptake, retention, and satisfaction were high for adolescents and caregivers. Feedback collected will improve BRAVA for future evaluations, including a randomized controlled trial.

Trauma-Informed Care Interventions Used in Pediatric Inpatient or Residential Treatment Mental Health Settings and Strategies to Implement Them: A Scoping Review.

Trauma-informed care (TIC) is an approach to care emerging in research and in practice that involves addressing the needs of individuals with histories of trauma. The aim of this scoping review was to examine the current literature relating to TIC interventions used in pediatric mental health inpatient and residential settings. We sought to answer the following two research questions: (a) What are the TIC interventions used in pediatric inpatient and residential treatment mental healthcare settings and what are their components? and (b) What are the implementation goals and strategies used with these TIC interventions? We conducted this scoping review according to JBI (formerly Joanna Briggs Institute) methodology for scoping reviews. We included any primary study describing a TIC intervention that was implemented at a specific site which identified and described implementation strategies used. Of 1,571 identified citations and 54 full-text articles located by handsearching, 49 met the eligibility criteria and were included, representing 21 distinct TIC interventions. We present the reported aim, ingredients, mechanism, and delivery (AIMD) of TIC interventions as well as the implementation goals and strategies used, which varied in detail, ranging from very little information to more detailed descriptions. In the context of these findings, we emphasize the complexity of TIC and of TIC interventions, and the importance of identifying and clearly reporting TIC intervention goals, intervention details, and implementation strategies. We suggest applying intervention frameworks or reporting guidelines to support clear and comprehensive reporting, which would better facilitate replication and synthesis of published TIC interventions.

Validating existing clinical cut-points for the parent-reported Strengths and Difficulties Questionnaire in a large sample of Canadian children and youth. / Validation des seuils cliniques dans la version remplie par les parents du Questionnaire sur les points forts et les points faibles au sein d'un vaste échantillon d'enfants et de jeunes canadiens.

INTRODUCTION: The Strengths and Difficulties Questionnaire (SDQ), for assessing behavioural and emotional difficulties, has been used internationally as a screening measure for mental health problems. Our objective was to validate the existing (British) SDQ cut-points in a sample of Canadian children and youth, and develop new Canadian SDQ cut-points if needed. METHODS: This study includes data from children and youth aged 6 to 17 years from the Canadian Health Measures Survey (n = 3435) and outpatient records from the Children's Hospital of Eastern Ontario (n = 1075). The parent-reported SDQ data were collected. We adjusted the existing SDQ cut-points using a distributional and receiver-operating characteristic (ROC) curve approach. We subsequently calculated the sensitivity, specificity and diagnostic odds ratio of the existing and new SDQ clinical cut-points to determine whether the new cut-points had better clinical utility, using both analytic approaches. RESULTS: Our data show differences in the screening effectiveness between the existing British and the Canadian-specific clinical cut-points. Specificity is maximized using the Canadian distributional cut-points, improving the likelihood of identifying true negative results. The total SDQ score met the threshold for clinical utility (diagnostic odds ratio > 20) using both the existing and new cut-points; however, the individual scales did not reach clinical utility threshold using either cut-points. CONCLUSIONS: Future Canadian SDQ research should consider the new cut-points derived from our study population and the existing British cut-points to allow for historical and international comparisons.

A pediatric virtual care evaluation framework and its evolution using consensus methods.

BACKGROUND: The use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care. METHODS: We brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program. RESULTS: The resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program. CONCLUSIONS: This virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

Meeting the service needs of youth with and without a self-reported mental health diagnosis during COVID-19.

Background: The COVID-19 pandemic catalyzed major changes in how youth mental health (MH) services are delivered. Understanding youth's MH, awareness and use of services since the pandemic, and differences between youth with and without a MH diagnosis, can help us optimize MH services during the pandemic and beyond. Objectives: We investigated youth's MH and service use one year into the pandemic and explored differences between those with and without a self-reported MH diagnosis. Methods: In February 2021, we administered a web-based survey to youth, 12-25 years, in Ontario. Data from 1373 out of 1497 (91.72%) participants were analyzed. We assessed differences in MH and service use between those with (N=623, 45.38%) and without (N=750, 54.62%) a self-reported MH diagnosis. Logistic regressions were used to explore MH diagnosis as a predictor of service use while controlling for confounders. Results: 86.73% of participants reported worse MH since COVID-19, with no between-group differences. Participants with a MH diagnosis had higher rates of MH problems, service awareness and use, compared to those without a diagnosis. MH diagnosis was the strongest predictor of service use. Gender and affordability of basic needs also independently predicted use of distinct services. Conclusion: Various services are required to mitigate the negative effects of the pandemic on youth MH and meet their service needs. Whether youth have a MH diagnosis may be important to understanding what services they are aware of and use. Sustaining pandemic-related service changes require increasing youth's awareness of digital interventions and overcoming other barriers to care.

Contexte: La pandémie de la COVID-19 a catalysé des changements majeurs de la manière dont les services de santé mentale (SM) sont dispensés aux jeunes. Comprendre la SM des jeunes, la connaissance et l'utilisation des services depuis la pandémie, et les différences entre les jeunes avec et sans un diagnostic de SM peut nous aider à optimiser les services de SM durant la pandémie et au-delà. Objectifs: Nous avons investigué la SM et l'utilisation des services des jeunes un an après le début de la pandémie et exploré les différences entre ceux avec et sans un diagnostic de SM auto-rapporté. Méthodes: En février 2021, nous avons administré un sondage en ligne à des jeunes de 12 à 25 ans en Ontario. Les données de 1373 participants sur 1497 (91,72 %) participants ont été analysées. Nous avons évalué les différences de SM et d'utilisation des services entre ceux avec (N = 623, 45,38 %) et sans (N = 750, 54,62 %) un diagnostic de SM auto-rapporté. Les régressions logistiques ont servi à explorer le diagnostic de SM comme prédicteur de l'utilisation de services tout en contrôlant les confusions. Résultats: 86,73 % des participants ont rapporté une SM pire depuis la COVID-19, sans différences entre les groupes. Les participants ayant un diagnostic de SM avaient des taux plus élevés de problèmes de SM, de connaissance et d'utilisation des services comparé à ceux sans diagnostic. Le diagnostic de SM était le prédicteur le plus fort de l'utilisation de services. Le sexe et l'abordabilité des besoins de base prédisaient aussi indépendamment l'utilisation de services distincts. Conclusion: Divers services sont nécessaires pour atténuer les effets négatifs de la pandémie sur la SM des jeunes et répondre à leurs besoins de service. Savoir si les jeunes ont un diagnostic de SM peut être important pour comprendre quels services ils connaissent et utilisent. Soutenir les changements de services liés à la pandémie exige d'accroître la connaissance des jeunes des interventions numériques et de surmonter d'autres obstacles des soins.

Rate of adolescent inpatient admission for psychosis during the COVID-19 pandemic: A retrospective chart review.

AIM: Given the concerns for mental health (MH) impacts on children and adolescents during the COVID-19 pandemic, as well as the relative paucity of research in this field, this retrospective study compares the rate of paediatric inpatient MH admissions for psychosis for a period of 11 months before and during the pandemic. METHODS: We used administrative data to compare the rate and clinical characteristics of patients (<18 years) admitted to a psychiatric inpatient unit for a psychotic illness before (March 17, 2019 to February 17, 2020) and during (March 17, 2020 to February 17, 2021) the COVID-19 pandemic. RESULTS: Results showed a 66% increase in inpatient psychosis admissions from pre-pandemic rates. More males were admitted with psychosis during the pandemic. Age and length of hospitalization were not significantly different across time periods. CONCLUSIONS: Results highlight the importance of accessible MH care for paediatric patients with psychosis during the pandemic.

Peripheral and neural correlates of self-harm in children and adolescents: a scoping review.

BACKGROUND: Self-harm in children and adolescents is difficult to treat. Peripheral and neural correlates of self-harm could lead to biomarkers to guide precision care. We therefore conducted a scoping review of research on peripheral and neural correlates of self-harm in this age group. METHODS: PubMed and Embase databases were searched from January 1980-May 2020, seeking English language peer-reviewed studies about peripheral and neural correlates of self-harm, defined as completed suicide, suicide attempts, suicidal ideation, or non-suicidal self-injury (NSSI) in subjects, birth to 19 years of age. Studies were excluded if only investigating self-harm in persons with intellectual or developmental disability syndromes. A blinded multi-stage assessment process by pairs of co-authors selected final studies for review. Risk of bias estimates were done on final studies. RESULTS: We screened 5537 unduplicated abstracts, leading to the identification of 79 eligible studies in 76 papers. Of these, 48 investigated peripheral correlates and 31 examined neural correlates. Suicidality was the focus in 2/3 of the studies, with NSSI and any type of self-harm (subjects recruited with suicidality, NSSI, or both) investigated in the remaining studies. All studies used observational designs (primarily case-control), most used convenience samples of adolescent patients which were predominately female and half of which were recruited based on a disorder. Over a quarter of the specific correlates were investigated with only one study. Inter-study agreement on findings from specific correlates with more than one study was often low. Estimates of Good for risk of bias were assigned to 37% of the studies and the majority were rated as Fair. CONCLUSIONS: Research on peripheral and neural correlates of self-harm is not sufficiently mature to identify potential biomarkers. Conflicting findings were reported for many of the correlates studied. Methodological problems may have produced biased findings and results are mainly generalizable to patients and girls. We provide recommendations to improve future peripheral and neural correlate research in children and adolescents, ages 3-19 years, with self-harm.

Parenting during the COVID-19 pandemic: The sociodemographic and mental health factors associated with maternal caregiver strain.

INTRODUCTION: The COVID-19 pandemic has introduced new stressors for parents ("caregivers") that may affect their own and their child's mental health (MH). We explored self-reported levels of caregiver strain (parents' perceived ability to meet parenting demands), and the MH and sociodemographic factors of caregivers to identify predictors of strain that can be used to guide MH service delivery for families. METHODS: We administered a web-based survey to Ontario caregivers with a child between 4 and 25 years old, between April and June 2020. We analyzed information from 570 maternal caregivers on their sociodemographics, youngest (or only) child's MH, their own MH, and the degree of caregiver strain experienced since the pandemic. We used linear regressions (unadjusted and adjusted models) to explore the relationship between caregiver strain and sociodemographics, child MH and caregiver MH. RESULTS: Over 75% of participants reported "moderate-to-high" caregiver strain. More than 25% of caregivers rated their MH as "poor" and 20% reported moderate-to-severe anxiety. Forty-five percent of the variance in caregiver strain was accounted for by child age, caregiver anxiety, and multiple child and caregiver MH variables. Younger child age and higher caregiver anxiety were the greatest predictors of caregiver strain. CONCLUSION: We found a relationship between child age, child and caregiver MH variables, and caregiver strain. Given the interrelatedness of these factors, supporting caregivers' MH and lessening their role strain becomes critical for family well-being. Evidence-based individual, family, and public health strategies are needed to alleviate pandemic-related strain. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Risk of Mental Health Problems in Children and Youths Following Concussion.

IMPORTANCE: Concussion may exacerbate existing mental health issues. Little evidence exists on whether concussion is associated with the onset of new psychopathologies or long-term mental health problems. OBJECTIVE: To investigate associations between concussion and risk of subsequent mental health issues, psychiatric hospitalizations, self-harm, or suicides. DESIGN, SETTING, AND PARTICIPANTS: This population-based retrospective cohort study including children and youths aged 5 to 18 years with a concussion or orthopedic injury incurred between April 1, 2010, and March 31, 2020, in Ontario, Canada. Participants had no previous mental health visit in the year before the index event for cohort entry and no prior concussion or traumatic brain injury 5 years before the index visit. Data were collected from provincewide health administrative databases. Participants with concussion were included in the exposed cohort, and those with an orthopedic injury were included in the comparison cohort; these groups were matched 1:2, respectively, on age and sex. EXPOSURES: Concussion or orthopedic injury. MAIN OUTCOMES AND MEASURES: The primary outcome was mental health problems, such as psychopathologies and psychiatric disorders, identified from health care visits in emergency departments, hospitalizations, or primary care settings. Secondary outcomes were psychiatric hospitalizations, self-harm health care visits, and death by suicide (identified in health care or vital statistics databases). RESULTS: A total of 152 321 children and youths with concussion (median [IQR] age, 13 [10-16] years; 86 423 [56.7%] male) and 296 482 children and youths with orthopedic injury (median [IQR] age, 13 [10-16] years; 171 563 [57.9%] male) were matched by age and sex. The incidence rates of any mental health problem were 11 141 per 100 000 person-years (exposed group) and 7960 per 100 000 person-years (unexposed group); with a difference of 3181 (95% CI, 3073-3291) per 100 000 person-years. The exposed group had an increased risk of developing a mental health issue (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.37-1.40), self-harm (aHR, 1.49; 95% CI, 1.42-1.56), and psychiatric hospitalization (aHR, 1.47; 95% CI, 1.41-1.53) after a concussion. There was no statistically significant difference in death by suicide between exposed and unexposed groups (HR, 1.54; 95% CI, 0.90-2.61). CONCLUSIONS AND RELEVANCE: Among children and youths aged 5 to 18 years, concussion was associated with an increased risk of mental health issues, psychiatric hospitalization, and self-harm compared with children and youths with an orthopedic injury.

Cannabis-related emergency department visits by youths and their outcomes in Ontario: a trend analysis.

BACKGROUND: Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex. METHODS: Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13, 14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for cannabis poisoning and mental disorders due to cannabinoids. We categorized presentations as "less severe" versus "more severe" using scores assigned by nurses at triage. RESULTS: We examined 14 697 778 emergency department visits. Cannabis-related visits increased from 3.8 per 10 000 youths (95% confidence interval [CI] 3.5-4.0) in 2003 to 17.9 (95% CI 17.4-18.4) in 2017, a 4.8-fold increase (95% CI 4.4-5.1). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios ≥ 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10 000 (95% CI 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% CI 20.9-22.9) among those aged 14-18 years, and 0.8 per 10 000 (95% CI 0.5-1.0) among those aged 10-13 years. In 2017, 88.2% (95% CI 87.3%-89.0%) of cannabis-related visits and 58.1% (95% CI 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe," (rate ratio 1.52, 95% CI 1.50-1.53). Similarly, in 2017, 19.0% (95% CI 18.0%-20.1%) of cannabis-related visits and 5.8% (95% CI 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3, 95% CI 3.1-3.5). INTERPRETATION: Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.

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.

Building Resilience and Attachment in Vulnerable Adolescents (BRAVA): a brief group intervention for adolescents with mild-to-moderate suicidal ideation and their caregivers.

INTRODUCTION: Suicidal Ideation (SI) is common in adolescents and increases the risk of completed suicide. Few brief interventions have been shown to reduce SI in adolescents. The objective of this study was to evaluate the feasibility of a novel brief group intervention, building resilience and attachment in vulnerable adolescents (BRAVA), designed for adolescents and their caregivers to reduce adolescent SI. METHODS: The study was a pre-post, noncontrolled trial in which 46 adolescents were enrolled in the BRAVA intervention. Adolescents and caregivers completed an intake assessment, six BRAVA group sessions, and an exit assessment 1-week post-BRAVA. RESULTS: Adolescents' SI decreased significantly after completing the BRAVA treatment (pre-post difference = 18.1, 95% CI = 10.01-26.12). Significant improvements in associated symptoms of depression, anxiety, and perceived stress were also observed. Caregivers had reduced perceived stress (pre-post difference = 2.7, 95% CI = 0.30-5.16) and reduction in attachment avoidance (difference = 1.6, 95% CI = 0.29-2.91). Treatment satisfaction was high across the six modules. The rolling entry feature of the intervention allowed participants to begin treatment approximately 2 weeks sooner compared to waiting for the next group cycle. CONCLUSIONS: Study results demonstrate that the BRAVA intervention has the potential to reduce SI among adolescents who present to hospital services in crisis. Further studies are required to establish BRAVA's efficacy in a randomized controlled trial.

Development of a Clinical Pathway for the Assessment and Management of Suicidality on a Pediatric Psychiatric Inpatient Unit.

PURPOSE: This article describes steps taken by a mental health inpatient multidisciplinary team to develop a clinical pathway for the assessment and management of suicidality in a pediatric psychiatric inpatient unit. PATIENTS AND METHODS: The setting for this project is a 19-bed inpatient psychiatry unit providing care for children and adolescents (6-17 years of age) in a tertiary care pediatric hospital in Ontario, Canada. Three Lean methodologies were used: 1) The A3 process was used to articulate a problem statement and help clarify expectations, determine goals, and uncover, address and encourage discussion of potential issues; 2) Process mapping was used to show how work process activities are sequenced from the time of the patient's admission to discharge; and 3) Standard work, where consideration was given to the breakdown of the work into categories which are sequenced, organized and repeatedly followed. Generally accepted methodologies for developing clinical pathways were used to create a framework and algorithm for the assessment and management of suicidality in psychiatrically hospitalized children and adolescents. RESULTS: The clinical pathway development resulted in six steps from admission to discharge: intake process, inclusion/exclusion criteria, data integration and treatment formulation, interventions, determination of readiness for discharge, and the discharge process. CONCLUSION: This framework, developed with the aim to standardize care for psychiatrically admitted suicidal children and adolescents, may serve as a flexible template for use in similar settings and could be adapted according to local realities and resources.

The HEADS-ED: Evaluating the Clinical Use of a Brief, Action-Oriented, Pediatric Mental Health Screening Tool.

OBJECTIVES: This effectiveness study aimed to evaluate the clinical use of the HEADS-ED tool for patients presenting to a pediatric emergency department (PED) for mental health (MH) care. METHODS: In this pragmatic trial, PED physicians used the HEADS-ED to guide their assessment and identify areas of MH need in 639 patients (mean [SD], 15.16 [1.40] years; female, 72.6%) who presented to the emergency department with MH concerns between May 2013 and March 2014. RESULTS: The HEADS-ED guided consultation to psychiatry/crisis, with 86% receiving a recommended consult. Those with a HEADS-ED score of greater than or equal to 8 and suicidality of 2 (relative risk, 2.64; confidence interval, 2.28-3.06) had a 164% increased risk of physicians requesting a consult compared with those with a score of less than 8 or greater than or equal to 8 with no suicidality of 2. The HEADS-ED mean score was significantly higher for those who received a consult (M = 6.91) than those who did not (M = 4.70; P = 0.000). Similarly, the mean score for those admitted was significantly higher (M = 7.21) than those discharged (M = 5.28; P = 0.000). Agreement on needs requiring action between PED physicians and crisis intervention workers was obtained for a subset of 140 patients and ranged from 62% to 93%. CONCLUSIONS: Results support the HEADS-ED's use by PED physicians to help guide the assessment and referral process and for discussing the clinical needs of patients among health care providers using a common action-oriented language.

Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study.

BACKGROUND: Self-harm is increasing among adolescents, and because of changing behaviours, current data are needed on the consequences of self-harm. We sought to investigate the trends related to hospital presentation, readmission, patient outcome and medical costs in adolescents who presented with self-harm to the emergency department. METHODS: We used administrative data on 403 805 adolescents aged 13-17 years presenting to Ontario emergency departments in 2011-2013. Adolescents with self-harm visits were 1:2 propensity matched to controls with visits without self-harm, using demographic, mental health and other clinical variables. Five years after the index presentation, hospital or emergency department admission rates for self-harm, overall mortality, suicides and conservative cost estimates were compared between the 2 groups. RESULTS: Of 5832 adolescents who visited Ontario emergency departments in 2011-2013 after self-harm (1.4% of visits), 5661 were matched to 10 731 adolescents who presented for reasons other than self-harm. Adolescents who presented with self-harm had a shorter time to a repeat emergency department or hospital admission for self-harm (hazard ratio [HR] 4.84, 95% confidence interval [CI] 4.44-5.27), more suicides (HR 7.96, 95% CI 4.00-15.86), and higher overall mortality (HR 3.23, 95% CI 2.12-4.93; p < 0.001). The positive predictive value of self-harm-related emergency department visits for suicide was 0.7%. Adolescents with self-harm visits had mean 5-year estimates of health care costs of $30 388 compared with $19 055 for controls (p < 0.001). INTERPRETATION: Adolescents with emergency department visits for self-harm have higher rates of mortality, suicide and recurrent self-harm, as well as higher health care costs, than matched controls. Development of algorithms and interventions that can identify and help adolescents at highest risk of recurrent self-harm is warranted.

Non-suicidal self-injury in Shanghai inner bound middle school students.

BACKGROUND: Non-suicidal self-injury (NSSI) behaviour is very common among adolescents. Its prevalence and behavioural characteristics may vary according to regional and cultural differences. Investigation of NSSI locations and diagnosis of adolescents with NSSI are relatively lacking in China. AIMS: The study objective was to determine the prevalence and features of NSSI among middle school students in Shanghai. METHODS: The participants were from grade 6 to 8 selected from three junior schools in Jing'an District. Consenting students completed the Ottawa Self-Injury Inventory to determine the prevalence and characteristics of NSSI. Those who indicated NSSI within the past month were administered the Mini-International Neuropsychiatric Interview for Children and Adolescents to assess for emotional disorders. RESULT: The result shows 510 participants (21.7%; mean age 13.51 (0.97) years old; 56.7% female) reported at least one instance of NSSI during the previous 12 months. NSSI was significantly more common in girls than boys (24.9% vs 18.5%; χ2=14.03, p=0.00). Commonly reported reasons for NSSI were for internal and external emotion regulation (87.9%, 82.3%) and social influence (57.8%). Anxiety disorders were the most common (28.9%) disorder associated with NSSI. CONCLUSION: The rate of NSSI of middle school students in Shanghai inner bound is similar to those reported in North American and European youth. It is essential that school mental health professionals are aware of how to manage NSSI within the school setting.

Changing Rates of Self-Harm and Mental Disorders by Sex in Youths Presenting to Ontario Emergency Departments: Repeated Cross-Sectional Study.

OBJECTIVE: To document the rates of intentional self-harm and mental disorders among youths aged 13 to 17 years visiting Ontario emergency departments (EDs) from 2003-2017. METHODS: This was a repeated cross-sectional observational design. Outcomes were rates of adolescents with (1) at least 1 self-harm ED visit and (2) a visit with a mental disorder code. RESULTS: Rates of youths with self-harm visits fell 32% from 2.6/1000 in 2003 to 1.8 in 2009 but rose 135% to 4.2 by 2017. The slope of the trend in self-harm visits changed from -0.18 youths/1000/year (confidence interval [CI], -0.24 to -0.13) during 2003 to 2009 to 0.31 youths/1000/year (CI, 0.27 to 0.35) during 2009 to 2017 (P < 0.001). Rates of youths with mental health visits rose from 11.7/1000 in 2003 to 13.5 in 2009 (15%) and to 24.1 (78%) by 2017. The slope of mental health visits changed from 0.22 youths/1000/year (CI, 0.02 to 0.42) during 2003 to 2009 to 1.84 youths/1000/year (CI, 1.38 to 2.30) in 2009 to 2017 (P < 0.001). Females were more likely to have self-harm (P < 0.001) and mental health visits (P < 0.001). Rates of increase after 2009 were greater for females for both self-harm (P < 0.001) and mental health (P < 0.001). CONCLUSIONS: Rates of adolescents with self-harm and mental health ED visits have increased since 2009, with greater increases among females. Research is required on the determinants of adolescents' self-harm and mental health ED visits and how they can be addressed in that setting. Sufficient treatment resources must be supplied to address increased demands for services.

Family Factors and Repeat Pediatric Emergency Department Visits for Mental Health: A Retrospective Cohort Study.

OBJECTIVES: Approximately 45% of youth presenting to the emergency department (ED) for mental health (MH) concerns will have a repeat ED visit. Since youth greatly depend on their caregivers to access MH services, the objective of this study was to determine if family characteristics were associated with repeat ED visits. METHODS: A retrospective cohort study of youth aged 6-18 years (62% female) treated at a tertiary pediatric ED for a discharge diagnosis related to MH was conducted. Data were gathered from medical records, telephone interviews, and questionnaires. Family factor contribution was analyzed using a multivariable logistic regression model controlling for demographic, clinical and service utilization factors. Variables associated with earlier and more frequent visits were determined using cox regression and negative binomial regression. RESULTS: Of 266 participants, 70 (26%) had a repeat visit. While caregiver history of MH treatment decreased the odds of having a repeat ED visit, family functioning and perceived family burden were not associated with repeat visits. Post-visit MH services, prior psychiatric hospitalization, higher severity of symptoms, and living closer to the hospital increased the odds of repeat visits. CONCLUSIONS: This study examined the contribution of multiple family factors in predicting repeat MH visits to the ED. Results suggest caregiver characteristics may impact the decision to return. Healthcare providers should therefore consider caregiver and youth service utilization factors to inform patient management and discharge planning.

OBJECTIFS: Environ 45 % des adolescents qui se présentent au service d'urgence (SU) pour des raisons de santé mentale (SM) auront une visite répétée au SU. Puisque les adolescents dépendent beaucoup de leurs aidants pour avoir accès aux services de SM, l'objectif de cette étude était de déterminer si les caractéristiques familiales étaient associées aux visites répétées au SU. MÉTHODES: Une étude de cohorte rétrospective a été menée sur des adolescents de 6 à 18 ans (62 % de sexe féminin) traités dans un SU pédiatrique tertiaire pour un diagnostic lié à la SM posé au moment du congé. Les données ont été recueillies d'après les dossiers médicaux, les entrevues téléphoniques et les questionnaires. La contribution des facteurs familiaux a été analysée à l'aide d'un modèle de régression logistique multivariable après contrôle des facteurs démographiques, cliniques et d'utilisation des services. Les variables associées à des visites précédentes et plus fréquentes ont été déterminées à l'aide de la régression de Cox et la régression binomiale négative. RÉSULTATS: Sur les 266 participants, 70 (26 %) avaient une visite répétée. Les antécédents de traitement de SM des aidants diminuaient les probabilités d'avoir une visite répétée au SU, et le fonctionnement familial et le fardeau familial perçu n'étaient pas associés à des visites répétées. Les services de SM ultérieurs à la visite, une hospitalisation psychiatrique précédente, une gravité plus élevée des symptômes et le fait d'habiter à proximité de l'hôpital augmentaient les probabilités de visites répétées. CONCLUSIONS: Cette étude a examiné la contribution de multiples facteurs familiaux à la prédiction de visites répétées au SU pour raisons de SM. Les résultats suggèrent que les caractéristiques des aidants puissent influer sur la décision de retourner au SU. Les prestataires de soins de santé devraient donc prendre en compte les facteurs d'utilisation des services des aidants et des adolescents afin d'éclairer la prise en charge des patients et la planification du congé.

Evaluating the HEADS-ED Screening Tool in a Hospital-Based Mental Health and Addictions Central Referral Intake System: A Prospective Cohort Study.

OBJECTIVES: We evaluated the use of a mental health (MH) screening tool in a hospital-based centralized MH referral telephonic intake process. The tool is used to guide psychosocial screening in several domains: home; education; activities and peers; drugs and alcohol; suicidality; emotions, thoughts, and behaviors; and discharge resources (HEADS-ED). We wanted to understand the use of the tool to guide next step in care decision-making over the telephone. METHODS: Intake workers used the HEADS-ED tool to guide the assessment processes, identified areas of MH need, and made decisions about next step in care. We completed a retrospective chart review of all callers to the intake system over 4 months to gather initial decision at intake and subsequent steps in treatment. χ2 and analysis of variance tests were used to examine differences between HEADS-ED scores and next step in care. RESULTS: A total of 674 patients aged 3 to 19 years (mean age = 11.7 years, SD = 0.6; girls = 50.0%) called for services. Significant mean differences were found on total HEADS-ED scores between treatment options (F4,641 = 75.76; P < .001). Decision validity indicated that 86% (n = 506 of 587) of initial referrals matched treatments that were actually received. Uptake of the tool was 100%, and interrater reliability indicated strong agreement between raters (intraclass correlation coefficient = 0.82; P < .001). CONCLUSIONS: With our results, we support the use of the HEADS-ED tool in a telephone-based MH intake system to help guide the initial assessment and inform decision-making about fit of next step in care, both within the health center-based MH system and in the community.