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| Variations in Risk and Treatment Factors Among Adolescents Engaging in Different Types of Deliberate Self-Harm in an ... |
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[ Pobierz całość w formacie PDF ] Journal of Clinical Child & Adolescent Psychology, 39(4), 470–480, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 1537-4416 print = 1537-4424 online DOI: 10.1080/15374416.2010.486302 Variations in Risk and Treatment Factors Among Adolescents Engaging in Different Types of Deliberate Self-Harm in an Inpatient Sample Paul Boxer Department of Psychology, Rutgers University This study employs a framework adopted in 2008 by Jacobson, Muehlenkamp, Miller, and Turner to explore differences in risk and treatment factors in a sample of 476 ado- lescent inpatients grouped with relation to their involvement in deliberately self-harmful (DSH) behavior. Participants were assigned to groups indicating no DSH, nonsuicidal self-injury (NSSI) only, suicide attempts (SA) only, and NSSI þ SA. Groups were compared with respect to their status on a variety of background risk factors (e.g., maltreatment, presenting psychopathology, family history) and in-treatment behaviors (e.g., critical incidents resulting from self-injurious gestures) linked to DSH. Findings generally supported the conclusions drawn by Jacobson et al. in terms of the overall severity of youth exhibiting NSSI þ SA, with some important similarities observed between the NSSI-only and NSSI þ SA groups. Youth suicidality is a serious public health issue. For example, in 2007, 15% of high school students in the United States reported that they ‘‘seriously considered’’ suicide during the prior 12 months, whereas about 7% reported at least one suicide attempt (SA) and 2% reported at least one attempt requiring medical attention (Centers for Disease Control and Prevention, 2008). Recent studies on the prevalence of nonsuicidal self- injury (NSSI) show similar rates, with about 14% of youth reporting deliberate self-injury at some point in their lifetimes (Ross & Heath, 2002). Empirically sup- ported treatments and reliable assessment strategies exist for youth showing deliberate self-harm (DSH), which includes suicides, SA, parasuicides or suicidal gestures, and a variety of less destructive acts including cuts or burns made to the self (e.g., Miller, Rathus, & Linehan, 2007; Muehlenkamp, 2005; Nock & Prinstein, 2004; Shaffer & Pfeffer, 2001; Spirito & Esposito- Smythers, 2008). Despite advances made in the assess- ment and treatment of these behaviors, gaps remain. Different forms of deliberate self-injury show different prevalence rates, different profiles of risk, and different degrees of persistence (Borges, Angst, Nocl, Ruscio, & Kessler, 2008; Nock & Kessler, 2006; Prinstein et al., 2008). Yet relatively little research has explored different forms of deliberate self-harm in concert, particularly with respect to the characteristics of youth who have engaged in either suicidal acts or NSSI acts, or both. Recently, Jacobson, Muehlenkamp, Miller, and Turner (2008) presented evidence from a study of adolescents who received outpatient services showing meaningfully differ- ent symptom and diagnostic profiles across groups who showed only nonsuicidal self-harm, SA, both in combi- nation, or no self-harm at all. This study replicates and extends Jacobson et al.’s approach in a sample of youth admitted for inpatient treatment by investigating group differences with respect to behavior during treatment, as well as a variety of risk markers collected at intake. Risk factors for suicidality are well-known in the clinical This study was funded by a grant from the National Institute of Mental Health (MH72980). I acknowledge the support provided at various phases of this project by Robert Bailey, James Bow, Joy Wolfe Ensor, Rashmi Bhandari, Ruth Robinson, Esther Petrovich, Elizabeth Rakstis, Vicki Alley, Dianne Tomaine, Judy Valentine, and Rowell Huesmann. Assistance with data coding was provided by Sara Chase, Jessica Luitjohan, Rebecca Gerhardstein, Sarah Savoy, and Andrew Terranova. Correspondence should be addressed to Paul Boxer, Department of Psychology, Rutgers University, Newark, NJ 07102. E-mail: pboxer@ psychology.rutgers.edu literature (see King & Merchant, 2008, for 471 VARIATIONS IN RISK AND TREATMENT FACTORS review), as much empirical work has been done to identify the correlates of both suicidal ideation and SA (e.g., Dubow, Kausch, Blum, Reed, & Bush, 1989). This information has been codified in the practice parameters of the American Academy of Child and Adolescent Psychiatry (Shaffer & Pfeffer, 2001). Major individual risk factors include being male, a history of previous attempts, and current mood disorder along with current elevated agitation. Social-contextual risk factors include isolation or poor quality social support, maltreatment by caretakers, and victimization by peers. Although the literature on risk factors for NSSI is relatively less elaborated, extant studies suggest similar profiles of risk for this kind of DSH with evidence indicating greater risk overall in cases of cooccurring patterns of NSSI and SA. Based on clinical interviews conducted with 89 adolescent inpatients, Nock, Joiner, Gordon, Lloyd-Richardson, and Prinstein (2006) observed that 70% of adolescents reporting histories of NSSI also reported previous SA. These youth reported more extensive histories of NSSI via a greater variety of methods and less pain associated with self-harmful acts. The consensus in the extant literature on the patterns and correlates of NSSI and SA appears to be that despite their differences, most notably with respect to the under- lying intent to die present in SA but not NSSI (see Hooley, 2008), NSSI and SA can and frequently do cooccur. However, NSSI and SA are unique syndromes with some shared and some nonshared correlates. For example, studies by Muehlenkamp and Gutierrez (2004, 2007) used data from normative samples of adolescents to examine the extent to which underlying depression, suicidal ideation, and attitudes toward life and death account for similarities or differences in NSSI and SA. Muehlenkamp and Gutierrez (2004) observed in a sample of 390 youth that adolescents who engage in either NSSI or SA showed elevated levels of depression, suicidal ideation, and negative attitudes toward life in comparison to adolescents who engage in neither. There were no significant differences in depression or suicidal ideation between the NSSI and SA groups, but the NSSI group reported less negative attitudes toward life than did the SA group. In an extension of this study, Muehlenkamp and Gutierrez (2007) observed in a sample of 540 adolescents that youth who engage in both NSSI and SA show differ- ent patterns of suicidal ideation, depression, and attitudes toward life in comparison to youth who engage only in NSSI. The NSSI þ SA group reported signifi- cantly more anhedonia and negative self-evaluation, and significantly fewer reasons for living (the SA-only group was too small for reliable inferential analysis). These findings suggest that youth who engage in NSSI and SA probably are at greatest risk for continued DSH and that youth who fall potentially are showing the greatest overall levels of psychopathology and associated risk among youth engaging in one or the other form of DSH. As Muehlenkamp and Gutierrez (2007) noted, research on unique and overlapping NSSI and SA thus far has been somewhat limited with respect to investigat- ing underlying shared etiological factors between the two forms of DSH. Indeed, the current literature base in this area has relied mostly on larger community samples such as those just reported or relatively smaller samples of psychiatric inpatients. For example, in a study of 95 adolescents, Guertin, Lloyd-Richardson, Spirito, Donaldson, and Boergers (2001) observed that adolescents with histories of NSSI þ SA had elevated risk and psychopathology profiles compared to adoles- cents with histories only of SA. Larger samples with elevated risk for DSH are needed for fuller hypothesis testing regarding the shared and unique features of youth showing different configurations of NSSI and SA. Recently, Jacobson and colleagues (2008) examined data from a large (N ¼ 227) racially = ethnically diverse (70% Hispanic, 20% Black = African American) and mostly (68%) female sample of adolescents who presented to an outpatient adolescent depression and suicide program affiliated with an urban hospital in the northeast. The authors analyzed data from self-report questionnaires and semistructured clinical interviews administered during routine intake procedures for the treatment program. Based on responses to the Lifetime Parasuicide Count (Comtois & Linehan, as cited by Jacobson et al., 2008), youth were classified into one of four groups representing different configurations of DSH: none (no DSH), NSSI only, SA only, and combined NSSI þ SA. These classifications were made regardless of the specific form or frequency of self-harm but rather with attention to the suicidal intent of the behavior. Thus, as Jacobson et al. (2008, p. 366) described, a youth who engaged in a mix of self-harmful behaviors, some with suicidal intent and some without, would be classified as NSSI þ SA. About half of their sample (n ¼ 119) was classified as no-DSH, with roughly equal distribution of youth across the three DSH groups (ns ¼ 30–40). Through analyses of group differences, Jacobson et al. (2008) discovered symptom and diagnosis-specific features of DSH. For example, only borderline person- ality features were predictive of membership in the NSSI group, whereas major depression and PTSD were predic- tive of membership in the SA and NSSI þ SA groups relative to no-DSH. Further, with regard to indicators of suicidal ideation and depressive symptoms, the NSSI group mirrored the no-DSH group. Jacobson et al. (2008) acknowledged limitations to their study, including the potential for underpowered analyses, a reliance on cross-sectional data, and a sample comprised into this category 472 BOXER predominantly of Hispanic girls. Yet their analysis represents a significant step forward for research on self-injurious behavior given their use of data from a relatively large outpatient sample and application of a clinically meaningful group classification scheme to infer differences among youth showing various configurations of self-injury. The present study extends Jacobson et al.’s (2008) approach to a larger, higher-risk sample of adolescent inpatients. The present study is part of a larger translational action research project conducted jointly by academic researchers and the professional clinical staff of a public, secure inpatient psychiatric hospital for children and adolescents. In this study the complete, archived clinical records of youth admitted consecutively over a 28-month period were analyzed to address the issue of whether youth showing different configurations of deliberately self-harmful behaviors also manifested different patterns of behavior during treatment and showed different degrees of background risk factors upon admission. As with Jacobson et al. (2008), analyses were mainly exploratory; however, it was hypothesized that youth who had engaged in both NSSI and SA prior to admis- sion would show the highest levels of DSH during inpatient treatment as evidenced by their involvement in critical incidents spurred by DSH behavior, the amount of time they spent on ‘‘special precautions’’ for DSH, and the amount of time their treatment plans were modified temporarily by more restrictive management plans for DSH behaviors. Further, the NSSI þ SA group was expected to show the highest levels of pretreatment risk across a variety of risk markers including, for example, maltreatment experiences, out-of-home place- ment histories, broadband indicators of psychopath- ology, and intellectual functioning. anxiety, bipolar, or unspecified mood disorders), 15% had primary diagnoses of thought disorder (psychotic disorders including schizophrenia, thought disorder, or schizoaffective disorder), 12% behavior disorder (conduct, oppositional-defiant, disruptive, or attention deficit-hyperactivity disorders), 4% posttraumatic stress disorder, and 5% other disorders (e.g., adjustment disorders, reactive attachment disorder). The analysis sample was comprised of youths ages 10 to 17 years (M age in years at admission ¼ 13.9, SD ¼ 2.1; 250 boys, 226 girls) admitted consecutively to a secure, publicly funded inpatient psychiatric hospi- tal in the Midwest. In the state where this hospital is located, the facility traditionally has served as the ‘‘last resort’’ treatment center for youth in the public mental health system, and thus most inpatients are admitted with high levels of chronic emotional and = or behavioral difficulties and low levels of overall functioning. The sample was ethnically = racially diverse (boys: 45.2% Black = African American, 46% White = Caucasian, 2.4% Hispanic = Latino = a, 1.2% Native American, 5.2% Other or Mixed-Racial; girls: 45.6% Black = African American, 41.6% White = Caucasian, 2.7% Hispanic = Latino = a, 0.9% Native American, 9.2% Other or Mixed-Racial). Parti- cipants represented a wide range of economic back- grounds per U.S. Census 2000 data on participants’ home ZIP codes (median home values from $27,800 to $309,800; percentage of local population in poverty from 2% to 39%; median household incomes from $17,680 to $87,740). Participants came from a variety of custodial situations: homes with two biological parents or one biological = one stepparent (26.2%), single parents only (34.5% biological mother, 3.8% biological father), grandparents (5.7%), adoptive parents (12.2%), foster parents (3.6%), extended families (10.7%), or another configuration (3.3%). Mean length of stay in the facility was 96 days (SD ¼ 116.9); median length of stay was 36 days with a range of 1 to 636 days. METHOD Participants Measures=Sources of Data As noted the data analyzed for this study were drawn from the database of a larger project (N ¼ 484) examin- ing various forms of aggressive behavior in the youth psychiatric population (Boxer, 2007; Boxer & Terranova, 2008). Participants for this study were the 476 youths (98.3% of full sample) who did not receive any Axis I diagnoses of pervasive developmental disorders (autism, Asperger’s disorder, etc.). Youth with such diagnoses were excluded to minimize the influence of any poten- tially stereotypic behavior patterns common to the pervasive developmental disorders diagnostic profile on the documentation of deliberate self-harm prior to and during treatment. Of the remaining youth, most (64%) had primary diagnoses of mood disorder (depression, This study relied on existing clinical records. Data were obtained from a variety of sources: intake reports com- pleted by teams consisting of a psychiatrist, psychologist, social worker, and psychiatric nurse; a computerized critical incident database maintained by the hospital’s Chief Information Officer with data extracted from inci- dent reports filed by nurses, child care workers, and = or psychiatrists; daily observation logs completed by child care workers; medical notes and orders made by unit psy- chiatrists during the course of treatment; and treatment logs and plans maintained by therapists. Intake clinicians were required to assess risk for self-harm during treatment by inquiring about histories of this behavior at intake, including a clear accounting of the number 473 VARIATIONS IN RISK AND TREATMENT FACTORS of SA ever made. Except for information contained in the critical incident database, all data were collected and coded by master’s-level clinical psychology interns working in the host facility. All data were deidentified by the host facility before being transferred to the author to adhere to the Health Information Portability and Accountability Act. of days on precautions divided by number of days in treatment). 3. Behavior management plans for deliberate self-harm: amount of time a special treatment plan, more restrictive than the regular treatment plan, was in force to target self-directed aggressive behavior (from treatment logs; number of days plan was in force divided by number of days in treatment). All three of these indicators were log-transformed for inferential analyses in order to reduce skewness. History of DSH. Coders rated the presence and extent of NSSI (excluding SA) and SA. For NSSI, coders were instructed to attend to any mention of self-directed aggressive behavior emitted intentionally to cause harm (e.g., cutting self with object, scratching self with finger- nails, choking self, head-banging). Coders used a 3-point rating system to indicate the extent of this behavior, with codes reflecting developmental persistence (0 ¼ none mentioned,1 ¼ form of aggression noted during a single developmental period, and 2 ¼ form of aggression noted during two or more developmental periods). Discrete developmental periods considered were early childhood (ages 0–4), middle childhood (ages 5–10), early ado- lescence (ages 11–13), and middle adolescence (ages 14–17). Higher scores thus reflected greater persistence of the behavior. For SA, coders were instructed to tally the number of attempts noted in the intake assessment. Background risk factors. Coders also extracted information regarding a variety of identified risk markers for DSH, including the following 1. Maltreatment (physical, sexual, and emotional abuse as well as neglect; coded as 0 ¼ none noted; 1 ¼ form of maltreatment mentioned, but no legal status noted; and 2 ¼ form of maltreatment noted as ‘‘substantiated’’; see Boxer & Terranova, 2008 for evidence of validity). 2. Prior out-of-home placements (counts of previous placements in psychiatric hospitals, residential treatment centers, foster homes, and juvenile detention). 3. Global Assessment of Functioning (GAF) score (American Psychiatric Association, 2000) assigned at intake. GAF scores range from 0 to 100, with lower scores indicating greater impairment; a mid- range score of 50 represents ‘‘serious symptoms’’ or ‘‘serious impairment in social, occupational, or school functioning’’ (APA, 1994). Studies suggest that GAF scores can be assigned with acceptable degrees of interrater reliability during initial diagnostic assessments (e.g., S ¨derberg, Tungstr ¨m, & Armelius, 2005). GAF scores at intake were assigned by psychiatrists as part of their diagnostic assessment. 4. Family history of mental illness or criminal behavior (rated as 0 ¼ none noted,1 ¼ noted in only one family member who was not a first-degree relative, and 2 ¼ noted in two or more family members or in at least one first-degree relative). 5. Externalizing, internalizing, and critical problems indicated by the Devereaux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994). Per the manual (Naglieri et al., 1994), these scales have established high levels of internal reliability (coefficient alphas ranging from .88 to .98) as well as criterion validity (verified discrimi- nation between hospitalized and control samples of youth). DSMD scales were completed by the individual who admitted the child to the hospital (typically the primary caregiver). The DSMD DSH during inpatient treatment. The management and expression of DSH during treatment was measured by a number of indicators: 1. Critical incidents of deliberate self-harm: number of seclusions and restraints (critical incidents) in which a youth was involved due to deliberate self-harm (from the computerized incident data- base maintained by the hospital’s information office). 1 2. Special precautions for deliberate self-harm: percentage of time youth was maintained on 1:1 supervision by child care staff due to psychiatrist determination of elevated risk for self-directed aggressive behavior (from medical orders; number 1 Seclusion involves moving an individual into an unfurnished room and preventing him or her from exiting until the he or she is deemed no longer to be at risk for harming self or other. Restraint refers to a restricting an individual’s movement via three possible methods. Physi- cal restraint involves staff limiting movement by holding a youth. Mechanical restraint involves the use of some apparatus to limit move- ment (e.g., strapping a youth to a bed). Chemical restraint involves the use of medication to reduce agitation. Chemical restraint is not applied as such at the host facility, and thus none of the incidents recorded for this study involved that form of restraint. Incidents occur when a mem- ber of the treatment staff determines that a youth’s behavior is present- ing the threat of imminent harm to him- or herself or another person. There are no other circumstances at the host facility that allow the use of seclusion or restraint. 474 BOXER generates T scores to indicate levels of psycho- pathology (i.e., M ¼ 50, SD ¼ 10); scores greater than 60 indicate clinical case status in the general population, and scores greater than 70 are con- sidered highly significant with respect to clinical levels of psychopathology (Naglieri et al., 1994). DSMD scales were completed by the individual who admitted the child to the hospital (following standard intake protocols, this was most often the child’s primary caregiver). difficult case questions. Critical incident data were extracted from the facility’s computerized database and provided directly by the facility’s Chief Information Officer. RESULTS Demographic Indicators Following Jacobson et al. (2008), the sample was divided into groups based on their histories of deliberately self-harmful behavior: none reported (n ¼ 146, 30.7%); self-directed aggression only, no SA noted (NSSI; n ¼ 119, 25%); SA only, no other self-harm noted (n ¼ 64, 13.4%); and a combined group with both forms of deliberate self-harm noted (NSSI þ SA; n ¼ 147, 30.9%). The NSSI þ SA group showed greater persis- tence over time of NSSI compared to the NSSI group, t(264) ¼ 2.03, p < .05, d ¼ .250. Table 1 shows the breakdown of these four groups by sex, average age, race = ethnicity status, and length of stay in treatment. Boys were overrepresented in the ‘‘none’’ group, v 2 (1) ¼ 10.96, p < .01, whereas girls were overrepresented in the NSSI þ SA group, v 2 (1) ¼ 4.25, p < .05. There were no significant group differences in age at admission. Racial = ethnic minority youth were overrepresented in the ‘‘none’’ group, v 2 (1) ¼ 13.26, p < .001, and in the SA group, v 2 (1) ¼ 6.25, p < .05. There were significant group differences in length of stay, F(3, 475) ¼ 10.76, p < .001; youth in the NSSI and NSSI þ SA groups spent more time in treatment than did youth in the ‘‘none’’ and SA groups per post hoc Tukey Honestly Significant Dif- ference comparisons (all pairwise p < .01). In all but the NSSI þ SA group, youth were significantly more likely than not to avoid critical incidents during treatment (all p < .05); yet almost half of the youth in the NSSI þ SA group were involved in at least one incident. However, the groups did not differ in mean times to first critical incident. Procedures All procedures were reviewed and approved by human subjects research committees at the host facility, the state agency overseeing activities at the facility, and the author’s university. Information contained in the inpatient charts was coded by clinical psychology interns trained and supervised by the author. Three coders first coded independently a set of 55 cases (11% of the sample), which overlapped with 55 cases from a pilot feasibility study in which the coding scheme was developed (Boxer, Bhandari, & Bow, 2003). Because those 55 cases had been coded using a system very simi- lar to the one implemented in the current study, the 55 were used to establish interrater reliability among the coders and with the codes assigned during the feasibility study. Reliability analyses indicated that all three interns were coding at adequate levels of agreement with the feasibility study (all codes > 70% agreement; most codes > 80% agreement) and at very high levels with one another (intraclass correlation coefficients > .90). Next, the interns coded the remaining 429 cases separately (distributed across coders; one coded 110 cases, one 115, and the other 204). It should be noted that all information extracted by coders was based on counts of incidents, placements, and interventions; recording of the presence and devel- opmental persistence of events based on the wording in clinical assessment narratives; or the verbatim record- ing of different clinical indicators such as GAF scores. As interns in the host facility, the coders were thor- oughly familiar with the structure and format of the clinical records and thus knew precisely where to look in each chart for the necessary information. Coders were not tasked with making qualitative inferences about youths’ functioning or behavior, nor were they tasked with making judgments about whether information in clinical files was veridical to youths’ actual lived experi- ences. Rather, they were instructed explicitly to focus only on information available in the charts. Coders also were in regular contact with the author to discuss issues arising during the coding process and maintain fidelity to the coding scheme, and met periodically with an expert clinical research consultant Variation in Treatment Variables as a Function of Deliberate Self-Harm Group Status As previously noted, the NSSI and NSSI þ SA groups spent significantly more time in treatment than did the other two groups. Information on other variables recorded during treatment is presented in Table 2. Analyses of covariance (ANCOVA) were applied to control for the identified influence of sex and racial = ethnic minority status on group membership. In each analysis two sets of inferential tests were conducted beyond the omnibus F. First, single-df planned contrasts were used to test the hypothesis that the NSSI þ SA group would produce higher scores on the outcome to problem-solve [ Pobierz całość w formacie PDF ] |