Deliberate self-harm in adolescents

The association between non-suicidal self-injury and negative life events in children and adolescents in underdeveloped regions of south-western China

Background

The association between negative life events and Non-suicidal self-injury (NSSI) in children and adolescents has been extensively discussed. Nevertheless, little is known about the relationship between negative life events and repetition and severity of NSSI. This survey aims to understand the association between NSSI prevalence, severity, repetition and the negative life events in children and adolescents in underdeveloped regions in south-western China.

Methods

In this population-based cross-sectional study, 3,146 children and adolescents were included from underdeveloped regions of south-western China, and each of them requested to complete a self-assessment questionnaire. The Modified Version of Adolescents Self-Harm Scale (MASHS) and the Adolescent Self-rating negative Life Events Check-list were used to evaluate NSSI behaviors and negative life events, respectively. The statistical implementation of this study was carried out in the R statistical software, and the logistic regression analysis method was used to analyze the relationship between negative life events and adolescents' non-suicidal self-injury behaviors.

Results

The average age of all included participants was 13.31 years old. The lifetime prevalence of NSSI was 47.0% (95% CI [36.3-58.0%]). Gender, grade level and ASLEC was positively associated with NSSI. Further analysis revealed that, for all five dimensions of ASLEC, only interpersonal relationship factor (IRF) (OR 1.77 (95% CI [1.06-2.97])), health adaptation factor (HAF) (OR 2.08 (95% CI [1.31-3.31])) showed prominent association with NSSI. Multivariate Logistic regression models revealed that, repetitive NSSI (OR 4.54 (95% CI [3.66-5.63])) and NSSI severity (OR 9.01 (95% CI [6.11-13.29])) were positively associated with ASLEC.

Conclusion

NSSI is very common among children and adolescents in underdeveloped regions of south-western China. Negative life event are positively associated with NSSI, repeated NSSI, and severe NSSI. Negative life events centered intervention measures might be effective in reducing NSSI among school children and adolescents in underdeveloped regions of south-western China.

Rural youth in distress? Youth self-harm presentations to a rural hospital over 10 years

Introduction Despite growing awareness of increasing rates of youth suicide and self-harm in New Zealand, there is still little known about self-harm among rural youth. Aim This study compared: (1) rates of youth self-harm presentations between a rural emergency department (ED) and nationally available rates; and (2) local and national youth suicide rates over the decade from January 2008 to December 2017. Methods Data were requested on all presentations to Ashburton Hospital ED coded for 'self-harm' for patients aged 15-24 years. Comparative data were obtained from the coroner, Ministry of Health and the 2013 census. Analyses were conducted of the effects of age, time, repetition, method, ethnicity and contact with mental health services on corresponding suicide rates. Results Self-harm rates in Ashburton rose in the post-earthquake period (2013-17). During the peri-earthquake period (2008-12), non-Māori rates of self-harm were higher than for Māori (527 vs 116 per 100000 youth respectively), reflecting the national trend. In the post-earthquake period, although non-Māori rates of self-harm stayed stable (595 per 100000), there was a significant increase in Māori rates of self-harm to 1106 per 100000 (Chi-squared = 14.0, P < 0.001). Youth living within the Ashburton township showed higher rates than youth living more rurally. Discussion Youth self-harm behaviours, especially self-poisoning, have increased since the Canterbury earthquakes in the Ashburton rural community. Of most concern was the almost ninefold increase in Māori self-harm presentations in recent years, along with the increasing prevalence among teenagers and females. Possible explanations and further exploratory investigation strategies are discussed.

Mental status and suicide probability of young people: A cross-sectional study

OBJECTIVE

The most important determinant of suicide ideation, tendency and initiative is the presence of mental disorders. Since the number of those who lost their lives due to suicide in the world rose rapidly among the young population, the World Health Organization emphasizes the importance of assessing young people in the high-risk age group to prevent suicidal behavior. This study aimed to determine psychological symptom levels and suicide probability in young people.

METHOD

The cross-sectional research consisted of 15-24 year-old individuals (N=348), who have sought a psychiatric clinic between February and June, 2015. The Research Data was collected by applying Data Collection Form, Suicide Probability Scale (SPS) and Brief Symptom Inventory (BSI). SPSS 22.0 statistical package program was used for data analysis.

RESULTS

There was a statistically significant difference (p<0.05) between the mean SPS scores according to education, psychiatric treatment, self-harm, smoking and drinking status of the participants in the study. Apart from this, there was also a statistically significant correlation between anxiety, depression, negative self and hostility according to the SPS and BSI subscales (p<0.001, r=0.739; p<0.001, r=0.729; p<0.001, r=0.747; p<0.001, r=0.715; respectively).

CONCLUSION

The results of our study show that suicide risk is significantly higher in young people with depression, anxiety, negative self-perception and hostility symptoms. In this regard, we suggest the relevance of assessing the suicide risk of young people seeking a psychiatric clinic, with thorough attention to those who have high potential for suicide.

Self-inflicted Cut Injury as Common Method of Deliberate Self Harm: A Retrospective Study from Nepal

CONTEXT

Deliberate self-injury, a fairly common condition is present across all culture. It is defined as intentional, direct injuring of body tissue without suicidal intent. We continue to lack a sufficient understanding of this behavior in the context of South East Asian region.

AIMS

This study aims to explore the characteristics of self-cutting, and gender differences in homologous group of youth applying for foreign employment in Nepal.

SETTINGS AND DESIGN

Cross-sectional, single interview method in an out-patient setting.

SUBJECTS AND METHODS

The youths applying for foreign employment were screened for self-harm attempt using single question. Screen positive individuals were applied with inclusion and exclusion criteria. The data were collected in a single interview by consultant psychiatrist.

RESULTS

Males were more than females and the mean age (standard deviation) at the time of act and current presentation were 16.52 (3.13) and 24.70 (5.54) years, respectively. Various methods were used in self-inflicting cut, and certain amount of stress was present in the majority of the participants. There was no significant difference between male and female in all descriptive characteristics except for mean age at the time of presentation.

CONCLUSIONS

The descriptive results from Nepal are keeping with most of the published literature. The study is the first one from Nepal, and we expect that this will help in laying a good foundation for further studies with stronger methodologies.

Identifying depression among adolescents using three key questions: a validation study in primary care

BACKGROUND

Depression in adolescents is a serious psychiatric illness. GPs play an important role in identifying adolescents with depression and those at risk of developing depression. Few validated tools are suitable for identifying adolescent depression in general practice.

AIM

To determine if three verbally asked key questions are valid for identifying depression in adolescents.

DESIGN AND SETTING

A cross-sectional, general practice multicentre, validation study was conducted in Oslo, Norway, and Aarhus, Denmark.

METHOD

A total of 294 adolescents answered three verbally asked key questions followed by a Composite International Diagnostic Interview (CIDI) for psychiatric diagnosis. Inclusion criteria were age (14-16 years) and fluency in the Norwegian or Danish language. The primary outcome was ROC curve statistics in terms of sensitivity and specificity, predictive values, and likelihood ratios of the three key questions. Secondary outcomes were Loevinger's H, Cronbach's α, and prevalence of depression.

RESULTS

The three key questions met the criteria for construct and criterion validity for detecting depression among the adolescents. ROC curve statistics for the three key questions demonstrated an AUC of 0.79 for the answer 'yes' to either screening question and of 0.73 for the answer 'yes' to the help question. The positive predictive value was 31% and the negative predictive value was 97%.

CONCLUSION

The three key questions are useful for identifying depression in adolescents in primary health care.

Self-harm and its association with internet addiction and internet exposure to suicidal thought in adolescents

BACKGROUND/PURPOSE

Self-harm (SH) is a risk factor for suicide. We aimed to determine whether internet addiction and internet exposure to confided suicidal ideation are associated with SH in adolescents.

METHODS

This study was a cross-sectional survey of students who self-completed a series of online questionnaires including a sociodemographic information questionnaire, questionnaire for suicidality and SH, Chen Internet Addiction Scale (CIAS), Patient Health Questionnaire (PHQ-9), multi-dimensional support scale (MDSS), Rosenberg self-esteem scale (RSES), Alcohol Use Disorder Identification Test-Consumption (AUDIT-C), and questionnaire for substance abuse.

RESULTS

A total of 2479 students completed the questionnaires (response rate = 62.1%). They had a mean age of 15.44 years (range 14-19 years; standard deviation 0.61), and were mostly female (n = 1494; 60.3%). The prevalence of SH within the previous year was 10.1% (n = 250). Among the participants, 17.1% had internet addiction (n = 425) and 3.3% had been exposed to suicidal content on the internet (n = 82). In the hierarchical logistic regression analysis, internet addiction and internet exposure to suicidal thoughts were both significantly related to an increased risk of SH, after controlling for gender, family factors, exposure to suicidal thoughts in the real life, depression, alcohol/tobacco use, concurrent suicidality, and perceived social support. However, the association between internet addiction and SH weakened after adjusting for the level of self-esteem, while internet exposure to suicidal thoughts remained significantly related to an increased risk of SH (odds ratio = 1.96; 95% confidence interval: 1.06-3.64).

CONCLUSION

Online experiences are associated with SH in adolescents. Preventive strategies may include education to increase social awareness, to identify the youths most at risk, and to provide prompt help.

Direct and indirect effects of maltreatment typologies on suicidality in a representative Northern Irish sample: Psychopathology only partially mediates the relationship

There has been a rise in suicide rates among men who grew up during the 1970's in Northern Ireland (NI). Conflict exposures (CEs) have been linked with suicide ideation but not attempts. Civil conflict has also been linked with aggressive parenting which is associated with the development of aggressive drives, psychopathology and suicidality. This study investigated (1) cohort specific associations between latent classes (LCs) of maltreatment and (2) associations between LCs, CEs, psychopathology and suicidality. Data were from NI Study of Health and Stress (N = 1986). Maltreatment and suicidality were queried using validated measures. Psychiatric assessments were based on DSM-IV criteria. Logistic regression, latent class analysis, chi square tests and mediation analyses were conducted. Two at risk LCs were identified, entitled "family violence exposure" (FVE, 10.4%; Male, 55.4%) and "family violence and sexual abuse exposure" (FVSAE, 1.2%; Female, 90.5%). Both were more likely to have experienced CEs (FVE = 71%; FVSAE = 77.5%) than the low risk class. The FVE were more likely to be male; aged 35-49 and to suffer from a mental disorder. The FVSAE class all endorsed rape, were more likely to be separated and to suffer from a mental disorder. CEs uniquely predicted ideation but not enactment. Psychopathology partially mediated the relationship between LCs and suicidality. FVE and FVSAE directly increased the odds of enactment. These findings are original and highly pertinent and they should be used to inform any strategy for addressing the cohort specific and trauma related rise in suicide rates in NI.

Incidence and Course of Adolescent Deliberate Self-Harm in Victoria, Australia, and Washington State

PURPOSE

There have been few longitudinal studies of deliberate self-harm (DSH) in adolescents. This cross-national longitudinal study outlines risk and protective factors for DSH incidence and persistence.

METHODS

Seventh and ninth grade students (average ages 13 and 15 years) were recruited as state-representative cohorts, surveyed, and then followed up 12 months later (N = 3,876), using the same methods in Washington State and Victoria, Australia. The retention rate was 99% in both states at follow-up. A range of risk and protective factors for DSH were examined using multivariate analyses.

RESULTS

The prevalence of DSH in the past year was 1.53% in Grade 7 and .91% in Grade 9 for males and 4.12% and 1.34% for Grade 7 and Grade 9 females, respectively, with similar rates across states. In multivariate analyses, incident DSH was lower in Washington State (odds ratio [OR] = .67; 95% confidence interval [CI] = .45-1.00) relative to Victoria 12 months later. Risk factors for incident DSH included being female (OR = 1.93; CI = 1.35-2.76), high depressive symptoms (OR = 3.52; CI = 2.37-5.21), antisocial behavior (OR = 2.42; CI = 1.46-4.00), and lifetime (OR = 1.85; CI = 1.11-3.08) and past month (OR = 2.70; CI = 1.57-4.64) alcohol use relative to never using alcohol.

CONCLUSIONS

Much self-harm in adolescents resolves over the course of 12 months. Young people who self-harm have high rates of other health risk behaviors associated with family and peer risks that may all be targets for preventive intervention.

Coping Strategies in Adolescents Who Self-Harm

Background: Adolescent self-harm (SH) is a major public health concern, associated with poor outcomes. The use of ineffective coping is often referred to in explanatory models of adolescent SH. Aims: To assess the relationship between SH and coping strategies in a large sample of school-aged adolescents. Method: A sample of public school students (n = 1,713), aged between 12 and 20 years, were examined using an anonymously completed questionnaire. SH was defined according to strict criteria through a two-stage procedure. Study participants were divided into two groups: no self-harm and lifetime self-harm. The differences between groups were explored, including logistic regression analyses (controlling for anxiety and depression effects), to reveal which coping strategies better predicted lifetime SH. Results: The use of nonproductive strategies was associated with SH in both genders, particularly self-blame and tension reduction. Strategies involving consulting significant others for support were used less in the SH group, especially among male subjects. The preferential use of a productive coping style was negatively associated with the SH group in both genders. Conclusion: The results support previous data regarding a different pattern of coping strategies used by adolescents who harm themselves. The use of self-rating instruments and the cross-sectional nature of the study limit our results.

Differences on adolescent life goal profile scale between a clinical and non-clinical adolescent sample

OBJECTIVE

This study aimed to determine similarities and differences on perceived importance and perceived attainability of life goals between a clinical and non-clinical adolescent sample.

METHOD

244 students and 54 adolescent patients completed the Adolescent Life Goal Profile Scale (ALGPS). The ALGPS measures perceived importance and perceived attainability of four main life goal categories: Relations, Generativity, Religion, and Achievements. As a control, we used five measures of mental health, quality of life, and personality.

RESULTS

There were no differences on perceived importance on the Generativity, Religion, and Achievement life goal factor, but patients perceived relation-oriented goals less important than non-patients. Perceived attainability of life goals factors was lower for patients on all life goals except for Generativity. Compared to non-patients, patients were less happy and satisfied and had lower sense of coherence and self-efficacy. Patients were also less emotionally stable, had lower conscientiousness, but higher intellect.

CONCLUSIONS

Though patients appear less content with life in general than non-patients, chances are that they uphold their concern and care for others, remain devoted in their religious stand, and stay committed to their achievement-related goals. The lower perceived importance of relations within the patient group should be awarded clinical attention.

Evaluation of the Relation between Deliberate Self-Harm Behavior and Childhood Trauma Experiences in Patients Admitted to a Secondary-Care Psychiatric Outpatient Clinic for Adolescents and Young Adults

INTRODUCTION

The aim of this study was to determine the prevalence and the features of deliberate self-harm (DSH) behavior in patients admitted to the psychiatric outpatient clinic for adolescents and young adults and also to detect the association between the act of DSH and childhood traumas.

METHOD

In this study, we included all patients who were admitted to the secondary-care psychiatric outpatient clinic for adolescents and young adults in Bakırkoy Research and Training Hospital Psychiatry, Neurology and Neurosurgery throughout a month. A sociodemographic data form, the Childhood Trauma Questionnaire (CTQ-28), Childhood Abuse and Neglect Question List and the Deliberate Self-Harm and Intent Screening Form were applied to three hundred participants.

RESULT

The prevalence of DSH was 50.0% among the participants (56.8% for females and 28.8% for males). Childhood abuse was detected in 57.0% of all participants (60.4% of females and 46.6% of males). Among patients with act of DSH, the rate of childhood abuse was 71.3%, while it was 42.7% in the subjects without act of DSH.

CONCLUSION

DSH is a common behavior among adolescent psychiatric patients. It is more common in females than in males. The prevalence of experience of childhood abuse and neglect is remarkably high and is associated with self-harm behavior.

Incidence and risk factors for suicide attempts in a general population of young people: a Danish register-based study

OBJECTIVE

To estimate the Danish epidemiological long-term incidence rates for suicide attempts in the general population of children and adolescents, and to analyze the impact from single and multiple risk factors on the risk of suicide attempts.

METHOD

We used longitudinal register data from a total cohort of all individuals born between 1983 and 1989 and living in Denmark to calculate incidence rates. From the cohort, we identified all who have attempted suicide, and matched 50 controls to each case. A nested case-control design was used to estimate the impact from risk factors on the risk for index suicide attempts. We established a link to the biological parents and identified risk factors for two generations. Risk factors were analyzed in a conditional logistic regression model.

RESULTS

We identified 3718 suicide attempters and 185,900 controls (189,618 individuals, aged 10-21 years). We found increasing incidence rates during the period 1994-2005, and higher incidence rates for girls and the oldest adolescents. Mental illness was the strongest independent risk factor (IRR = 4.77, CI = (4.35-5.23), p < 0.0001), but parental mental illness (psychopharmacological drugs: IRR = 1.27, CI = (1.18-1.37), p < 0.0001) and socio-demographic factors (parents not living together: IRR = 1.38, CI = (1.28-1.48), p < 0.0001) were also significant independent risk factors. Exposure to multiple risk factors increased the risk significantly.

CONCLUSIONS

Suicide attempt is a multi-factorial problem, and a problem on the increase in the period studied. Individuals exposed to multiple risk factors are at the highest risk for suicide attempts, and when spotted or in contact with authorities they should be given proper care and treatment to prevent suicide attempts and death.

The effect of cognitive behavior therapy on decision making in adolescents who self-harm: a pilot study

Research shows poor decision making in adolescents who self-harm and a positive correlation between decision-making abilities and duration since last self-harm episode. This exploratory study investigated whether decision making in self-harming adolescents could be improved through treatment with a novel cognitive behavior therapy (CBT). It also investigated whether improvement in decision making following treatment was linked to self-harm cessation. Adolescent self-harmers receiving CBT (n = 24) or no treatment (n = 9) and healthy controls (n = 22) were longitudinally compared on the Iowa gambling task (IGT). Significant IGT improvements were only observed for adolescents who self-harm following CBT. CBT may benefit adolescent self-harmers and generate decision-making improvements.

Examining the link between nonsuicidal self-injury and suicidal behavior: a review of the literature and an integrated model

Self-injurious behaviors (SIB) refer to behaviors that cause direct and deliberate harm to oneself, including nonsuicidal self-injury (NSSI), suicidal behaviors, and suicide. Although in recent research, NSSI and suicidal behavior have been differentiated by intention, frequency, and lethality of behavior, researchers have also shown that these two types of self-injurious behavior often co-occur. Despite the co-occurrence of NSSI and suicidal behavior, however, little attention has been given as to why these self-injurious behaviors may be linked. Several authors have suggested that NSSI is a risk factor for suicidal behavior, but no comprehensive review of the literature on NSSI and suicidal behavior has been provided. To address this gap in the literature, we conducted an extensive review of the research on NSSI and suicidal behavior among adolescents and adults. First, we summarize several studies that specifically examined the association between NSSI and suicidal behavior. Next, three theories that have been proposed to account for the link between NSSI and suicidal behavior are described, and the empirical support for each theory is critically examined. Finally, an integrated model is introduced and several recommendations for future research are provided to extend theory development.

Family environment, expressed emotion and adolescent self-harm: a review of conceptual, empirical, cross-cultural and clinical perspectives

Self-harm in young people is a complex and pervasive problem with a number of co-existing risk factors. Although research has implicated a range of family variables in understanding the onset, maintenance and prevention of adolescent self-harm, relatively little attention has been given to the expressed emotion (EE) construct. Based on a narrative review and synthesis of peer-reviewed literature up to and including 2011, this paper considers the conceptual background and empirical evidence for the role of family environment in the expression of adolescent self-harm, with a particular focus on EE. The clinical implications of this literature for working with young people and families from different cultures are also addressed. In summary, the surveyed research provides insufficient evidence for a direct causal link between family environment and adolescent self-harm, with questions raised about the temporal sequencing of measured variables, specificity of implicated family risk factors, and the nature and role of protective factors in families. Emerging evidence for an association between high EE and adolescent self-harm requires replication in well-controlled, prospective studies. There is also a lack of empirically-supported, family-based treatment modalities for adolescents who self-harm. Intervention strategies should be guided by personalised formulation, taking into account individual vulnerabilities, strengths and social contexts, as well as cultural norms for family environment.

Self-harm and suicide attempts among high-risk, urban youth in the U.S.: shared and unique risk and protective factors

The extent to which self-harm and suicidal behavior overlap in community samples of vulnerable youth is not well known. Secondary analyses were conducted of the “linkages study” (N = 4,131), a cross-sectional survey of students enrolled in grades 7, 9, 11/12 in a high-risk community in the U.S. in 2004. Analyses were conducted to determine the risk and protective factors (i.e., academic grades, binge drinking, illicit drug use, weapon carrying, child maltreatment, social support, depression, impulsivity, self-efficacy, parental support, and parental monitoring) associated with both self-harm and suicide attempt. Findings show that 7.5% of participants reported both self-harm and suicide attempt, 2.2% of participants reported suicide attempt only, and 12.4% of participants reported self-harm only. Shared risk factors for co-occurring self-harm and suicide attempt include depression, binge drinking, weapon carrying, child maltreatment, and impulsivity. There were also important differences by sex, grade level, and race/ethnicity that should be considered for future research. The findings show that there is significant overlap in the modifiable risk factors associated with self-harm and suicide attempt that can be targeted for future research and prevention strategies.

Mental disorders in self-cutting adolescents

PURPOSE

Self-cutting as a form of self-harm is common in general population adolescents. The aim of this study was to investigate the prevalence of mental disorders and associated factors among self-cutting community-dwelling adolescents.

METHODS

A sample of adolescents who reported current self-cutting (n = 80) was drawn from a large sample of community adolescents (n = 4205). Of these 80 individuals, 44 consented to further detailed assessment. An age- and gender-matched control subject was selected for each study subject. Data collection included Structured Clinical Interviews for DSM-IV-TR, the Beck Depression Inventory, the Alcohol Use Disorders Identification Test (AUDIT), and the Youth Self-Report for adolescents aged 11-18 years (YSR).

RESULTS

Major depressive disorder (63% vs. 5%), anxiety disorders (37% vs. 12%), and eating disorders (15% vs. 0%) were more common among self-cutting girls (n = 41) than among controls. None of the self-cutting boys (n = 3) had a DSM-IV-TR Axis I mental disorder. In multivariate model, the presence of major depressive disorder, the AUDIT score and the YSR internalizing subscale score were the factors that were independently associated with the presence of self-cutting in girls.

CONCLUSIONS

Major depressive disorder, signs of alcohol misuse, and internalizing behavior strongly associate with self-cutting in community-dwelling adolescents, especially in girls.

Age and gender differences in the use of various poisoning methods for deliberate parasuicide cases admitted to loghman hospital in Tehran (2000-2004)

Different methods of poisoning used by individuals with the diagnosis of parasuicide admitted to the Loghman Hospital, Tehran, from 2000 to 2004 were investigated, with particular focus on gender and age differences. Drugs, pesticides, and other agricultural chemicals (women: 12.7%, men: 9%) were the most commonly used methods. In males, the percentage of use of drugs increased with age, but the frequency of pesticides use decreased with age. In females, drugs were most often used in the youngest age group, whereas the use of pesticides was lowest in the youngest age category. Females outnumbered males, especially in the youngest age group of 10 to 19 years olds. Drugs and pesticides were the substances used most often for parasuicide in each age group regardless of gender.

Associations between psychotic-like experiences and mental health status and other psychopathologies among Japanese early teens

Psychotic-like experiences (PLEs) are considered predictive of mental health problems later in life. However, little has been known about the mental health status and psychopathological distress in adolescents with PLEs in the general population. To investigate the associations between PLEs and mental health status or psychopathologies in a community sample of adolescents in a school-based cross-sectional fashion, PLEs were studied using a self-rating questionnaire in 5073 Japanese junior-high school students aged 12-15 years. Mental health status was evaluated using the 12-item General Health Questionnaire (GHQ-12). Psychopathologies, lifestyle, victimization, and interpersonal and help-seeking attitudes were also studied using a self-rating questionnaire. Fifteen percent of the students reported definitely having experienced at least one PLE. A dose-response relationship between the severity of PLEs and the prevalence of poor mental health status was observed. PLEs were also significantly associated with psychopathologies (strong anxiety in the classroom: OR = 1.4, 95% CI 1.2-1.6; suicidal ideation: OR = 2.1, 95% CI 1.8-2.4; self-harm behaviors: OR = 1.4, 95% CI 1.0-1.9; difficulty falling asleep due to hypersensitivity to environmental noise: OR = 1.7, 95% CI 1.4-2.0; difficulty concentrating due to hypersensitivity to environmental noise: OR = 1.5, 95% CI 1.3-1.8; physically assaulting others: OR = 1.3, 95% CI 1.0-1.5; bullying others, OR = 1.3, 95% CI 1.1-1.5; irritability when exchanging e-mails: OR = 1.3, 95% CI 1.0-1.6). Adolescents with PLEs in the community suffer from a wide range of psychopathological problems during crucial developmental periods [corrected]