Attention-deficit hyperactivity disorder and nonsuicidal self-injury in a clinical sample of adolescents: the role of comorbidities and gender

ADHD Symptoms in Childhood and Big Five Personality Traits in Adolescence: A Five-Year Longitudinal Study in Girls

Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental condition characterized by developmentally extreme and impairing symptoms of inattention and/or hyperactivity/impulsivity. Great interest has emerged in the ways ADHD and its underlying symptom dimensions relate to the development of personality traits. Much extant research on this topic is cross-sectional, relying on self-report measures and male samples. Herein, we present data from a prospective, longitudinal study of a socioeconomically and racially diverse sample of girls, including those with ADHD and a matched neurotypical comparison sample. We examined how parent- and teacher-reported ADHD in middle childhood relate to self-reported Big Five personality traits in adolescence. As expected, childhood ADHD diagnosis prospectively predicted lower self-reported Conscientiousness, lower Agreeableness, and higher Neuroticism in adolescence. With ADHD diagnosis covaried, Inattention (IA) predicted only low Conscientiousness, Hyperactivity/Impulsivity (HI) predicted only low Agreeableness, and neither predicted adolescent Neuroticism. An exploratory moderator analysis showed that family income moderated the effects of IA and HI on the negativity of adolescent self-descriptions of their own personalities, with more pronounced negative effects for girls in families with higher (rather than lower) income. Familial pressures to achieve in higher-income families may be linked to more pronounced negative ramifications of ADHD on personality development.

The role of cognitive disengagement syndrome in non-suicidal self-injury among adolescents with attention deficit hyperactivity disorder

AIMS

We aimed to investigate the relationship between Cognitive Disengagement Syndrome (CDS) and non-suicidal self injury (NSSI) in adolescents with attention deficit hyperactivity disorder (ADHD).

METHODS

A semi-structured psychiatric interview and an NSSI screening questionnaire were conducted. Questionnaires assessing CDS (with daydreamer, sleepy, and slow subdimensions), depression, anxiety, self-esteem, emotion regulation, coping strategies, and loneliness were administered.

RESULTS

Among 104 participants (n: 63, 60.6% girls), the combined type of ADHD was the most common (66.3%), and 35 adolescents (27 girls) were in the NSSI+ group. Although only depression and ADHD were found to be predictors of NSSI in ADHD, CDS was associated with many risk factors of NSSI in ADHD: depression, anxiety, emotion dysregulation, low self-esteem, and emotion-oriented coping ways. After controlling for the effects of cognitive problems/inattentiveness, depression, and anxiety, CDS still correlated with low self-esteem and emotion dysregulation. The daydreamer and slow sub-dimensions of CSD differed between NSSI+ and NSSI- groups, while sleepy did not.

CONCLUSIONS

CDS is associated with several relevant factors, indirectly relating it to self-harm in ADHD. CDS increases the vulnerability to mental health changes that could lead to NSSI in adolescence with ADHD.

Non-suicidal Self-injury History Moderates the Association Between Maternal Emotional Support and Adolescent Affect During Conflict

Onset of non-suicidal self-injury (NSSI) is most frequent during adolescence. Etiological models indicate that abnormal affective reactivity and regulation within interpersonal contexts is related to heightened NSSI risk. The current study examined the effects of maternal emotional support on adolescent sympathetic nervous system (SNS) activity and observed anger during a conflict discussion among 56 mother-daughter dyads consisting of healthy adolescents and adolescents with a history of self-injury. During the conflict discussion task, maternal emotional support and adolescent anger were coded from behavior, and cardiovascular pre-ejection period was used to index SNS responding. Results demonstrated that maternal emotional support was negatively associated with adolescent anger and SNS activity during the conflict. However, these associations were not significant among adolescents with heightened NSSI history. Maternal emotional support may serve as an interpersonal mechanism for adolescent physiological and behavioral regulation, yet may function differently among adolescents with more frequent NSSI.

Specific and cumulative effects of childhood maltreatment on nonsuicidal self-injury in Chinese adolescents: The moderating effect of sleep disturbance

BACKGROUND

Numerous studies have examined the relationship between childhood maltreatment (CM) and nonsuicidal self-injury (NSSI). However, few studies have explored both the specific and cumulative effects of CM on NSSI. Additionally, the impact of sleep disturbance on the association between CM and NSSI remains unclear.

OBJECTIVES

To comprehensively explore the effects of CM on NSSI, and to determine whether these effects are moderated by sleep disturbance.

PARTICIPANTS AND SETTING

A retrospective study was conducted in April 2021 among a representative sample of 21,340 students aged 11-20 years in China.

METHODS

All participants completed questionnaires assessing CM, sleep disturbance, and NSSI. Adjusted multivariate logistic regression models were utilized to evaluate the associations between CM and NSSI, as well as the impact of sleep disturbance.

RESULTS

The findings revealed that 13.0 % of adolescents reported occasional NSSI, while 25.2 % reported repetitive NSSI. Except for sexual abuse, all subtypes of CM were significantly associated with increased odds of both occasional and repetitive NSSI. A significant dose-response relationship was observed between cumulative CM and repetitive NSSI. Stratification analyses by sleep disturbance indicated that adolescents reporting sleep disturbance had a higher risk of developing repetitive NSSI, irrespective of the type of CM experienced. Furthermore, a dose-response relationship was identified between cumulative CM and repetitive NSSI among adolescents reporting sleep disturbance.

CONCLUSION

This study demonstrated that CM increases the risk of NSSI among Chinese adolescents, and sleep disturbance plays a moderating role. Interventions targeting sleep disturbance may hold significance in reducing NSSI.

A study of the interactive mediating effect of ADHD and NSSI caused by co-disease mechanisms in males and females

Background

Non-suicidal self-injury (NSSI), of which the predisposing factors are complex and diverse, profoundly affects the physical and mental health of young people. Therefore, this work established an NSSI intermediary network model considering the interaction of multiple factors. A mediating effect between attention-deficit/hyperactivity disorder (ADHD) and NSSI, considering the influence of comorbidities, such as depression, anxiety, and impulsive personality, was proposed based on sex differences.

Methods

A total of 2,689 middle school students in Ningbo City, Zhejiang Province, China, were randomly sampled and participated in this study. Data regarding their demographic characteristics, attention deficit, hyperactivity/impulsivity, NSSI, anxiety, depression, internet addiction, and other comorbid symptoms were collected and analyzed. After initially screening the data, variables were assessed for significance using a single-factor inter-group difference analytic method, and a binary logistic regression analysis was performed. The intermediary effect of factors influencing NSSI in males and females was also analyzed.

Results

The overall NSSI rate was 15.16%. The results showed that the impact of individual impulsivity characteristics (impulsiveness, the ADHD with hyperactivity/impulsivity subtype) on NSSI behavior was not significant (regression results, P > 0.05). The degree of association between ADHD with attention deficit and ADHD with comprehension deficit subtypes, and other comorbid symptoms (depression, anxiety, and internet addiction disorder) and NSSI, with odds ratios (ORs) of 7.6/6.42/436.68/3.82/1.86, and 95% bootstrap confidence intervals (CIs) of 4.64, 12.87/3.46, 12.67/137.42, 2659.13/2.32, 6.37/1.31, 2.82, respectively. The results also showed significant effects of ADHD subtypes on comorbid symptoms and the path effects of NSSI (P < 0.01). Among them, the mediating effect was the strongest when anxiety was the mediating variable, and the mediating effect of girls was higher than that of boys.

Conclusion

The results of this work demonstrated the influence of ADHD symptoms on NSSI behavior. Among patients with ADHD, patients with subtypes with obvious attention deficit characteristics were more likely to exhibit NSSI behavior, whereas the hyperactive impulse subtype had no direct impact on NSSI. We conclude that adolescent impulsivity may not be directly related to NSSI behavior and that impulsive characteristics jointly affect NSSI behavior through a series of NSSI comorbid symptoms. Notably, the probability of symptom onset and the degree of comorbidity was significantly higher in girls than in boys of the same age, and girls were more prone to NSSI behavior. These findings provide effective theoretical support for the prevention and treatment of adolescent NSSI behavior.

Proposition of a transdiagnostic processual approach of emotion dysregulation based on core triggers and interpersonal styles

Emotion dysregulation (ED) has primarily been described in patients suffering from borderline personality disorder (BPD) and is an integral part of this diagnosis, but it is also a transdiagnostic construct that can be found in several other psychiatric disorders. The strong relationships between ED and BPD may lead clinicians to underestimate ED associated to other clinical contexts. This can lead to difficulties in diagnostic and treatment orientation, especially in the context of comorbidities. In this article, after reviewing the literature on the development and functioning of emotion dysregulation, and on the evidence for emotion dysregulation in eight disorders (borderline personality disorder, pathological narcissism with/without narcissistic personality disorder, obsessive-compulsive personality disorder, antisocial personality disorder, bipolar disorder, autism spectrum disorder, complex post-traumatic stress disorder, and adult attention deficit hyperactivity disorder), we present a transdiagnostic processual model of emotion dysregulation based on core triggers and interpersonal styles to try to address this issue and to provide a simple but technical tool to help clinicians in their diagnostic assessment and treatment orientation. By focusing more on typical patterns and interpersonal dynamics than only on categories, we believe that this model may contribute to the actual need for improvement of our current psychiatric classifications, alongside other well-studied and under-used dimensional models of psychopathology (e.g., HiTOP, AMPD), and may be useful to build more specific treatment frameworks for patients suffering from ED.

Psychiatric comorbidities in women with cardiometabolic conditions with and without ADHD: a population-based study

BACKGROUND

Leveraging a large nationwide study of Icelandic women, we aimed to narrow the evidence gap around female attention-deficit/hyperactivity disorder (ADHD) and cardiometabolic comorbidities by determining the prevalence of obesity, hypertension, type 2 diabetes, and cardiovascular diseases among women with ADHD and examine the association between cardiometabolic conditions and co-occurring ADHD with anxiety and mood disorders, alcoholism/substance use disorder (SUD), self-harm, and suicide attempts.

METHODS

We conducted a cross-sectional analysis of the nationwide, all-female, population-based SAGA Cohort Study (n = 26,668). To ascertain diagnoses and symptoms, we used self-reported history of ADHD diagnoses, selected cardiometabolic conditions and psychiatric disorders, and measured current depressive, anxiety, and PTSD symptoms through appropriate questionnaires (PHQ-9, GAD-7, and PCL-5). We calculated age-adjusted prevalences of cardiometabolic conditions by women's ADHD status and estimated adjusted prevalence ratios (PR) and 95% confidence intervals (CI), using modified Poisson regression models. Similarly, we assessed the association of cardiometabolic conditions and co-occurring ADHD with current psychiatric symptoms and psychiatric disorders, using adjusted PRs and 95% CIs.

RESULTS

We identified 2299 (8.6%) women with a history of ADHD diagnosis. The age-adjusted prevalence of having at least one cardiometabolic condition was higher among women with ADHD (49.5%) than those without (41.7%), (PR = 1.19, 95% CI 1.14-1.25), with higher prevalence of all measured cardiometabolic conditions (myocardial infarctions (PR = 2.53, 95% CI 1.83--3.49), type 2 diabetes (PR = 2.08, 95% CI 1.66-2.61), hypertension (PR = 1.23, 95% CI 1.12-1.34), and obesity (PR = 1.18, 95% CI 1.11-1.25)). Women with cardiometabolic conditions and co-occurring ADHD had, compared with those without ADHD, substantially increased prevalence of (a) all measured mood and anxiety disorders, e.g., depression (PR = 2.38, 95% CI 2.19-2.58), bipolar disorder (PR = 4.81, 95% CI 3.65-6.35), posttraumatic stress disorder (PR = 2.78, 95% CI 2.52-3.07), social phobia (PR = 2.96, 95% CI 2.64-3.32); (b) moderate/severe depressive, anxiety, and PTSD symptoms with PR = 1.76 (95% CI 1.67-1.85), PR = 1.97 (95% CI 1.82-2.12), and PR = 2.01 (95% CI 1.88-2.15), respectively; (c) alcoholism/SUD, PR = 4.79 (95% CI 3.90-5.89); and (d) self-harm, PR = 1.47 (95% CI 1.29-1.67) and suicide attempts, PR = 2.37 (95% CI 2.05-2.73).

CONCLUSIONS

ADHD is overrepresented among women with cardiometabolic conditions and contributes substantially to other psychiatric comorbidities among women with cardiometabolic conditions.

Physical and mental illness comorbidity among individuals with frequent self-harm episodes: A mixed-methods study

Background

Research has indicated an increased risk of self-harm repetition and suicide among individuals with frequent self-harm episodes. Co-occurring physical and mental illness further increases the risk of self-harm and suicide. However, the association between this co-occurrence and frequent self-harm episodes is not well understood. The objectives of the study were (a) to examine the sociodemographic and clinical profile of individuals with frequent self-harm (regardless of suicidal intent) episodes and, (b) the association between physical and mental illness comorbidity, self-harm repetition, highly lethal self-harm methods, and suicide intent.

Methods

The study included consecutive patients with five or more self-harm presentations to Emergency Departments across three general hospitals in the Republic of Ireland. The study included file reviews (n = 183) and semi-structured interviews (n = 36). Multivariate logistic regression models and independent samples t-tests were used to test the association between the sociodemographic and physical and mental disorders comorbidity on highly lethal self-harm methods and suicidal intent, respectively. Thematic analysis was applied to identify themes related to physical and mental illness comorbidity and frequent self-harm repetition.

Findings

The majority of individuals with frequent self-harm episodes were female (59.6%), single (56.1%), and unemployed (57.4%). The predominant current self-harm method was drug overdose (60%). Almost 90% of the participants had history of a mental or behavioral disorder, and 56.8% had recent physical illness. The most common psychiatric diagnoses were alcohol use disorders (51.1%), borderline personality disorder (44.0%), and major depressive disorder (37.8%). Male gender (OR = 2.89) and alcohol abuse (OR = 2.64) predicted the risk of a highly lethal self-harm method. Suicide intent was significantly higher among those with a diagnosis of major depressive disorder (t = 2.43; p = 0.020). Major qualitative themes were (a) the functional meaning of self-harm (b) self-harm comorbidity (c) family psychiatric history and (d) contacts with mental health services. Participants described experiencing an uncontrollable self-harm urge, and self-harm was referred to as a way to get relief from emotional pain or self-punishment to cope with anger and stressors.

Conclusion

Physical and mental illness comorbidity was high among individuals with frequent self-harm episodes. Male gender and alcohol abuse were associated with highly lethal self-harm methods. The mental and physical illness comorbidity of individuals with frequent self-harm episodes should be addressed via a biopsychosocial assessment and subsequent indicated treatment interventions.

Associations of impulsivity, hyperactivity, and inattention with nonsuicidal self-injury and suicidal behavior: longitudinal cohort study following children at risk for neurodevelopmental disorders into mid-adolescence

BACKGROUND

The knowledge of how the separate Attention-Deficit/Hyperactivity Disorder (ADHD) subdimensions (impulsivity, hyperactivity, and inattention) are associated with nonsuicidal self-injury (NSSI) and suicidal behavior (SB) is limited. The objective of this study was to investigate the associations of childhood ADHD subdimensions with NSSI and SB in children at risk of neurodevelopmental disorders (NDDs; including ADHD).

METHODS

The sample (N = 391) included twin pairs where at least one twin screened positive for at least one NDD or common comorbidity at age 9 or 12. Data on ADHD subdimensions was collected through a telephone interview with a caregiver/legal guardian at age 9 or 12, and data on NSSI and SB was collected through an in-person clinical assessment at age 15. The associations between the ADHD subdimensions and NSSI or SB were tested in three different models: (1) univariable, (2) together with the other ADHD subdimensions, and (3) in a confounder-adjusted model including other NDD symptoms in addition to ADHD subdimensions, for NSSI and SB separately.

RESULTS

A total of 32 (8.2%) adolescents reported life-time engagement of NSSI, and 18 (4.6%) SB. Childhood impulsivity was associated with SB and childhood inattention with NSSI, in all models. Hyperactivity was not meaningfully associated with any of the outcomes.

CONCLUSION

Impulsivity and inattention, but not hyperactivity, may be of particular importance in understanding SB and NSSI. Brief screening for impulsivity and inattention in childhood could facilitate detection of children vulnerable to NSSI and SB and indicate valuable information for preventive and intervention strategies.

Psychotherapeutic interventions specifically developed for NSSI in adolescence: A systematic review

Non-suicidal self-injury (NSSI) is a clinically significant behavior with high relevance and prevalence, especially affecting approximately 17-18% of the adolescent population worldwide. The aim of this study is to perform a systematic review to evaluate the effectiveness of the available Specific Psychotherapeutic Interventions (SPI) focused on the reduction of NSSI behaviors. A systematic review was performed analyzing PsychINFO, MEDLINE, Web of Science, PubMed and Cochrane CentralRegister of Controlled Trials to identify studies of interest from January 2010 to December 2020. According to PRISMA guidelines, only 13 studies were included in the review. Six SPI were found to specifically and significantly reduce NSSI in adolescents: Developmental Group Psychotherapy (DGP), Therapeutic Assessment (TA), Cutting Down Program (CDP), Emotional Regulation Individual Therapy for Adolescents (ERITA), Treatment for Self-Injurious Behaviors (T-SIB) and Intensive Contextual Treatment (ICT). Furthermore, relevant improvements in anxiety and depression symptoms were observed. The results of this review demonstrate the effectiveness of these interventions, mainly the CPD and T-SIB, which are the only SPI that have been studied using Randomized Controlled Trial (RCT). Considering the clinical relevance and associated functional impairment of NSSI, more research is needed to replicate the results and to increase knowledge about SPIs.

Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions

Attention-deficit/hyperactivity disorder (ADHD) - and its underlying behavioral dimensions of inattention and hyperactivity-impulsivity - have been understudied in females. We first cover the conceptual issues of prevalence, diagnostic practices, diversity, comorbidity, and causal factors, plus forces limiting awareness of ADHD in females. After a narrative review of cross-sectional and longitudinal findings, we conclude the following. (a) Girls meet diagnostic criteria for ADHD at just under half the rates of boys, a ratio that becomes much closer to equal by adulthood. (b) Girls and women with ADHD show a predominance of inattention and associated internalizing problems; boys and men display greater levels of hyperactive-impulsive symptoms and associated externalizing problems. (c) Sex differences in ADHD symptoms and related outcomes depend heavily on the clinical versus nonreferred nature of the samples under investigation. (d) Females with ADHD experience, on average, serious impairments, with a particularly heightened risk for problems in close relationships and engagement in self-harm. (e) Clinicians may overlook symptoms and impairments in females because of less overt (but still impairing) symptom manifestations in girls and women and their frequent adoption of compensatory strategies. Our review of predictors and mediators of adult outcomes highlights (a) the potential for heterotypically continuous pathways in females with childhood ADHD and (b) developmental progressions to self-harm, intimate partner violence, unplanned pregnancy, and comorbid psychopathology. Focusing on ADHD in females is necessary to characterize causal and maintaining mechanisms with accuracy and to foster responsive interventions, as highlighted in our closing list of clinical implications and research priorities.

Different Ways to Drown Out the Pain: A Meta-Analysis of the Association Between Nonsuicidal Self-Injury and Alcohol Use

OBJECTIVE

There is a significant overlap in the motivations for nonsuicidal self-injury (NSSI) and alcohol use. Moreover, several theories would predict that more frequent alcohol use is likely associated with more NSSI engagement. Still, the size and direction of this association has not been well documented in the literature.

METHOD

To address this gap, the goal of this article was to conduct a meta-analysis of the relation between alcohol use and NSSI.

RESULTS

Across 57 samples and 141,669 participants, we found that there was a significant positive association between NSSI and alcohol use, odds ratio = 1.78, 95% confidence interval [1.53, 2.07], k = 64, m = 52. Moderator analyses found that this effect was stronger for younger samples and samples with more severe alcohol use problems.

CONCLUSIONS

These results help establish a link between NSSI and alcohol use. Implications and future directions for NSSI research and intervention are discussed.HighlightsThere are several reasons to think that NSSI and alcohol use are linked.No reviews or meta-analyses have been conducted.We found a significant and small effect linking greater NSSI with greater alcohol use.

Associations between executive function impairment and biochemical abnormalities in depressed adolescents with non-suicidal self-injury

BACKGROUND

H protons magnetic resonance spectroscopy (¹H-MRS) has been used to detect the biochemical metabolism changes and the mechanism of executive dysfunction in major depressive disorder (MDD). While, finding information associated with non-suicidal self-injury (NSSI) among adolescents with MDD is challenging. The present study aimed to examine the executive function and biochemical metabolism alterations, as well as to elucidate their associations in depressed adolescents with NSSI.

METHODS

A total of 86 adolescents with MDD (40 with NSSI, and 46 without NSSI) and 28 healthy controls were recruited in the current study. The executive function was assessed by Digital symbol test (DST), Wisconsin Card Sorting Test (WCST), Trail Making Test, part B (TMT-B), and Verbal fluency (VF). Bilateral metabolite levels of the prefrontal cortex (PFC), anterior cingulated cortex (ACC), lenticular nucleus (LN) of basal ganglia and thalamus were obtained by ¹H-MRS at 3.0 T, and then the ratios of N-acetyl aspartate (NAA) and choline-containing compounds (Cho) to creatine (Cr) were determined, respectively. Finally, association analysis was conducted to investigate their relationships.

RESULTS

The depressed adolescents with NSSI showed significantly lower VF scores than those without NSSI and healthy controls. We also found significantly higher NAA/Cr ratios in the right thalamus, while significantly lower Cho/Cr ratios in the right thalamus of NSSI group than the MDD without NSSI group and healthy controls. And NSSI group also showed lower NAA/Cr ratio in the right LN than the MDD without NSSI group. For MDD with NSSI, the NAA/Cr ratios of the left thalamus were positively correlated with the time of TMTB and the Cho/Cr ratios of the left ACC were positively correlated with the VF scores.

CONCLUSIONS

Depressed adolescents with NSSI may have executive dysfunction and NAA and Cho metabolism abnormalities in the thalamus. And the NAA/Cr ratios of the right LN could distinguish NSSI from depressed adolescents. Further, the executive dysfunction may be associated with the abnormal NAA metabolism in the left thalamus and ACC.

Self-harm as the first presentation of attention deficit hyperactivity disorder in adolescents

BACKGROUND

Self-harm (SH) in adolescence has previously been shown to significantly overlap with both attention deficit hyperactivity disorder (ADHD) and emotional dysregulation (ED). Our objective as such was to investigate the relationship between self-harm and ADHD in our population and consider its clinical relevance.

METHODS

This case series analysis examined 124 presentations of SH in 13- to 17 year-olds to Accident and Emergency Departments in South West London (97F:27M). Strength and Difficulties Questionnaires (SDQs) were used to screen for ADHD/hyperactivity and ED, and scores were compared with reference data obtained from Meltzer et al. (1999, International Review of Psychiatry (Abingdon, England), 15, 185).

RESULTS

Mean SDQ ADHD/hyperactivity scores were significantly higher in our SH sample compared to reference data (p < .0001). Furthermore, significantly greater ED scores were found in our sample compared with the control reference data.

CONCLUSION

Our findings contribute to the evidence for an important link between ADHD and clinical presentations of SH and suggest there to be value in screening girls presenting to A&E with self-harm for ADHD. We speculate that ED plays a role in the evolution of SH in dysregulated ADHD. We recommend that clinicians assessing adolescents have self-harmed to be aware of possible ADHD symptoms and screen as appropriate; however, future research examining the temporal association between ADHD, emotional dysregulation and self-harm is required to establish causal direction.

Non-Suicidal Self-Injury: An Observational Study in a Sample of Adolescents and Young Adults

Non-Suicidal Self-Injury (NSSI) is the self-inflicted destruction of body tissues without suicidal intent with a prevalence of 1.5% to 6.7% in the youth population. At present, it is not clear which emotional and behavioral components are specifically associated with it. Therefore, we studied NSSI in a clinical sample of youth using the Ottawa Self-injury Inventory and the Barratt Impulsiveness Scale 11. The Mann-Whitney test was used to compare the numerical responses provided to the tests. We found 54 patients with NSSI, with a mean age of 17 years. Scores were analyzed in the total sample and in four subgroups. In the total sample, Internal Emotion and External Emotion Regulation, Craving, Non-Planning and Total Impulsivity were significantly associated with NSSI. There were statistically significant differences in Craving between patients with multiple NSSI episodes, suicide attempts and multiple injury modes and patients of other corresponding subgroups, in Internal Emotion Regulation, Sensation Seeking and Motor Impulsivity between NSSI patients with suicide attempts and no suicide attempts, and in Cognitive Impulsivity between NSSI patients with multiple injury modes and one injury mode. It is necessary to carefully evaluate the components underlying NSSI in order to activate personalized treatment options.

Mental Health Care Costs Among Youth with Comorbid Mental Disorders

This exploratory study described the distribution of mental health service costs in youth with mental disorder and determined if costs differed for youth with comorbid internalizing and externalizing disorder compared to those with comorbid internalizing disorders. Data come from youth (8-17 years; n=75) receiving mental health services at a children's hospital in Canada. Billing amounts specified in the Health Insurance Act of Ontario were used to estimate costs. Overall, past-year service use costs were $7436.63. Hospitalizations represented the largest cost. Youth with comorbid internalizing and externalizing disorders had higher total (β=0.81 [0.17, 1.45]), hospital (β=0.93 [0.03, 1.84]), and professional (β=0.87 [0.04, 1.69]) costs. These preliminary findings suggest that comorbidity type is associated with the costs of past-year mental health services used by youth. Research is needed to understand the reasons for elevated costs and whether the increased services used by youth with comorbid internalizing and externalizing disorders are effective.

The Association of Nonsuicidal Self-Injury with Quality of Life and Mental Disorders in Clinical Adolescents-A Network Approach

Although earlier research has highlighted that psychiatric disorders significantly impair patients' quality of life (QoL), few studies have examined the relationship between nonsuicidal self-injury (NSSI) and QoL. Our aim was to investigate whether QoL mediates the mental disorder-NSSI relationship, and to study the QoL ratings agreement of self and parents in a clinical population of adolescents. We involved 202 adolescents from Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest, aged 13-18 years. All participants completed the Deliberate Self-Harm Inventory, Inventar zur Erfassung der Lebensqualität bei Kindern und Jugendlichen, and the Mini International Neuropsychiatric Interview Kid. To map the interrelationship between the NSSI, mental disorders, and QoL dimensions, Mixed Graphical Models were estimated. Adolescents with a history of NSSI rated their QoL to be significantly lower than adolescents without NSSI. Self and parents' QoL ratings are closer in the NSSI sample than in the no-NSSI sample. Among all QoL dimensions, only family problems had a direct significant association with NSSI engagement. Our results highlight that, contrary to our hypothesis, the presence of mental disorders mediates the relationship between most QoL dimensions and the occurrence of NSSI. Our results draw attention to the potential causal effect of environmental factors (e.g., peer problems) on mental disorders that, in turn, result in NSSI. The present paper highlights the importance of network modelling in clinical research.

Before the damage is done: Early childhood hyperactivity difficulties in adolescents with deliberate self-harm - findings from the DALSC cohort

BACKGROUND

Deliberate self-harm (DSH) is a growing issue among Danish adolescents, and a dramatic increase in the incidence of DSH has been observed since the turn of the millennium. The importance of early childhood factors on later development has been established, but research on the trajectories of DSH is still scarce, and longitudinal studies are much needed.

METHOD

Participants were 3,291 children and their mothers from The Danish Longitudinal Survey of Children (DALSC), a Danish population-based birth cohort from 1995. Logistic regression and mediation analyses were used to examine significant early childhood determinants of self-harming behavior in adolescence.

RESULTS

The study found that 17.9% of the children had a history with DSH at the age of 18 years. A significant relationship was found between the likelihood of DSH at the age of 18 years and hyperactivity difficulties assessed through the Strengths and Difficulties Questionnaire (SDQ) at 3 and 7 years of age. Using a mediation model, it is documented that difficulties in peer relationships at the age of 11 years is a partial mediator explaining 19% of the variation.

LIMITATIONS

i) a vague definition of self-harm in the questionnaires; ii) lack of sample representation as children of lower socio-economic groups have lower participation rates, and only Danish-ethnicity children have been sampled; iii) possibility of omitted variable bias.

CONCLUSION

The adolescents engaging in DSH are experiencing a more complex range of psychosocial problems than those who do not have experience with DSH. The main finding of the study is that hyperactivity as a risk factor for the development of DSH in adolescence can be identified as early as 3-7 years of age. This relationship between the very early occurring hyperactivity and later DSH, to the best of our knowledge, has not previously been described.

Injuries in children and adolescents with psychiatric disorders

BACKGROUND

Unintentional injuries are a leading cause of morbidity and mortality in children of all ages. Prevention strategies require knowledge of risk factors, and behavior and psychiatric disorders have been suggested to influence the risk of injury during childhood. While externalizing disorders have been found to increase the risk for injuries, results are mixed regarding internalizing disorders, such as affective and anxiety conditions, and Autism Spectrum Disorders (ASD). There is a need for large scale studies relying on robust data sources. The aim of the present study was to examine the association between psychiatric disorders and injuries requiring medical attention, in a large population-based cohort of 350,000 children and adolescents in Sweden.

METHODS

Data were obtained from the regional health care database Vega. Psychiatric diagnoses and injury diagnoses obtained during 2014-2018 for individuals aged 0-17 years in 2016 were extracted. Descriptive statistics were used to examine differences in 5-year injury prevalence between children with and without different psychiatric diagnoses. Logistic regression was used in age-stratified models to test the association between psychiatric diagnoses and injuries requiring medical attention.

RESULTS

The results show an increased risk for concurrent injuries in general, but the patterns vary by age and psychiatric disorder. Externalizing disorders and anxiety conditions were associated with concurrent injuries, while individuals with ASD had a lower risk for most injuries included. Affective disorders were associated with an increased risk for wounds, concussion, complications and poisoning, while the risk for fractures was decreased. Self-inflicted injury was more common in all psychiatric conditions investigated during adolescence, except for ASD. Children and adolescents with many types of psychiatric disorders were also at increased risk for a concurrent maltreatment diagnosis.

CONCLUSIONS

A general pattern of increased risk for concurrent injuries in children and adolescents with most psychiatric diagnoses was found, but the associations vary by age and type of psychiatric disorder. The results add to the literature on risk factors for injuries in children and adolescents, supporting diagnosis specific patterns. Several psychiatric diagnoses were associated with a marked increase in injury risk, indicating a high burden of disease for affected individuals.

Nonsuicidal Self-Injury: Its Associations With Pathological Internet Use and Psychopathology Among Adolescents

BACKGROUND/HYPOTHESES

As risk factors for nonsuicidal self-injury (NSSI), most studies highlight the importance of internalising disorders, while only a few researches show the connection between externalising disorders and NSSI. Although some papers have introduced the idea that increasing prevalence rates of NSSI are connected to the broader use of the internet, associations between NSSI and pathological internet use (PIU) are understudied. According to our hypothesis, there is a connection between PIU and NSSI, but this is mediated by psychopathological factors from both internalising and externalising dimensions.

METHODS

In line with the dimensional approach of psychiatric disorders, participants (N = 363) were recruited from both clinical (N = 202 psychiatric inpatient) and nonclinical (N = 161 adolescents from secondary schools) settings. Measurements: Demographic Questionnaire; Strengths and Difficulties Questionnaire (SDQ); Deliberate Self-Harm Inventory (DSHI); Young Diagnostic Questionnaire for Internet Addiction (YDQ), Mini International Neuropsychiatric Interview Kid (M.I.N.I. Kid).

RESULTS

There was high NSSI frequency (39.9%-71% of them were girls) in our sample. NSSI was significantly more frequent among those who showed threshold symptoms on SDQ than in the subthreshold group [H(3) = 53.293, p <.001]. In the NSSI frequency, there was also a significant difference between 'normal' internet users and both 'maladaptive' and 'pathological' internet users [H(2) = 10.039, p <.05 p = .007]. According to the mediator models, the relationship between PIU and NSSI is not a direct association; it is mediated by all examined psychopathological factors (M.I.N.I. kid diagnoses) except for obsessive-compulsive disorder (OCD), alcohol abuse and dependence, and adjustment disorder.

CONCLUSIONS

We found a high frequency of NSSI. According to our results, PIU in itself is not a risk factor for NSSI but might become a risk factor in the presence of comorbid psychiatric disorders. All of these findings draw the attention of clinicians to the importance of careful screening of comorbid disorders with PIU.

Association of Internet Addiction With Nonsuicidal Self-injury Among Adolescents in China

IMPORTANCE

Both nonsuicidal self-injury (NSSI), defined as the direct, deliberate damage of one's body tissue without suicidal intent, and internet addiction among adolescents are public health concerns. However, the possible association of NSSI with internet addiction is not well understood.

OBJECTIVE

To examine the occurrence of internet addiction with NSSI and any sex differences among Chinese adolescents.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, cross-sectional, survey study was conducted from February 18 to October 15, 2015, among adolescents aged 11 to 20 years from 343 classes in 45 public high schools across 5 provinces of China. Data analysis was performed from August 1, 2018, to March 1, 2019.

EXPOSURES

Possible internet addiction and internet addiction.

MAIN OUTCOMES AND MEASURES

Less-frequent (1-4 times) NSSI and more-frequent (≥5 times) NSSI were surveyed using the Chinese version of the Functional Assessment of Self-Mutilation.

RESULTS

A total of 15 623 students (8043 male [51.5%] and 7580 female [48.5%]) aged 11 to 20 years (mean [SD] age, 15.1 [1.8] years) participated. Of these, 4670 participants (29.9%) met the criteria for possible internet addiction and 509 participants (3.3%) met the criteria for internet addiction. A total of 2667 students (17.1%) engaged in less-frequent NSSI, while 1798 students (11.5%) engaged in more-frequent NSSI in the 12 months preceding the survey. Both possible internet addiction and internet addiction were associated with less-frequent or more-frequent NSSI. The adjusted odds ratios were 1.29 (95% CI, 1.17-1.42) for possible internet addiction and 1.41 (95% CI, 1.11-1.80) for internet addiction for less-frequent NSSI; for more-frequent NSSI, the adjusted odds ratios were 1.75 (95% CI, 1.56-1.96) for possible internet addiction and 2.66 (95% CI, 2.10-3.38) for internet addiction. These associations were similarly observed among age groups of 11 to 14, 15 to 17, and 18 to 20 years. No sex disparities were found in the associations of internet addiction with NSSI, except among adolescents aged 11 to 14 years, where the odds ratios for possible internet addiction with less-frequent NSSI were higher in male adolescents (1.53; 95% CI, 1.25-1.88) than female adolescents (1.13; 95% CI, 0.90-1.47).

CONCLUSION AND RELEVANCE

Internet addiction appears to be associated with NSSI, and the findings of this study suggest that the association was similar between male adolescents and female adolescents. These data suggest that evaluation of the risk of NSSI for adolescents in association with internet addiction may help health care professionals in developing preventive interventions for NSSI.

Economic Burden and Disability-Adjusted Life Years (DALYs) of Attention Deficit/Hyperactivity Disorder

Objective: We investigated the economic burden and disability-adjusted life years (DALYs) for attention deficit/hyperactivity disorder (ADHD) in the Republic of Korea. Method: Using the National Health Insurance Service claims data for the population aged 19 years or younger, a prevalence-based approach was used to calculate the DALYs of ADHD. Direct medical costs, direct nonmedical costs, and indirect costs resulting from ADHD were estimated to calculate the economic burden of ADHD. Results: A total of 69,353 people in Korea were diagnosed with ADHD in 2012. The burden of ADHD as measured by the prevalence-based approach was 32,605 DALYs. The total economic burden of ADHD was US$47.55 million, which accounted for approximately 0.004% of Korean GDP (gross domestic product) in 2012. Conclusion: Our findings shed light on the considerable burden of ADHD, emphasizing the need for policies that can encourage ADHD treatment and enhance compliance.

Nonsuicidal Self-Injury and Suicide: The Role of Life Events in Clinical and Non-Clinical Populations of Adolescents

BACKGROUND

Nonsuicidal self-injury (NSSI) is highly prevalent in clinical and non-clinical populations of adolescents. Several studies have supported both the distinction and the strong association between NSSI and suicidal behavior. Although there is a great deal of data on the role of life events in both suicidal behavior and NSSI, few studies have assessed the role of life events in the NSSI-suicidal behavior relationship. Our aims were to explore the relationship between NSSI and suicidal behavior, and the possible moderating role of stressful life events in a clinical and non-clinical adolescent population.

METHOD

A clinical (n = 202) and a nonclinical (n = 161) population of adolescents, aged 13-18 years were assessed. The Mini International Neuropsychiatric Interview Kid, Deliberate Self-Harm Inventory and the Life Events List were used. Group differences related to suicidal behavior, NSSI, and life events were tested with Wilcoxon tests. Two- and three-way interactions were tested with negative binomial regression models including zero-inflation parameter.

RESULTS

The prevalence of suicidal behavior (W = 7,306, p < .001), NSSI (W = 9,652, p < .001) and life events (W = 10,410 p < .001) were significantly higher in the clinical than in the non-clinical group. Between number of life events and NSSI, a moderate effect size (.38, 95%CI [.28,.46]) was found. The main effect of NSSI (χ² (1) = 109.65, p < .001) and group membership (χ² (1) = 39.13, p < .001) predicted suicidal behavior; the main effect of quantity of life events did not explain suicidal behavior. The interaction between NSSI and number of life events (χ² (1) = 10.49, p < .01) was associated with suicidal behavior. Among interpersonal, non-interpersonal events and adverse childhood circumstances, only interpersonal events were associated with both suicidal behavior (χ² (1) = 6.08, p < .05) and had a moderating effect (χ² (1) = 8.59, p < .01) on the NSSI-suicidal behavior relationship. Patterns of the effects of life events on the NSSI-suicidal behavior relationship did not differ in the two groups.

CONCLUSION

Our results confirm the importance of prevention and intervention of NSSI, considering its high prevalence and frequent co-occurrence with suicidal behavior in both clinical and non-clinical adolescent populations. Moreover, to support NSSI and suicide prevention, we would like to highlight the importance of stressful life events, especially those associated with interpersonal conflicts, require special attention.

Prevalence and Clinical Correlates of Self-Harm Behaviors in Gilles de la Tourette Syndrome

Introduction: Major symptoms of Gilles de la Tourette syndrome (GTS) are tics, but in 90% of cases, psychiatric comorbidities occur. Self-harm behaviors (SHBs) could result from deliberate action and unintentional injury from tics. Methods: We examined 165 consecutive GTS patients aged 5 to 50 years (75.8% males). The median duration of GTS was 14 years (interquartile range, 9-22 years). The patients were evaluated for GTS and comorbid mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Self-harm behavior was diagnosed during the interview. To determine a direct relationship between SHB and clinical variables, we conducted two analyses, at the time of evaluation and lifetime. We also compared the group of children and adults with SHB. We also tried to distinguish between deliberate (non-tic-related SHB) and accidental (tic-related SHB). Results: Lifetime SHB was reported by 65 patients (39.4%), and in 55 of the cases, it was present at the time of evaluation. The age at the onset of SHB was reported in 55 of the cases (84.6%), and the median was 10 years (interquartile range, 7-13 years). In 30 of the patients (46.2%), SHB was evaluated as mild; in 26 (40%), as moderate; and in only 9 cases (13.9%), as severe. In the multivariable analysis for the predictor of lifetime SHB, attention-deficit/hyperactivity disorder (p = 0.016) and obsessive-compulsive disorder (OCD; p = 0.042) were determined as risk factors, while for current SHB, only tic severity (p < 0.0001) was statistically significant. When comparing predictors of SHB for children and adults, tic severity was determined as predictor for lifetime SHB in children (p < 0.0001), while the anxiety disorder was associated with lifetime SHB in adults (p = 0.05). Similarly, tic severity was a predictor of current SHB in the children group (p = 0.001), but this was not confirmed for adults. The group of patients with tic-related and non-tic-related SHB did not differ. Conclusions: Self-harm behavior appears mostly in children and adolescents and rarely begins in adulthood. Self-harm behavior is associated mainly with tic severity, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder. Clinical correlates of SHB are age related and differ at different points of life. Tic severity is the main factor associated with SHB in children. In the adult group, anxiety disorder and other psychiatric comorbidities may play the most important role.