New Research May Help Clinicians Identify Children at a Higher Risk for Self-harm Events

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Authors of a new study identified 4 distinct profiles of psychiatric comorbidity that can help health care professionals better assess children at elevated risk for a self-harm event.

Findings were published online May 1, 2023, in the journal Pediatrics.

“Predicting which children are at risk for serious self-harm events, such as suicide attempts or self-injurious behaviors, in the emergency department is extremely challenging,” said senior author James Antoon, MD, PhD, MPH, assistant professor of pediatrics and hospital medicine at Monroe Carell Jr. Children’s Hospital, Vanderbilt University Medical Center, in a press release. “Our study provides an important step in evaluating the whole child in relation to self-harm risk assessment. These profiles can be used to better inform clinical decision making by providing a better assessment of overall risk of self-harm.”

A prior psychiatric diagnosis is one of the strongest risk factors for self-harm behavior in children and adolescents, according to Antoon and colleagues. “Traditional analyses link individual psychiatric diagnosis to risk of self-harm independent of other comorbidities. The overall risk for a set of diagnoses is unknown,” wrote researchers.

To identify profiles of psychiatric comorbidity and their association with serious self-harm events in youth, Antoon and colleagues enrolled 1098 children aged 5-18 years hospitalized with a neuropsychiatric event (NPE) between April 2016 and March 2020 at Monroe Carell Jr. Children’s Hospital or Children’s Hospital of Colorado in Aurora.

Investigators identified 12 NPE categories among study participants: self-harm, mood disorders, psychosis/hallucination, altered mental status, ataxia/movement disorders, encephalitis, seizures, dizziness, headache, sleeping disorders, and vision changes.

Bayesian profile regression was used to detect distinct clinical profiles of risk for self-harm events from 32 covariates: age, sex, and 30 mental health diagnostic groups, according to the study.

Among the 1098 participants, the median age was 14 years and a total of 406 (37%) children had a serious self-harm event outcome. Children who had a self-harm event outcome were more likely to be older, transferred to a psychiatric inpatient facility, and self-identify as “White” or “other” race/ethnicity, according to investigators.

Researchers described the following 4 distinct profiles:

• Low-risk: Composed primarily of children aged 5-9 years that had a nonmental health diagnosis and an absence of mood disorders, behavioral disorders, psychotic disorders, developmental disorders, and trauma or substance-related disorders.
• Moderate-risk: Characterized by the inclusion of several mood disorders in the absence of depressive disorders.
• High-risk: Included girls aged 14-17 years with depression and anxiety in conjunction with substance- and trauma-related disorders. Personality and eating disorders were also significant for this profile.
• Very-high risk: Included boys aged 10-13 years with mood and developmental disorders (eg, autism spectrum disorder or intellectual disability).

Compared with the average outcome risk of the entire study cohort, investigators found that the low-risk profile (n=494, 45%) had the lowest median risk of 0.04 (interquartile range [IQR] 0.03-0.04; odds ratio [OR] 0.08, 95% CI 0.04-0.15). “Even though they constituted the lowest risk profile, it should be noted that our study population included individuals hospitalized for an NPE and therefore likely represents a population with a greater risk of self-harm events to that of the general population,” wrote Antoon et al.

The moderate-risk group (n=88, 8%) had the same risk as that of the baseline risk for the entire cohort (37%) and served as the reference group, with a median risk of 0.30 (IQR 0.27-0.33), according to the results. The high-risk profile (n=393, 36%) had a median risk of 0.69 (IQR 0.67-0.71; OR 5.09, 95% CI 3.11-8.38) and the very-high risk group (n=123, 11%) had the highest median risk of 0.79 (IQR 0.73-0.79; OR 7.21, 95% CI 3.69-15.20).

“Our study provides a novel approach that takes the child’s entire medical and psychiatric profile into account and assesses what overall constellations of factors are associated with imminent self-harm,” said Antoon in the press release. Moreover, “the findings reveal unique and distinct patterns of comorbidity that are also distinguishable between age and sex,” the authors wrote.

“Our findings are preliminary because the profiles were developed using data from 1000 children with neuropsychiatric complaints at 2 academic children’s hospitals,” added investigators. “Future studies should focus on validating these risk profiles in a larger, more heterogeneous population of children and adolescents.”

Reference: Antoon JW, Sekmen M, Zhu Y, et al. Characteristics associated with serious self-harm events in children and adolescents. Pediatrics. Published online May 1, 2023. doi:10.1542/peds.2022-059817.