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In this article, we argue for expanded efforts to integrate administrative data systems as a "practical strategy" for developing a richer understanding of child abuse and neglect. Although the study of child maltreatment is often critiqued for being atheoretical, we believe that a more pressing concern is the absence of population-based and prospective epidemiological data that can be used to better understand the distribution and interacting nature of risk and protective factors for maltreatment. We begin by briefly addressing the relevance of empirical observations to etiological theories of child maltreatment. Although the latter is widely cited as critical to the development of effective prevention and intervention responses, less attention has been paid to the role of population-based data in the development of theories relevant to highly applied research questions such as those pertaining to child abuse and neglect. We then discuss how child protection data, in isolation, translates into a relatively narrow range of questions that can be asked and answered, with an inherently pathology-focused construction of risks and little attention paid to strengths or protective factors. We next turn to examples of recent findings--spanning multiple countries--emerging from information integrated across data systems, concluding by calling for expanded administrative data linkages in an effort to better understand and prevent child maltreatment.

Objectives: To identify factors associated with repeat emergency department (ED) presentations for suicide-related behaviors (SRB)--hereafter referred to as repetition--among children/youth to aid secondary prevention initiatives. To compare rates of repetition in children/youth with substantiated maltreatment requiring removal from their parental home with their peers in the general population. Methods: A population-based (retrospective) cohort study was established for children/youth with a first ED SRB presentation at risk for repetition in the Province of Ontario, Canada between 1 January 2004 and 31 December 2008. Children/youth legally removed from their parental home because of substantiated maltreatment (n = 179) and their population-based peers (n = 6,305) were individually linked to administrative health care records over time to ascertain social, demographic, and clinical information and subsequent ED presentations for SRB during follow-up. These children/youth were described and their repetition-free probabilities over time compared. To identify factors associated with repetition we fit multivariable, recurrent event survival analysis models stratified by repetition and present unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Results: Children/youth with substantiated maltreatment (as noted) were two times more likely to have repetition than their peers after adjustments for social, demographic, and clinical factors (conditional on prior ED SRB presentations). A number of these factors were independently associated with repetition. No one factor distinguished between having a first and second repetition nor was more strongly associated with repetition than another. Conclusions: The risk of repetition is higher in children with substantiated maltreatment (as noted) than their peers. No one factor stood out as predictive of repetition. Implications for secondary prevention initiatives include a non-selective approach, sensitive to family difficulties and the need to better contextualize repetition and harness data linkages. (Contains 2 figures and 2 tables.)

Objectives: To determine whether the rates of a first presentation to the emergency department (ED) for suicide-related behavior (SRB) are higher among children/youth permanently removed from their parental home because of substantiated maltreatment than their peers. To describe the health care settings accessed by these children/youth before a first SRB presentation to help design preventive interventions. Methods: A population-based (retrospective) cohort of 12-17-year-olds in Ontario, Canada was established. Children/youth removed from their parental home because of the above noted maltreatment (n = 4683) and their population-based peers (n = 1,034,546) were individually linked to administrative health care records over time to ascertain health service use and subsequent ED presentations for SRB during follow-up. Person-time incidence rates were calculated and Cox regression models used to estimate adjusted hazard ratios (HR) and corresponding 95% confidence intervals (CI). Results: After controlling for demographic characteristics and prior health service use, maltreated children/youth were about five times more likely to have a first ED presentation for SRB compared to their peers, in both boys (HR: 5.13, 95% CI: 3.94, 6.68) and girls (HR: 5.36, 95% CI: 4.40, 6.54). Conclusions: Children/youth permanently removed from their parental home because of substantiated child maltreatment are at an increased risk of a first presentation to the ED for SRB. The prevention of child maltreatment and its recurrence and the promotion of resilience after maltreatment has occurred are important avenues to study toward preventing ED SRB presentations in children/youth. Provider and system level linkages between care sectors may prevent the need for such presentations by providing ongoing environmental support. (Contains 1 figure and 4 tables.)

Child sexual abuse and suicide-related behaviors are associated, but it remains unclear if the strength of this association differs in boys and girls. In a systematic review of this association in children and youth, we identified 16 relevant studies, all cross-sectional surveys of students. The association is stronger in boys specific to suicide attempt(s). Adjustments for potential confounding variables explained some, but not all of this sex difference. While additional research would strengthen causal inferences, this sex difference may be influenced by the nature and timing of child sexual abuse as well as the sex of the perpetrator, which in turn shapes the disclosure of these events.

OBJECTIVES: Self-harm is an important public health issue among youth, including as a major risk factor for suicide(a leading cause of death in this age group). This study used population-based emergency department data to describe clinical and demographic characteristics of emergency department presentations for self-harm among youth(12-17 year- olds) in the province of Ontario, Canada. METHODS: Administrative data capturing every emergency department visit in Ontario between April 1, 2002 and March 31, 2009 were used to identify and describe self-harm presentations. RESULTS: Over the 7-year period between 2002/03 and 2008/09, there were 16,835 self-harm presentations by 12,907 youth. Two thirds of self-harm presentations were self-poisonings (almost always with medicinal agents), followed by self- cutting, which accounted for about one quarter. Incidence rates were higher in girls than boys, increased with age, were inversely related to neighbourhood income and were highest in rural areas. Self-harm accounted for about 1 in 100 emergency department presentations by youth, but also a disproportionate number of presentations triaged as high acuity or admitted to hospital (about 1 in 20). CONCLUSION: Self-harm is an important public health issue, requiring a comprehensive approach to prevention. Ontario has useful data with which to study emergency department presentations for self-harm, and the similarities between self-harm presentations among Ontario youth and those reported from the United States and Europe suggest generalizability of results between populations. Further research is needed to address the reasons for the geographic differences in frequency of self-harm. KEY WORDS: Self-injurious behavior; emergency medical services; child; adolescent; epidemiology OBJECTIFS : L'automutilation est un important probleme de sante publique chez les jeunes, ainsi qu'un grand facteur de risque de suicide (une des principales causes de mortalite dans ce groupe d'age). A l'aide des donnees populationnelles des services d'urgence, nous decrivons le profil clinique et demographique de jeunes (12-17 ans) s'etant presentes aux urgences dans la province de l'Ontario, au Canada, apres s'etre automutiles. METHODE : Nous avons utilise des donnees administratives saisissant toutes les visites aux urgences en Ontario survenues entre le 1er avril 2002 et le 31 mars 2009 pour reperer et decrire les cas d'automutilation. RESULTATS : Sur les sept annees de l'etude (2002-2003 a 2008-2009), il y a eu 16 835 cas d'automutilation chez 12 907 jeunes. Les deux tiers des cas d'automutilation etaient des auto-empoisonnements (presque toujours avec des agents medicinaux), suivis par des coupures autoinfligees (environ le quart des incidents). Les taux d'incidence etaient plus eleves chez les filles que chez les garcons, augmentaient avec l'age, etaient inversement lies au revenu selon le quartier et atteignaient les plus hauts niveaux en milieu rural. L'automutilation representait environ 1 cas sur 100 chez les jeunes s'etant presentes aux urgences, mais aussi un nombre demesure de cas orientes vers les soins aigus ou hospitalises (environ 1 sur 20). CONCLUSION : L'automutilation est un important probleme de sante publique qui exige une demarche de prevention globale. L'Ontario detient des donnees utiles pour etudier les cas d'automutilation geres par les services d'urgence; les ressemblances entre les cas d'automutilation chez les jeunes de l'Ontario et ceux declares aux Etats-Unis et en Europe montrent que les resultats obtenus dans differentes populations pourraient etre generalisables. Il faudrait pousser la recherche pour decouvrir les raisons des ecarts geographiques dans la frequence de l'automutilation. MOTS CLES : comportement automutilatoire; secours medicaux d'urgence; enfant; adolescent; epidemiologie, Self-harm refers to non-fatal self-poisoning or self-injury, irrespective of the apparent purpose. (1) Similar to non-fatal suicide-related behaviours, (2) self-harm encompasses suicide attempts as well as non-suicidal self-injury. Self-harm is [...]

This study was carried out with three goals: (1) to determine the prevalence of suicidal ideation and suicide attempts among the homeless; (2) to determine what aspects of homelessness predict suicidality; and (3) to determine which aspects remain predictive after controlling for key covariates, such as mental illness. A sample of 330 homeless adults were interviewed. Sixty-one percent of the study sample reported suicidal ideation and 34% had attempted suicide. Fifty-six percent of the men and 78% of the women reported prior suicidal ideation, while 28 percent of the men and 57% of the women had attempted suicide. Childhood homelessness of at least 1 week without family members and periods of homelessness longer than 6 months were found to be associated with suicidal ideation. Psychiatric diagnoses were also associated with suicidality in this sample.

The purpose of this study is to describe gender differences in the use of outpatient mental health services and to identify potential determinants of this use. The study sample, N = 7475 respondents 18-64 years, was drawn from the Mental Health Supplement to the Ontario Health Survey. For theoretical and empirical reasons, type of mental disorder was defined as: a Mood and/or Anxiety Disorder (Mood/Anx) or a Substance Use Disorder and/or Antisocial Behaviours (Subs/Asb) within the past year. Use was defined in relation to providers seen within the past year. Descriptive and multiple logistic regression analyses were employed including type of mental disorder, social and economic factors. Female gender remained positively associated with any use despite adjustments (adjusted OR: 1.7; 95% CI: 1.2; 2.4). The magnitude of this association was consistent across the levels of the study variables and various measures of use except volume of use where there were no gender differences. Mood/Anx appeared to mediate the gender-use relationship and was strongly associated with use (adjusted OR: 8.4; 95% CI: 5.9; 11.9). Subs/Asb was also related to use (adjusted OR: 2.6; 95% CI: 1.5; 4.3) but not to the same degree as Mood/Anx. Mood/Anx explained 60% of the crude Subs/Asb-use relationship. The evidence to suggest that Subs/Asb mediated the gender-use relationship was mixed. These findings raise questions about gender differences in illness and reporting behaviours and the health care system in its preferential treatment of women and those with Mood/Anx. Keywords: Canada; Mental health service utilization; Mental disorders; Substance abuse; Anxiety; Gender

Objective: We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care.Method: This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases ( n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated.Results: Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: 'other' injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, 'undetermined' injuries and poisonings in both sexes (aORs > 5), 'unintentional' poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days.Conclusions: The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern. [ABSTRACT FROM AUTHOR]

Objective: Prior year medical care was compared among youth dying by suicide to their peers. Effect modification of these associations by age or place of residency (rural versus larger community sizes) was examined in a large, medically insured population.Method: This population-based case control study used data from the Office of the Chief Coroner in Ontario, Canada, linked to health care administrative data to examine associations between medical care for mental health or other reasons (versus no medical care) and suicide. Decedents ( n = 1203 males and n = 454 females) were youth (aged 10 to 25 years) who died by suicide in Ontario between April 2003 and March 2014, inclusive. Peers of the same ages were frequency matched to decedents on sex and place of residency. Logistic regression was used to calculate odds ratios and 95% confidence intervals and to test effect modification.Results: Associations with mental health care were stronger in decedents than peers with a gradation of care (i.e., outpatient only, emergency department [ED], inpatient care) in both sexes. However, these associations were weaker among youth living in rural communities. Furthermore, older males (aged 18 to 25 years) were less likely than younger males (aged 10 to 17 years) to access the ED (ambulatory care only). This decrease was observed in rural and larger communities alongside no increase in medical care for other reasons.Conclusions: Geographical and age-related barriers to mental health care exist for youth who die by suicide. Preventive efforts can address these barriers, intervening early and integrating services, including the ED. [ABSTRACT FROM AUTHOR]

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