Highlights of Pediatric Academic Societies' 2006 Annual Meeting

2006年4月29日－5月2日

美国加利福尼亚州旧金山

April 29, 2006 - May 2, 2006, San Francisco, California

Revisiting the 2004 AOM Management Guidelines
William T. Basco, Jr., MD   
Overview
As part of their annual meeting, the Pediatric Academic Societies (PAS) and the Pediatric Infectious Diseases Society cosponsored a Hot Topic session where a number of speakers reviewed diagnosis and treatment of acute otitis media (AOM). The session began with a review of management guidelines and included descriptions of the most recent data related to current treatment approaches.

Review of the AOM Guidelines
Guidelines published in 2004 by the Subcommittee on Management of Acute Otitis Media of the American Academy of Pediatrics (AAP)[1] were reviewed by Dr. Jerome O. Kline,[2] Boston University School of Medicine, Boston, Massachusetts. He primarily focused on 4 areas: (1) the definition of AOM; (2) the recommendation to consider watchful waiting with certain patients; (3) recommendations for initial therapy and second-line treatment; and (4) possible prevention of AOM.

According to the AAP guidelines, the following criteria are essential for the diagnosis of AOM:

Recent onset of signs and symptoms of middle ear inflammation

Presence of middle ear effusion, with either bulging of the tympanic membrane, decreased mobility, or an air-fluid level

Signs and symptoms of middle ear inflammation such as erythema or otalgia (ear pain)
Dr. Kline stressed that determination of some of the criteria may necessitate use of pneumatic otoscopy (ie, to demonstrate decrease in tympanic membrane mobility).

To successfully implement these guidelines, a clinician must be able to determine whether a patient has severe AOM or nonsevere AOM. The challenges of determining severe or nonsevere AOM were also reviewed in more detail later in the session. A general definition of severe AOM includes a temperature greater than 39º C in association with severe otalgia.

Perhaps the most controversial aspect of the 2004 guidelines is the suggestion that selected patients may be managed with watchful waiting instead of being treated with antibiotics at the time of diagnosis. For the purposes of the recommendations, the guidelines divided patients with AOM into 2 categories, based on the clarity of the history and the physical examination findings -- a certain and an uncertain group. The guidelines suggest children younger than 6 months of age should be treated with antibiotics regardless of the clarity of AOM diagnosis, so that even uncertain cases should be treated with antibiotics. Children aged 6 to 24 months with certain AOM should also receive antibiotics. However, if the diagnosis is uncertain and the symptoms are not severe, the practitioner could consider watchful waiting, with reassessment within 72 hours.[1]

For children older than 24 months, those with certain AOM can be observed if the symptoms are not severe, and all with uncertain diagnoses should be observed. Dr. Kline maintained that it is too early to know whether these suggestions for watchful waiting have met with widespread acceptance by clinicians. Additional data are needed before this can be determined.

The importance of the recommended first- and second-line therapies put forth in the guidelines was reiterated. A first-line drug would be prescribed if treatment was initiated at diagnosis or after symptoms continue or worsen during a period of observation. It is Dr. Kline's opinion that the recommended drug therapy components of the guidelines have not been adequately followed by many clinicians.

For nonsevere episodes of AOM, amoxicillin remains the first-line drug of choice, whether prescribed at time of diagnosis or after failed observation. For severe episodes, the guidelines recommend the use of amoxicillin/clavulanic acid, again, whether prescribed at time of diagnosis or after failed observation.[1]

Dr. Kline stressed that cephalosporins should only be considered as acceptable first-line treatment for patients with penicillin allergy. The drug with the most universal acceptance as a second-line drug in a penicillin-allergic patient is ceftriaxone, given intramuscularly for 1 to 3 days; ceftriaxone intramuscularly was the consensus recommendation for treating severe AOM, regardless of whether treatment is initial, after observation, or after failed treatment with another antibiotic.

Dr. Kline concluded with a review of statistics about diagnosis of and prescribing for AOM. In 2003, Finklestein and colleagues[3] demonstrated a general decline in antibiotic prescribing from 1996-2000. In particular, the investigators demonstrated that the decrease in prescribing for AOM accounted for 59% of the decrease in overall antibiotic prescribing rates, and this drop was attributed to fewer diagnoses of AOM over the time period.

Implementing Watchful Waiting
Dr. David P. McCormick,[4] University of Texas Medical Branch, Galveston, Texas, discussed whether the concept of watchful waiting can work for children diagnosed with AOM. He reviewed the spectrum of AOM presentations and described a tool used to identify candidates for watchful waiting.

In an investigation by Siegel and colleagues,[5] almost 200 children with AOM were managed by providing a safety net prescription and treating pain. The parents were told to fill the safety net prescription if symptoms were not improved within 72 hours. This approach resulted in a 69% decrease in antibiotic prescribing -- only 31% of parents filled the prescription.[5] However, this investigation was not a randomized study.

McCormick and colleagues[6] designed and completed a randomized study, published in 2005. This investigation evaluated the safety, efficacy, and acceptability of a watchful waiting approach in children with nonsevere AOM. The 266 subjects had clinical symptoms and evidence of AOM seen on otoscopic examination. Nasopharyngeal cultures from each participant were obtained at enrollment and at Day 10.

The severity of participants' AOM symptoms were evaluated at enrollment and at Days 12 and 30. The classification of nonsevere involved symptom scores and physical finding scores previously developed by the authors.[7] Patients' AOM was considered nonsevere if they were in the lower 50% of the symptom/discomfort reporting scale.

Children in the treatment arm received amoxicillin at 90 mg/kg/day (divided twice daily) for 10 days. If a treatment-group subject experienced treatment failure, he or she was treated with amoxicillin/clavulanate (same dose as amoxicillin). Watchful waiting subjects initiated the amoxicillin-only treatment in the case of treatment failure of watchful waiting. No routine pain control regimen was prescribed. Parental satisfaction was measured by survey at Days 12 and 30. A participant was considered a treatment failure if he or she returned during Days 1-12 with a symptom severity index higher than their severity index at enrollment, or if they returned with physical findings worse than at the initial visit

This study demonstrated that a watchful waiting approach could reduce overall antibiotic use by 66%: two thirds of the parents of children assigned to the watchful waiting arm did not fill the prescription for antibiotics during the 12-day observation period. However, the outcomes were slightly different for patients older or younger than 2 years of age. In children older than age 2, 77% were better within the 12-day observation period if they were treated with antibiotic compared with 76% of the patients with watchful waiting, a difference that was neither statistically nor clinically different.

In children younger than age 2, the study findings favored treatment. Among children younger than 2 years of age, 77% treated immediately with amoxicillin were better within the 12-day observation period compared with only 56% of those randomized to the watchful waiting arm. Antibiotic resistance of nasopharyngeal organisms was higher at Day 12 in the treatment group compared with the watchful waiting group.

Parental satisfaction scores were almost identical between the treatment and waiting groups at both the 12-day and 30-day visits. However, symptom diaries kept by parents documented quicker improvement for participants treated with amoxicillin, and this pattern held in the subgroup of children younger than 2 years of age. But this translated to a relatively small medication effect, because treatment group parents gave only an average of 4.3 fewer doses of pain medication compared with parents of watchful waiting subjects. There was also no difference in visit behavior, and no differences in days of daycare or work missed, despite the fact that children younger than 2 years of age did seem to have more failures with watchful waiting.

On the basis of these data, the overall conclusion was that children older than 2 years of age with nonsevere AOM seem to be excellent candidates for watchful waiting. Children younger than 2 years of age may not be good candidates for this approach.

A grading system developed by Dr. McCormick and colleagues[7] for classifying AOM was described. Although specific scales can be used for AOM symptom grading, these primarily focus on symptoms reported by the patient and/or parent. By contrast, the scale developed by McCormick and colleagues[7] focuses on the appearance of the tympanic membrane (TM). It goes from grade 0, a normal tympanic membrane, to grade 7, which includes acute inflammation, opacity, a bulging TM, as well as a bulla on the surface of the TM. An Internet link to this scale is provided at the conclusion of this summary.

Use of Antihistamines or Steroids as Adjuncts for Treatment of AOM
Data on the potential use of antihistamines and steroids in treating AOM were presented by Dr. Tasnee Chonmaitree,[8] University of Texas Medical Branch, Galveston, Texas. She began by reviewing some important concepts related to the use of adjunct treatment in AOM, including a reminder that viruses alone can cause AOM. Therefore, AOM is not just a pure bacterial disease. Because of this, previous investigators and clinicians have wondered whether adjunctive therapy would be useful in improving symptoms or other outcomes for patients with AOM.

Several studies that evaluated microbial results of middle ear fluid obtained from patients with AOM were described. In one, research demonstrated that bacteria alone caused 55% of the cases of AOM, with another 19% of cases caused by bacteria and viruses combined. Viruses were the sole agents of AOM in relatively few subjects.[9] The possibility of a mixed infection sheds interesting light on why some patients may fail initial antibiotic treatment: if a patient does not improve after beginning antibiotics for AOM, is it necessarily the case that the patient suffers from a resistant bacterium? In fact, the antibiotic may have been very effective in treating the bacterial component but not the viral coinfection, resulting in limited symptom improvement until the illness has run its course.

Data on use of antihistamines in treating AOM were also described. The basic science suggesting that treatment with antihistamines might be effective comes in part from Dr. Chonmaitree's own work, where she and colleagues[10] demonstrated that the middle ear fluid obtained from patients with bacterial AOM contained increased levels of histamine. They proceeded to test whether antihistamines would help as an adjunctive therapy for patients with AOM.

Two studies have helped clarify the potential use of adjunctive agents. The first, involving 80 patients, focused on the effect of antibiotic treatment on inflammatory mediators in the middle ear fluid.[11] Participants had myringotomy and fluid was obtained at enrollment as well as at Day 5 of treatment. In addition to antibiotic treatment, the patients were randomized to receive antihistamine for 5 days, prenisolone for 5 days, or placebo. At the end of the treatment period, there was no difference in histamine or leukotriene levels in the middle ear fluid of participants, regardless of treatment group.

The second study involved 179 patients, but did not include the double tympanocentesis.[12] All participants had suffered at least 2 previous episodes of AOM and were followed for 6 months after initial enrollment. They received antibiotic treatment and were randomized to receive antihistamine for 5 days, prenisolone for 5 days, or placebo.

This study again showed no difference in the clinical failure rate across treatment groups. A surprising finding was that participants who were treated with antihistamines had 73 days' average duration of middle ear effusion vs an average duration of 20 to 30 days for those treated with other methods. Therefore, the overall conclusion of the investigators was that the use of antihistamines not only did not improve histamine levels in the middle ear or clinical outcomes, but actually served to prolong middle ear effusion in these groups.

Dr. Chonmaitree concluded by providing the results of a Cochrane Database of Systematic Reviews on the question of whether antihistamine or decongestant use was beneficial for adjunct treatment of AOM.[13] The review contained 15 studies involving a total of more than 2600 pediatric patients; all were randomized controlled trials. The primary outcome of the studies was whether there was resolution of the AOM, with secondary outcomes being whether treatment provided symptom control, produced more medication side effects, or prevented complications of AOM.

The collective data showed that treatment with antihistamines or steroids did increase the rate of medication side effects, but neither produced benefit in treating AOM. Therefore, Dr. Chonmaitree concluded that, on the basis of her research findings and those analyzed in the Cochrane review, no benefits of steroid or antihistamine use in treatment of AOM have been identified.

Proper Antibiotic Use in AOM
The final presenter, Dr. Ron Dagan,[14] Soroka University Medical Center, Beer Sheva, Israel, began by emphasizing the following points:

Antibiotic use for AOM will reduce bacterial load in children under 2 years of age;

If bacterial eradication does not occur by Day 3 of treatment, this raises the risk of treatment failure or complication;

20% to 40% of children with AOM will have a recurrent episode within 2 months; and

Treating for AOM with antibiotics selects for more resistant pathogens in the nasopharynx.
These points raise interesting questions, including the issue of whether to select a different drug to treat AOM in a patient who has recently been treated for a different episode of AOM. Data to answer that question come in part from 108 cases of recurrent AOM studies by Liebovitz and colleagues.[15] These investigators demonstrated that 54% of recurrent AOM episodes were caused by organisms different from those causing the index episode, with another 28% being due to the same organism. This 28% represents the true relapse rate and is notably high.

Dr. Dagan's own work, published in 2001, demonstrated that although nasopharyngeal organisms may not be present in the middle ear at the time of diagnosis, the nasopharyngeal organisms will colonize the middle ear during the course of treatment.[16] These nasopharyngeal organisms may also be more resistant overall than those involved initially in the AOM episode. This raises the possibility that a treatment failure -- when a patient is not improved after 72 hours of therapy -- may result from adequate treatment of the initial causative organism, followed by opportunistic involvement by a resistant one.

This phenomenon was also demonstrated in almost 500 children studied by Libson and colleagues.[17] In this investigation, 208 children with sterile middle ear fluid had a positive nasopharyngeal culture. Within 3 weeks, 32% of those children experienced an episode of AOM. Among the 286 children with sterile middle ear fluid and sterile nasopharynx, only 22% experienced an episode of AOM within the subsequent 3 weeks. In addition, McCormick's previously reviewed study of watchful waiting demonstrated a similar phenomenon of more resistant bacteria being recovered from the nasopharynx after antibiotic treatment of AOM.[6]

Dr. Dagan's primary reason for reviewing these studies was to emphasize that although antibiotics have proven short-term benefits, they also have notable short-term complications, particularly with regard to selection for resistant organisms. The reviewed findings support the overall approach of providing more selective treatment of older children with AOM.

Conclusion
Although the presenters in the AOM sessions did not necessarily offer a lot of new information, these sessions served as a well-planned, focused review of the current state of the evidence and practice guidelines for diagnosing and treating this very common pediatric problem. There were 2 very important take-home reminders from these sessions. The first is to keep antibiotic treatment of AOM simple: high-dose amoxicillin at 80-90 mg/kg/day for first- line, nonsevere infections; amoxicillin/clavulanic acid for first-line severe infections. After that, ceftriaxone remains the second-line drug of choice. Oral cephalosporins should be reserved for penicillin-allergic patients. The second important take-home message is that watchful waiting seems to be associated with a high success rate when used with older children and can prevent selecting for resistant organisms.

Resources
Grading System Acute Otitis Media. Available at: http://www.utmb.edu/pedi_ed/AOM-Otitis/grading.htm. Accessed June 27, 2006.

References
American Academy of Pediatrics. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451-1465. Abstract
Klein JO. AOM treatment: making sense of the AAP/AAFP guidelines. Program and abstracts of the Pediatric Academic Societies' 2006 Annual Meeting; April 29-May 2, 2006; San Francisco, California.
Finkelstein JA, Stille C, Nordin J, et al. Reduction in antibiotic use among US children, 1996-2000. Pediatrics. 2003;112(3 Pt 1):620-627.
McCormick DP. Watchful waiting in non-severe AOM: how to select cases, and does it work in young children? Program and abstracts of the Pediatric Academic Societies' 2006 Annual Meeting; April 29-May 2, 2006; San Francisco, California.
Siegel RM, Kiely M, Bien JP, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. 2003;112(3 Pt 1):527-531.
McCormick DP, Chonmaitree T, Pittman C, et al. Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics. 2005;115:1455-1465. Abstract
McCormick DP, Saeed KA, Pittman C, et al. Bullous myringitis: a case-control study. Pediatrics. 2003;112:982-986. Abstract
Chonmaitree T. Antihistamine and corticosteroids: do they have any role in AOM treatment? Program and abstracts of the Pediatric Academic Societies' 2006 Annual Meeting; April 29-May 2, 2006; San Francisco, California.
Chonmaitree T. Viral and bacterial interaction in acute otitis media. Pediatr Infect Dis J. 2000;19(5 suppl):S24-S30.
Chonmaitree T, Patel JA, Lett-Brown MA, et al. Virus and bacteria enhance histamine production in middle ear fluids of children with acute otitis media. J Infect Dis. 1994;169:1265-1270. Abstract
McCormick DP, Saeed K, Uchida T, et al. Middle ear fluid histamine and leukotriene B4 in acute otitis media: effect of antihistamine or corticosteroid treatment. Int J Pediatr Otorhinolaryngol. 2003;67:221-230. Abstract
Chonmaitree T, Saeed K, Uchida T, et al. A randomized, placebo-controlled trial of the effect of antihistamine or corticosteroid treatment in acute otitis media. J Pediatr. 2003;143:377-385. Abstract
Flynn CA, Griffen GH, Schultz JK. Decongestants and antihistamines for acute otitis media in children. The Cochrane Database of Systematic Reviews. 2004;3. CD001727.DOI: 10.1002/14651858.CD001727.pub2.
Dagan R. Recurrent AOM -- is it influenced by antibiotics? Program and abstracts of the Pediatric Academic Societies' 2006 Annual Meeting; April 29-May 2, 2006; San Francisco, California.
Leibovitz E, Greenberg D, Piglansky L, et al. Recurrent acute otitis media occurring within one month from completion of antibiotic therapy: relationship to the original pathogen. Pediatr Infect Dis J. 2003;22:209-216. Abstract
Dagan R, Leibovitz E, Cheletz G, Leiberman A, Porat N. Antibiotic treatment in acute Otitis Media promotes superinfection with resistant Streptococcus pneumoniae carried before initiation of treatment. J Infect Dis. 2001;183:880-886. Abstract
Libson S, Dagan R, Greenberg D, Porat N, et al. Nasopharyngeal carriage of Streptococcus pneumoniae at the completion of successful antibiotic treatment of acute otitis media predisposes to early clinical recurrence. J Infect Dis. 2005;191:1869-1875. Abstract

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Teens at Risk: A Focus on Adolescent Suicide
William T. Basco, Jr., MD   
　

Introduction
Some of the most popular sessions at the Pediatric Academic Societies (PAS) annual meeting are the invited science presentations, where experts report on topics selected by the meeting program committee. At this year's meeting, PAS, in association with the Society for Adolescent Medicine, sponsored a minicourse about suicide in children and adolescents.[1]

Speakers participating in the minicourse included Dr. Donald E. Greydanus,[2] Professor of Pediatrics and Human Development, Michigan State University, Ann Arbor; Dr. Sheryl Ryan,[3] Chief of Adolescent Medicine, Department of Pediatrics, Yale University, New Haven, Connecticut; and Dr. Joseph L. Calles, Jr,[4] Director, Child & Adolescent Psychiatry, Michigan State University, Ann Arbor. Suicide epidemiology, risk factors for suicide, self-injurious behavior, and identification and management of patients with suicidal ideation or who have attempted suicide were addressed during the presentations.

Suicide Epidemiology
Suicide among youths recently has received a significant amount of attention in the United States, but concerns are long-standing. At a conference in Vienna in 1910 (attended by Sigmund Freud), participants expressed concern about a perceived excess of youth suicides.[4] Ironically, the 1989 Surgeon General report[5] focused on the problem of suicide in the United States, expressing conclusions similar to those reached at the Vienna conference: Not enough is known about suicide and its causes, and more research is needed in order to comprehensively address the problem.

Figures published in 2005 by the World Health Organization (WHO) estimated that approximately 877,000 suicides occur annually worldwide.[6] Approximately 200,000 of these occur among individuals 15 to 24 years of age. Rates vary from culture to culture and among ethnic groups. In the United States it is estimated that per 100,000 individuals, there are 10 to 15 deaths from suicide annually.[6] This equates to approximately 31,655 deaths from suicide in 2002 -- with about 2000 deaths occurring in individuals 15 to 19 years of age, and another 2000 occurring in those 20 to 24 years of age. Among the adolescents and young adults committing suicide each year in the United States, approximately 90% have some sort of mental illness, with depression constituting the majority of diagnoses.[7]

Historically, suicide rates have fluctuated in the United States.[8] In the 1930s, a time of economic instability, the rate was high. During the 1940s, rates declined. From the 1950s to the 1980s, rates again increased, coinciding with the post-adolescence of the baby boomer generation. From 1990 to 2004, overall suicide rates decreased slightly.[9] Dr. Greydanus expressed the possibility that the decrease could in part be related to an increased use of antidepressant medications during the past 10 to 15 years.[2]

However, when viewed over multiple decades, the suicide rate among adults doubled between 1960 and 2001. Adolescent suicide rates doubled as well during this period. According to the most recent national data from the Centers for Disease Control and Prevention, suicide is the third leading cause of death for individuals aged 10 to 24 years.[10] Injury and homicide are the top 2 causes of death, respectively, in this age group. It remains unclear as to whether some deaths commonly attributed to these categories (eg, driving a car into a wall or homicides) may actually be misclassified suicides.

Although females make more attempts at suicide, males are much more successful in completing suicide. This is partly because males typically choose more lethal methods such as firearms, hanging, and motor vehicles. Females tend to choose medication or drug overdosing and cutting, overall less lethal methods. Data published in 2004 showed firearms were involved in 49% of completed suicides among individuals aged 10 to 19 years; hanging in 38%, and poisoning in 7%. [11] Most research reviewing suicide attempts vs completions has demonstrated that there are between 40 and 60 attempts for every completion.[2]

It is important to note that the childhood suicide rate -- the rate among those 5 to 14 years of age -- has also increased over the past 30 years. In fact, this rate doubled between 1979 and 1992.[2] During the 1990s, there were approximately 300 suicides per year in this age group. Although there has recently been an increased focus on adolescent suicide, much less attention has been paid to this younger age group -- something Graydanus considers an unfortunate omission.[2]

It has been demonstrated that children and adolescents typically do not perceive suicide in the same way as adults. Mishara and colleagues[12] found that preschool children viewed death as sleeping, raising the question of whether children this age are actually capable of committing suicide. The researchers surmised that children in this age group who kill themselves very likely do not understand the finality of death.

By 6 to 7 years of age, 67% of the children in the study understood that everyone will eventually die. However, during their prepubertal years, many of the children still did not really understand the concept of permanent death. By age 12, 80% of the children still did not think about death occurring in healthy people.[12]

Among prepubertal children, depression is not usually a contributor to suicide. Suicide in young children is more likely to be related to family dysfunction, physical abuse, substance abuse, or schizophrenia.[13] The combination of suicidal ideation and disruptive behavior in this age group has also been associated with a marked increase in suicide risk. [14] Additionally, suicidal behavior during childhood significantly increases the risk that suicide will be completed in adolescence.

Depression and Other Risk Factors for Suicide
Multiple data provide a strong evidence base for the link between depression in childhood and/or adolescence and suicide. Olfson and colleagues[15] estimated that 9% of all teenagers make a suicide attempt and that 19% express suicidal ideation. In a cohort of depressed adolescents, 35% to 50% made a suicide attempt and 5% to 10%, diagnosed with a major depressive disorder, completed suicide within 15 years.[13] Among those surviving a suicide attempt, 71% had major depression or dysthymia; 64.5% were female.

Characteristics Associated With Suicide Risk
When children and adolescents completing suicide were compared with community controls, several factors were associated with increased risk of suicide, including mood disorders, familial psychiatric diagnoses, history of abuse, past suicide attempts, and the presence of a lethal means of suicide.[16] Gay and lesbian youth, perhaps because they have higher rates of depression than heterosexual adolescents, have also been shown to be at higher risk for suicidal ideation and suicide.[17]

In a post-suicide reconstruction of causes, Gould and colleagues[18] found that the leading risk factor for completed suicide among adolescent boys was a previous suicide attempt, followed by a major depressive disorder and substance abuse. For girls, major depressive disorder and substance abuse were the 2 leading risk factors. Family history of suicide also increased the risk 3 to 5 times that an individual would complete suicide. Additional risk factors identified include hopelessness, hostility, and negative self-concept.[19]

Adolescents with a combination of mood disorders and disruptive behaviors also have a significantly increased risk of suicide.[7,20] Data from the 1999 Youth Risk Behavior Survey showed that 17% of teens surveyed demonstrated at least 3 problem behaviors; this group comprised 60% of those who attempted suicide. The problem behaviors were additive for determining risk. For example, those with 1 problem behavior had a 2.3 times greater risk of suicide compared with youth with no problem behaviors. Individuals with 3 problem behaviors had a risk that was 18.3 times greater, with risk continuing to escalate as the number of problems increased.[20]

A history of sexual or physical abuse in early childhood has also been shown to increase the risk for suicide attempts.[21,22] Additional factors linked with suicide include the social acceptability of suicide (within one's religious framework or social network), social isolation, being the victim of bullying, familial and/or community dysfunction, and overall life stress.[4]

According to Graydanus, a factor many may consider to increase the risk of suicide -- asking an individual if he or she is planning to commit suicide -- has not been shown to precipitate suicide.[2,23] In fact, there are a number of potential advantages to asking a patient about suicide. Asking may help to prevent a suicide attempt by letting the patient know that someone cares. Asking also can help assess important issues such as whether there are firearms or drugs easily available, the specificity of a suicide plan, and the presence of other factors associated with increased risk of suicide completion. Identifying suicidal ideation allows recruitment of family and friends as allies, thus strengthening the social support around the individual and thereby lowering the risk of suicide completion.

Self-injurious Behavior
Self-injurious behavior (SIB) can be defined as a purposeful intent to inflict harm on one's body without an obvious intention of committing suicide. Currently, the prevalence of SIB among children and youth in the United States is not known.[3] Estimates indicate that SIB occurs in 20% to 60% of inpatient psychiatric populations and that with increasing levels of psychopathology, increasingly severe behavior can be found. Several psychological diagnoses or conditions have also been linked to increased risk of SIB. These include borderline personality disorder, depression, posttraumatic stress disorder, eating disorders, and abuse or trauma.[3]

Diagnostic features of SIB include:

An intentional desire to hurt oneself;

An inability to resist the impulse to injure oneself; and

Injury, not death, is the desired end result.
In a study of 6000 UK adolescents 15 to 16 years of age, 6.9% had experienced SIB within the past 12 months.[24] The rate was much higher in girls; 11.2% vs 3.2% in boys. Twelve percent of adolescents with SIB episodes had to seek medical care for the injury sustained.

Within this cohort, it was demonstrated that SIB could occur as a result of an irresistible urge. Completing the urge allowed release of whatever tension pushed the individual to self-injury, providing temporary respite. However, in many, tensions inevitably built again. If initial SIB provided relief for the person, he or she was at increased risk for repeating the behavior. Therefore, SIB is considered addictive in nature. Within this framework, some medication or drug overdoses could also be considered SIB.[24]

The UK study also identified some risk factors and predictors for SIB. For both boys and girls, a family history of SIB, drug abuse, and low self-esteem were contributing factors. A history of sexual trauma or abuse also markedly increased SIB risk. For girls, recent SIB by friends, anxiety, and impulsivity were linked to SIB; an additional factor for boys was suicidal behavior in friends.[24]

Although it was stressed that SIB should not be considered a step toward suicide, an overlap between SIB and suicide may exist. In a study of pediatric psychiatric inpatients, 63% of children with SIB also reported frequently experiencing suicidal ideation; 73% had made a suicide attempt in the previous 6 months.[25] However, 74% with SIB stated that they inflicted self-harm to release unbearable tension, not to commit suicide.

One difference that seems to support the contention that SIB is not a prelude to suicide is that, in general, SIB is conducted using methods less lethal than ones used in suicide. Another difference is that SIB is more repetitive in nature.

Although potential etiologic models for SIB have been proposed, there is no current consensus on cause(s).[3] It has been suggested that perhaps experiencing trauma in childhood limits a child's adaptive skills. The concept of impaired adaptation is the main tenet of the affect regulation theory -- SIB is viewed as a coping mechanism used by individuals who did not learn better mechanisms in childhood.[25] During her presentation, Dr. Ryan[3] raised an interesting notion: what if SIB, even though it is a maladaptive coping mechanism, is actually a better coping mechanism than suicide?

Another potential explanation is that the pain caused by SIB could decrease or help to overcome feelings of dissociation, thus bringing a person back to reality and serving as a connection to the present. It is also possible that the attention an individual may receive due to SIB may be a way to influence others and gain control over one's environment.[3]

Biologic theories suggest that SIB may be caused by a low level of serotonin -- providing an overlap with depression. Another interesting biological theory is that individuals with SIB may have an attenuated endogenous opioid system. It is postulated that perhaps it takes extreme situations, such as SIB, to trigger the opioid system of such individuals.

Intervention Strategies for SIB
The low level of disclosure of SIB to healthcare professionals, parents, and other adults represents a challenge to effectively identifying SIB, with identification being the first step in any intervention. It was suggested that clinicians be particularly aware of patients who wear clothing that hides much of their body, and that a thorough skin examination be included as part of the adolescent health maintenance visit. The practitioner should always inquire about any scars noted.[3]

Although pharmacotherapy may be included in the treatment of SIB, especially if there is an overlap with depression, behavioral therapies seem to show the most promise. In particular, dialectical behavior therapy is a promising option. This approach focuses on ineffective problem-solving skills and provides adaptive skills that are less injurious.[26] Steps to preventing SIB include promoting emotional health, preventing childhood trauma or treating trauma if this has already occurred, and helping to improve coping strategies through cognitive therapy.

Identification and Approach to Suicidal Ideation and Behavior
It has been shown that among youth, 1 suicide attempt raises the risk of suicide completion by 15-fold.[27] Therefore, the initial evaluation following a suicide attempt should be focused on clearly determining intent. On the basis of an extensive review of literature concerning the management of adolescents with suicidal ideation or attempt, Kennedy and colleagues[28] recommended that the following information be obtained:

The frequency of suicidal thoughts and how long these have been present;

The plan for the suicide, with particular emphasis on the details of the plan and the lethality of method selected;

Past history of suicide attempts;

The patient's access to lethal means of suicide;

The history or presence of psychiatric illness, with particular attention to diagnosis and medications;

Whether drug or alcohol use is present;

Family history of psychiatric illness, substance abuse, and suicide;

The relationships between the patient and parents or guardians;

Whether physical or sexual abuse occurred in the past; and

The sexual orientation of the patient.
It is also crucial to evaluate stressors and to assess whether the patient can state a reason or reasons for living.[2]

Outpatient Management of Suicide Attempt
Kennedy and colleagues[28] also formulated criteria for outpatient management of a patient who has made a suicide attempt. It is strongly suggested that if any of the criteria are not met, the patient should be hospitalized. The criteria include:

No inpatient medical treatment needed for conditions such as delirium;

No previous history of suicide attempt or a psychiatric disorder;

The patient should not be actively suicidal;

There should be an adult in the home where the adolescent will be cared for who has a good relationship with the adolescent, and this adult agrees to monitor the patient;

The monitoring adult agrees to remove all lethal suicide methods from the home;

Both the patient and the monitoring adult have a clear understanding of emergency contact procedures and when to return for additional care;

Further outpatient care has been arranged; and

Both the patient and monitoring adult agree with the plan and state they will comply with all recommendations.
It was stressed that even though a suicide contract (getting the patient to promise not to commit suicide until the clinician sees him or her again) has limited value, a treatment contract can serve to decrease the short-term risk of suicide.[4,29] A treatment contract should include frequent and quantifiable goals for follow-up and should incorporate steps aimed at improving the patient's mental and emotional state.

Treatment of Suicidal Behavior
The mental status of the patient should be assessed, and stressors identified. If depression is present, a combination of cognitive and medication therapy is recommended.[2,4]

Drs. Greydanus and Calles both addressed recent concerns about increased suicide risk in association with use of selective serotonin reuptake inhibitors (SSRIs) for treatment of depression. In 2005, the United States Food and Drug Administration (FDA) placed a black box warning on SSRI medications, citing an increased risk of suicide among children and adolescents taking this type of antidepressant. However, some experts are not sure the concern is justified.[30,31] They point out that patients being treated for depression are the individuals most often prescribed SSRIs. Therefore, the multitude of data supporting the strong link between depression and increased risk of suicide cannot be easily discounted.

Additionally, other data show the overall suicide rate has not increased over the past decade, though use of SSRIs has increased significantly during the same time period.[15] On the basis of this information, Greydanus contended the potential link between SSRI use and suicide does not seem to fit, at least not from an epidemiologic perspective.[2]

Although there is continued debate about risk associated with SSRI use in treatment of depressed children and adolescents, the acknowledged benefits of treatment are substantial.[31] Dr. Calles reiterated that untreated depression is clearly associated with a very high risk of suicide -- much higher than among patients being treated with antidepressants.[4] He stated that the overall number needed to treat to produce improvement in adolescents with depression is 9, whereas the number needed to harm (with respect to increased suicidal ideation) is 56. This means that 6 times more patients would benefit from treatment with antidepressants than the number who might have an increase in suicidal ideation.

The use of SSRIs in children and adolescents remains a difficult decision point for many clinicians. If use is being considered, frank discussions need to occur between clinician and parents/patient. It is incumbent upon the provider to fully inform those involved in treatment decisions about the potential risks and benefits. Currently, fluoxetine is the only antidepressant medication FDA approved for treatment of major depressive disorder in children.[4]

Reviewer Comments
The workshop on suicide covered a great deal of material, but was useful to generalists in several ways. First, the fact that suicide is the third leading cause of death in the United States for adolescents should be a rallying call for all healthcare providers. Just as resources have been poured into injury prevention (the number 1 cause), we would do well to focus on suicide as a public health problem and be increasingly aware of the potential for suicide ideation and suicide among our patient population.

Second, there is a strong statistical relationship between many problem behaviors and sociodemographic factors that contribute to an increased risk for adolescent suicide. Generalist practitioners should know warning signs and how to initiate and perform a comprehensive evaluation of a patient with suicide ideation or attempt. Kennedy and colleagues[28] have provided a particularly good resource that contains a review of risk factors and a how-to guide for a first-responder situation.

Finally, although most generalists encountering suicidal children and adolescents will probably leave the provision of behavioral therapy and pharmacotherapy to specialists, they can still play an important central role as the primary healthcare provider. This role may include meeting frequently with the patient, helping the patient and/or parents to dispel misperceptions about treatments, and identifying potential deterioration over time, just to name a few possible contributions.

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