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Non-Suicidal Self-Injury in Pediatric Bipolar Disorder: Clinical Correlates and Impact on Psychosocial Treatment Outcomes

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Abstract

Non-suicidal self-injury (NSSI) in childhood is not well documented, especially among youth with pediatric bipolar disorder (PBD). The current study evaluated prevalence and correlates of NSSI, and its impact on intervention response, in a randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy (CFF-CBT) versus Treatment As Usual (TAU), adjunctive to pharmacotherapy. This study included 72 children ages 7–13 (58% male) with PBD. NSSI and correlates were assessed at baseline; mood and psychiatric severity were measured longitudinally. NSSI was common: 31% endorsed NSSI behaviors; 10% reported thoughts of NSSI, in the absence of behaviors. Children engaging in NSSI reported higher depression, psychosis, suicidality, and hopelessness; lower self-esteem; and reduced family help-seeking in univariate analyses. In a multivariate logistic regression, high child depression and psychosis, and low family help-seeking, remained significantly associated with baseline NSSI. In mixed-effects regression models, presence of NSSI at baseline did not influence the response of depressive symptoms to treatment. Children who endorsed NSSI experienced steeper response trajectories for psychiatric severity, regardless of treatment group. Youth who denied NSSI showed poorer response to TAU for manic symptoms; mania trajectories in CFF-CBT were similar across youth. Thus, NSSI in PBD is common and associated with impairment. As children might engage in NSSI for different reasons, the function of NSSI should be considered in treatment. Since children without NSSI fared worse in TAU, it may be important to ensure that youth with PBD receive structured, intensive interventions. CFF-CBT was efficacious regardless of NSSI, and thus shows promise for high-risk children with PBD.

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References

  • Algorta, G. P., Youngstrom, E. A., Frazier, T. W., Freeman, A. J., Youngstrom, J. K., & Findling, R. L. (2011). Suicidality in pediatric bipolar disorder: Predictor or outcome of family processes and mixed mood presentation? Bipolar Disorders, 13, 76–86. doi:10.1111/j.1399-5618.2010.00886.x.

    Article  PubMed  PubMed Central  Google Scholar 

  • Altman, E. G., Hedeker, D., Peterson, J. L., & Davis, J. M. (1997). The Altman self-rating mania scale. Biological Psychiatry, 42, 948–955. doi:10.1016/s0006-3223(96)00548-3.

    Article  PubMed  Google Scholar 

  • Arbuthnott, A. E., & Lewis, S. P. (2015). Parents of youth who self-injure: A review of the literature and implications for mental health professionals. Child and Adolescent Psychiatry and Mental Health, 9, 35. doi:10.1186/s13034-015-0066-3.

    Article  PubMed  PubMed Central  Google Scholar 

  • Asarnow, J. R., Emslie, G., Clarke, G., Wagner, K. D., Spirito, A., Vitiello, B., et al. (2009). Treatment of selective serotonin reuptake inhibitor-resistant depression in adolescents: Predictors and moderators of treatment response. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 330–339. doi:10.1097/CHI.0b013e3181977476.

    PubMed  PubMed Central  Google Scholar 

  • Asarnow, J. R., Porta, G., Spirito, A., Emslie, G., Clarke, G., Wagner, K. D., et al. (2011). Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: Findings from the TORDIA study. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 772–781. doi:10.1016/j.jaac.2011.04.003.

    Article  PubMed  PubMed Central  Google Scholar 

  • Barbe, R. P., Bridge, J., Birmaher, B., Kolko, D., & Brent, D. A. (2004). Suicidality and its relationship to treatment outcome in depressed adolescents. Suicide and Life-threatening Behavior, 34, 44–55.

    Article  PubMed  Google Scholar 

  • Barrocas, A. L., Jenness, J. L., Davis, T. S., Oppenheimer, C. W., Technow, J. R., Gulley, L. D., et al. (2011). Developmental perspectives on vulnerability to nonsuicidal self-injury in youth. In J. B. Benson & J. B. Benson (Eds.), Advances in child development and behavior, Vol 40 (pp. 301–336). San Diego: Elsevier Academic Press.

    Chapter  Google Scholar 

  • Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck depression inventory-II. San Antonio: Psychological Corporation.

  • Birmaher, B., Axelson, D., Goldstein, B., Strober, M., Gill, M. K., Hunt, J., et al. (2009). Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: The course and outcome of bipolar youth (COBY) study. American Journal of Psychiatry, 166, 795–804. doi:10.1176/appi.ajp.2009.08101569.

    Article  PubMed  PubMed Central  Google Scholar 

  • Conners, C., & March, J. (1996). The Conners/march developmental questionnaire. Toronto: MultiHealth Systems, Inc.

    Google Scholar 

  • Curry, J., Rohde, P., Simons, A., Silva, S., Vitiello, B., Kratochvil, C., et al. (2006). Predictors and moderators of acute outcome in the treatment for adolescents with depression study (TADS). Journal of the American Academy of Child and Adolescent Psychiatry, 45, 1427–1439. doi:10.1097/01.chi.0000240838.78984.e2.

    Article  PubMed  Google Scholar 

  • Dickstein, D. P., Brazel, A. C., Goldberg, L. D., & Hunt, J. I. (2009). Affect regulation in pediatric bipolar disorder. Child and Adolescent Psychiatric Clinics of North America, 18, 405–420. doi:10.1016/j.chc.2008.12.003.

    Article  PubMed  Google Scholar 

  • DiClemente, R. J., Ponton, L. E., & Hartley, D. (1991). Prevalence and correlates of cutting behavior: Risk for HIV transmission. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 735–739. doi:10.1097/00004583-199109000-00006.

    PubMed  Google Scholar 

  • Esposito-Smythers, C., Goldstein, T., Birmaher, B., Goldstein, B., Hunt, J., Ryan, N., et al. (2010). Clinical and psychosocial correlates of non-suicidal self-injury within a sample of children and adolescents with bipolar disorder. Journal of Affective Disorders, 125, 89–97. doi:10.1016/j.jad.2009.12.029.

    Article  PubMed  PubMed Central  Google Scholar 

  • Fox, K. R., Franklin, J. C., Ribeiro, J. D., Kleiman, E. M., Bentley, K. H., & Nock, M. K. (2015). Meta-analysis of risk factors for nonsuicidal self-injury. Clinical Psychology Review, 42, 156–167. doi:10.1016/j.cpr.2015.09.002.

    Article  PubMed  PubMed Central  Google Scholar 

  • Fusar-Poli, P., Nelson, B., Valmaggia, L., Yung, A. R., & McGuire, P. K. (2014). Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: Impact on psychopathology and transition to psychosis. Schizophrenia Bulletin, 40, 120–131. doi:10.1093/schbul/sbs136.

    Article  PubMed  Google Scholar 

  • Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J. L., DelBello, M. P., & Soutullo, C. (2001). Reliability of the Washington University in St. Louis kiddie schedule for affective disorders and schizophrenia (WASH-U-KSADS) mania and rapid cycling sections. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 450–455. doi:10.1097/00004583-200104000-00014.

    Article  PubMed  Google Scholar 

  • Geller, B., Tillman, R., Bolhofner, K., & Zimerman, B. (2008). Child bipolar I disorder: Prospective continuity with adult bipolar I disorder; characteristics of second and third episodes; predictors of 8-year outcome. Archives of General Psychiatry, 65, 1125–1133. doi:10.1001/archpsyc.65.10.1125.

    Article  PubMed  PubMed Central  Google Scholar 

  • Goldstein, T. R., Birmaher, B., Axelson, D., Ryan, N. D., Strober, M. A., Gill, M. K., et al. (2005). History of suicide attempts in pediatric bipolar disorder: Factors associated with increased risk. Bipolar Disorders, 7, 525–535. doi:10.1111/j.1399-5618.2005.00263.x.

    Article  PubMed  PubMed Central  Google Scholar 

  • Goldstein, T. R., Birmaher, B., Axelson, D., Goldstein, B. I., Gill, M. K., Esposito-Smythers, C., et al. (2009). Psychosocial functioning among bipolar youth. Journal of Affective Disorders, 114, 174–183. doi:10.1016/j.jad.2008.07.001.

    Article  PubMed  Google Scholar 

  • Goldstein, T. R., Ha, W., Axelson, D. A., Goldstein, B. I., Liao, F., Gill, M. K., et al. (2012). Predictors of prospectively examined suicide attempts among youth with bipolar disorder. Archives of General Psychiatry, 69, 1113–1122. doi:10.1001/archgenpsychiatry.2012.650.

    Article  PubMed  PubMed Central  Google Scholar 

  • Goldstein, T. R., Fersch-Podrat, R. K., Rivera, M., Axelson, D. A., Merranko, J., Yu, H., et al. (2015). Dialectical behavior therapy for adolescents with bipolar disorder: Results from a pilot randomized trial. Journal of Child and Adolescent Psychopharmacology, 25, 140–149. doi:10.1089/cap.2013.0145.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hankin, B. L., & Abela, J. R. (2011). Nonsuicidal self-injury in adolescence: Prospective rates and risk factors in a 2(1/2) year longitudinal study. Psychiatry Research, 186, 65–70. doi:10.1016/j.psychres.2010.07.056.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hauser, M., Galling, B., & Correll, C. U. (2013). Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: A systematic review of prevalence and incidence rates, correlates, and targeted interventions. Bipolar Disorders, 15, 507–523. doi:10.1111/bdi.12094.

    Article  PubMed  PubMed Central  Google Scholar 

  • Horton, S. E., Hughes, J. L., King, J. D., Kennard, B. D., Westers, N. J., Mayes, T. L., & Stewart, S. M. (2016). Preliminary examination of the interpersonal psychological theory of suicide in an adolescent clinical sample. Journal of Abnormal Child Psychology, 44, 1133–1144. doi:10.1007/s10802-015-0109-5.

    Article  PubMed  Google Scholar 

  • Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11, 129–147. doi:10.1080/13811110701247602.

    Article  PubMed  Google Scholar 

  • Joiner, T. (2005). Why people die by suicide. Cambridge: Harvard University Press.

    Google Scholar 

  • Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 980–988. doi:10.1097/00004583-199707000-00021.

    Article  PubMed  Google Scholar 

  • Kazdin, A. E., Rodgers, A., & Colbus, D. (1986). The hopelessness scale for children: Psychometric characteristics and concurrent validity. Journal of Consulting and Clinical Psychology, 54, 241–245.

    Article  PubMed  Google Scholar 

  • Keenan-Miller, D., Peris, T., Axelson, D., Kowatch, R. A., & Miklowitz, D. J. (2012). Family functioning, social impairment, and symptoms among adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 1085–1094. doi:10.1016/j.jaac.2012.08.005.

    Article  PubMed  PubMed Central  Google Scholar 

  • Martin, G., Thomas, H., Andrews, T., Hasking, P., & Scott, J. G. (2015). Psychotic experiences and psychological distress predict contemporaneous and future non-suicidal self-injury and suicide attempts in a sample of Australian school-based adolescents. Psychological Medicine, 45, 429–437. doi:10.1017/s0033291714001615.

    Article  PubMed  Google Scholar 

  • McCubbin, H. I., Olson, D. H., & Larsen, A. S. (1991). F-COPES: Family crisis oriented personal evaluation scales. In H. I. McCubbin & A. I. Thompson (Eds.), Family assessment inventories for research and practice (2nd ed., pp. 203–218). Madison: University of Wisconsib-Madison.

    Google Scholar 

  • McCubbin, H. I., Thompson, A. I., & Elver, K. M. (1996). Youth coping index (YCI). In H. I. McCubbin, A. I. Thompson, & M. A. McCubbin (Eds.), Family assessment: Resiliency, coping and adaptation-inventories for research and practice (pp. 585–612). Madison: University of Wisconsin-Madison.

    Google Scholar 

  • Muehlenkamp, J. J. (2005). Self-injurious behavior as a separate clinical syndrome. American Journal of Orthopsychiatry, 75, 324–333. doi:10.1037/0002-9432.75.2.324.

    Article  PubMed  Google Scholar 

  • Nock, M. K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339–363. doi:10.1146/annurev.clinpsy.121208.131258.

    Article  PubMed  Google Scholar 

  • Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885–890. doi:10.1037/0022-006X.72.5.885.

    Article  PubMed  Google Scholar 

  • Nock, M. K., Prinstein, M. J., & Sterba, S. K. (2009). Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults. Journal of Abnormal Psychology, 118, 816–827. doi:10.1037/a0016948.

    Article  PubMed  PubMed Central  Google Scholar 

  • Olson, D. (2011). FACES IV and the circumplex model: Validation study. Journal of Marital and Family Therapy, 37, 64–80. doi:10.1111/j.1752-0606.2009.00175.x.

    Article  PubMed  Google Scholar 

  • Pavuluri, M. N., Graczyk, P. A., Henry, D. B., Carbray, J. A., Heidenreich, J., & Miklowitz, D. J. (2004a). Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Development and preliminary results. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 528–537. doi:10.1097/00004583-200405000-00006.

    Article  PubMed  Google Scholar 

  • Pavuluri, M. N., Henry, D. B., Devineni, B., Carbray, J. A., Naylor, M. W., & Janicak, P. G. (2004b). A pharmacotherapy algorithm for stabilization and maintenance of pediatric bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 859–867. doi:10.1097/01.chi.0000128790.87945.2f.

    Article  PubMed  Google Scholar 

  • Pavuluri, M. N., Henry, D. B., Devineni, B., Carbray, J. A., & Birmaher, B. (2006). Child mania rating scale: Development, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 550–560. doi:10.1097/01.chi.0000205700.40700.50.

    Article  PubMed  Google Scholar 

  • Perlis, R. H., Dennehy, E. B., Miklowitz, D. J., Delbello, M. P., Ostacher, M., Calabrese, J. R., et al. (2009). Retrospective age at onset of bipolar disorder and outcome during two-year follow-up: Results from the STEP-BD study. Bipolar Disorders, 11, 391–400. doi:10.1111/j.1399-5618.2009.00686.x.

    Article  PubMed  PubMed Central  Google Scholar 

  • Piers, E. V., & Herzberg, D. S. (2002). Piers-Harris Children's self-concept scale-second edition manual. Los Angeles: Western Psychological Services.

    Google Scholar 

  • Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., et al. (2011). The Columbia-suicide severity rating scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266–1277. doi:10.1176/appi.ajp.2011.10111704.

    Article  PubMed  PubMed Central  Google Scholar 

  • Poznanski, E. O., Grossman, J. A., Buchsbaum, Y., Banegas, M., Freeman, L., & Gibbons, R. (1984). Preliminary studies of the reliability and validity of the children’s depression rating scale. Journal of the American Academy of Child and Adolescent Psychiatry, 23, 191–197.

    Article  Google Scholar 

  • Ravens-Sieberer, U., & Bullinger, M. (1998). Assessing health-related quality of life in chronically ill children with the German KINDL: First psychometric and content analytical results. Quality of Life Research: an International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 7, 399–407.

    Article  Google Scholar 

  • Rohde, P., Seeley, J. R., Kaufman, N. K., Clarke, G. N., & Stice, E. (2006). Predicting time to recovery among depressed adolescents treated in two psychosocial group interventions. Journal of Consulting and Cliniclal Psychology, 74, 80–88. doi:10.1037/0022-006x.74.1.80.

    Article  Google Scholar 

  • Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983). A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40, 1228–1231.

    Article  PubMed  Google Scholar 

  • Spearing, M. K., Post, R. M., Leverich, G. S., Brandt, D., & Nolen, W. (1997). Modification of the clinical global impressions (CGI) scale for use in bipolar illness (BP): The CGI-BP. Psychiatry Research, 73, 159–171.

    Article  PubMed  Google Scholar 

  • Stewart, J. G., Esposito, E. C., Glenn, C. R., Gilman, S. E., Pridgen, B., Gold, J., & Auerbach, R. P. (2017). Adolescent self-injurers: Comparing non-ideators, suicide ideators, and suicide attempters. Journal of Psychiatric Research, 84, 105–112. doi:10.1016/j.jpsychires.2016.09.031.

    Article  PubMed  Google Scholar 

  • Van Meter, A. R., Moreira, A. L., & Youngstrom, E. A. (2011). Meta-analysis of epidemiologic studies of pediatric bipolar disorder. Journal of Clinical Psychiatry, 72, 1250–1256. doi:10.4088/JCP.10m06290.

    Article  PubMed  Google Scholar 

  • Van Meter, A. R., Burke, C., Kowatch, R. A., Findling, R. L., & Youngstrom, E. A. (2016). Ten-year updated meta-analysis of the clinical characteristics of pediatric mania and hypomania. Bipolar Disorders, 18, 19–32. doi:10.1111/bdi.12358.

    Article  PubMed  Google Scholar 

  • Vitiello, B., Emslie, G., Clarke, G., Wagner, K. D., Asarnow, J. R., Keller, M. B., et al. (2011). Long-term outcome of adolescent depression initially resistant to selective serotonin reuptake inhibitor treatment: A follow-up study of the TORDIA sample. Journal of Clinical Psychiatry, 72, 388–396. doi:10.4088/JCP.09m05885blu.

    Article  PubMed  PubMed Central  Google Scholar 

  • Weinstein, S. M., Van Meter, A., Katz, A. C., Peters, A. T., & West, A. E. (2015a). Cognitive and family correlates of current suicidal ideation in children with bipolar disorder. Journal of Affective Disorders, 173, 15–21. doi:10.1016/j.jad.2014.10.058.

    Article  PubMed  Google Scholar 

  • Weinstein, S. M., Henry, D. B., Katz, A. C., Peters, A. T., & West, A. E. (2015b). Treatment moderators of child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 116–125. doi:10.1016/j.jaac.2014.11.007.

    Article  PubMed  Google Scholar 

  • West, A. E., Weinstein, S. M., Peters, A. T., Katz, A. C., Henry, D. B., Cruz, R. A., & Pavuluri, M. N. (2014). Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 53, 1168–1178, 1178.e1161. doi:10.1016/j.jaac.2014.08.013.

  • Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the adolescent depression antidepressants and psychotherapy trial (ADAPT). American Journal of Psychiatry, 168, 495–501. doi:10.1176/appi.ajp.2010.10050718.

    Article  PubMed  Google Scholar 

  • Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: Reliability, validity and sensitivity. British Journal of Psychiatry, 133, 429–435.

    Article  PubMed  Google Scholar 

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Acknowledgements

The project described was supported by grants to Amy E. West from the National Institute of Mental Health (NIMH K23 MH079935) and Sally M. Weinstein from the American Foundation for Suicide Prevention Young Investigator Award (YIG-1-140-11).

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  1. Department of Psychology, Harvard University, 1044 William James Hall, 33 Kirkland Street, Cambridge, MA, 02138, USA

    Heather A. MacPherson

  2. Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA

    Sally M. Weinstein & Amy E. West

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  1. Heather A. MacPherson
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MacPherson, H.A., Weinstein, S.M. & West, A.E. Non-Suicidal Self-Injury in Pediatric Bipolar Disorder: Clinical Correlates and Impact on Psychosocial Treatment Outcomes. J Abnorm Child Psychol 46, 857–870 (2018). https://doi.org/10.1007/s10802-017-0331-4

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