Plenary Session P8  - Abuse and Self Harm

Chaired by Robert Blum - Minnesota USA

and Ann Sutton - Glasgow - Scotland

Chair - Rod McClymont is at the Department of Adolescent Medicine, Westmead Hospital and New Children's Hospital, Sydney, Australia where he has conducted the following work with his colleagues Simon Clarke, Gail Anderson, J. Benson & M. Kohn

Transitional Care in Adolescents with Eating Disorders.  Rod McClymont

Eating disorders are chronic illnesses which disable adolescents over many years.  The features and management of the 11-12 year old adolescent with anorexia nervosa is usually very different to that of the 17-18 year old. Many units try to manage patients with a wide age range in the same program. We describe a program in which four units with different types of services offer a logical transition from pre-puberty to adulthood with overlap of professionals involved and cohesive comprehensive management of patients.

Services managing young patients with eating disorders need to be aware of the issues of transition from child-centred to adult-centred care if patients are not to be lost to follow-up with subsequent increased morbidity, mortality and costs. Adolescents are vulnerable if there is no continuity of staff and resent having to divulge their secrets yet again. As eating disorders may take 6 to 9 years to resolve, care should include continuity of the relationship with at least some staff over the duration of this time.

Although high numbers have been lost to follow up, in general what we could say about figures could be said to be true there are between  0.2 to 1% of adolescents had anorexia nervosa fulfilling the criteria and at least 90% 0f these are girls, very few boys. In bulimia nervosa its’ more common, 1 to 5 % and there are more boys here, they represent 20 to 25%. Overall the rate appears also to be increasing. Mortality seems to have declined over the last 2 to 3 decades from an average of 10% to 5%. But the duration of the illness is static, the average duration of anorexia nervosa is around 5 to 7 years, it’s the average. The 50% go beyond that. With an average age of onset of around age 14 most of these adolescents will be affected well into their early 20s. Some 50 to 70% will make a good recovery in physiological terms. Menstruation, weight gain, but at least half will have on-going significant psycho-social problems in particular difficulties with long-term with relationships, depression and anxiety. In adolescents the course of eating disorders is further complicated by their developmental changes.

This just briefly shows how developmental stage which I loosely relate to chronological age and where the person is in the course of that 5 - 6 - 7 - 8 year illness can interact in a very complex way. In our experience the early or developmentally immature adolescents the ones who often present dehydrated as well as having significant food restriction, they often need resuscitation with nose-gastric feeds, they are very concrete in their thinking and they respond well to a very structured programme.

Those between ages 14 to 16 are of the very variable maturity, some 16 year olds behave more like 12 year olds and respond very well to strict guidelines, whereas some 14 year olds are very mature, they abstract thought processes and they do very well in a flexible programme. The later adolescent who has achieved abstract thought responds well to a programme that is flexible and allows their input in negotiation. Those who are more disturbed at this stage may need more intensive psychiatric care. Westmead Hospital and a New Children’s Hospital in Sydney, like many other institutions has developed a model for transition. In our case it centred around the Department of Adolescent Medicine which spans both hospitals. This model has been applied to other chronic illnesses but only recently to eating disorders. Interestingly the report from which this picture comes is illustrated with photograph of a young anorexic girl from our ward but at the time no thought was given to them as being part of the process.

We feel that transition is particularly significant for eating disorders as these patients and their family often resent to have to re-establish trust with new therapists and our experience is that transfer without transition frequently result in drop out from care or a loss of earlier gains. We’ve been able to initiate a transition process which started informally and is being facilitated by close physical proximity and co-appointed staff in New Children’s Hospital and adult’s hospital. A Child and Adolescent Psychiatry Department is also available for those who are more disturbed and there is easy transition on to an adult service which is a psychiatric run service. The children’s hospital normally looks after adolescents with eating disorders from age 11 to 14. We in the Adolescent Department of the adult’s hospital from 14 to 18 years old and those from 18 on - in the adult department. The transition is initiated based on the developmental stage of the adolescent from the more structured child hospital unit to a more open adult unit as required. 11 patients have been transitioned so far, 6 of these have gone from the children’s hospital to the adult hospital’s adolescent unit, 3 from the adult hospital’s adolescent unit to the adult ward there and 2 have transitioned right through from the Children’s Hospital to our adolescent unit and through on to the adult ward. This photo was taken with me at the adolescent ward 14^th birthday party, Simon Clarke, the tall one at the back, the unit director is always on the lookout for funding and publicity opportunities managed to rope in the  Director General of the Department of Health to officiate the occasion, I think we got some funding there. The young lady on the right, though undoubtedly she does have an eating disorder was actually in with asthma at the time and all the other young people there are girls who are in our in-patient anorexia or bulimia nervosa programme, 3 of them you can see have nasal gastric tubes. The girl who is second from the left Melanie is now 17 and a half, she was one of the first to be transitioned. She has a 2 or 3 year history of both bulimia and restricting, very difficult to engage, hated the  very structured environment down at children’s hospital, had a brief admissions for hypo-bulimia. Came up to us, again very requiring her initial carer to be to maintain contact with her, took months before she even spoke to me apart from 2 words which I won’t repeat. And has now further transitioned on to the adult service, she’s finished school, she is starting to work. And again I remain very much involved and there’s what kept things working with this girl has been having that continuity.

The girl on the far left very similar, bulimia, not too much of a problem from a weight point of view, but again didn’t respond well at children’s hospital, it was too restrictive for her and has done well with a more open programme, both as an in-patient and out-patient and is now transitioning to the adult programme.  The girl close from the left is very interesting, she is quite tall, looks quite mature, but at this stage she has only just turned 14 I think, but she was with her thinking also quite mature, was not getting anywhere in the kid’s hospital system, she was very resentful of a strict ward and managed to do very well in our ward but again the consistent thing was having the same family therapist, the same individual therapist through that process.

Overall the process has been a positive one from the young people involved and the staff. They see progress and they see a willingness to respond to their needs. Problems that have arisen are similar to other programmes, other transitional programmes that is, specifically difficulties in ensuring timely and reliable access to background notes, difficulties with predicting staff availability as they are responsible to more than one department and inflexible hospital administrative procedures. We are pleased with this apparent success that the next step is to implement objective procedures to evaluate this progress. Outcome studies in eating disorders have had many methodological problems, transitional programme outcome studies are few, very few control ones.

Treatment of eating disorders is expensive in terms of hospital beds and staff input. We do not develop objective methods to evaluate our progress and potential new methods of treatment, those who provide the funding, whether they are governments or whether they are insurance companies will demand it of us.

In 1993 the following methodological changes were proposed to improve research, the importance of clear definitions of who you are talking about, do they definitely have anorexia, why are you defining it as anorexia. Clear definitions about the patients, their weights, how long they’ve had the illness for, what their lowest weight was, many of these things are missing from studies. You need to have multiple outcome parameters, not just how they are doing from the point of view of their bones or their bodies but very closely looking at how they are functioning psychologically and with other people. The data that you collect needs to be reliable and objective, bringing up people who have had anorexia nervosa and saying, have you put on weight, is not a reliable way to get data but it’s commonly used. Co-operation by asking a partner, a parent can help you. Allocation of time is important as the longer you go obviously if there is improvement there will be less and less patience there. A clear and detailed description of your treatment is important, otherwise you can’t compare between studies and to account for those who have lost a follow up so we have some idea of the potential biases involved.

So in summary anorexia and bulimia are both chronic illnesses in adolescents which follow prolonged course, they are associated with significant morbidity. Mortality has improved, but morbidity in time terms remains the same. Loss to follow up is all too common in our experience and is part of the illness, these kids will readily take advantage of any gaps in the service. We must take the next step of development and application of effective and objective evaluation procedures because those who hold the purse strings will do it for us otherwise. Thank you.

Chairman: I think we can have one or two questions.  The question that was raised for those who didn’t hear it is that at a recent meeting the Director of the National Institute of Mental Health in the US indicated that he didn’t see a lot of new treatments for anorexia nervosa in process or even on the horizon. And the question was, from your perspective is that true?

R.M. Very simply, yes, I agree with that statement. There is a lot written but the use of word promising at the moment - no, in terms of changing outcomes medically - no.

Chairman: Thank you very much. Our next speaker is Professor Ueli Buhlmann. Ueli is Chief of Paediatrics of Triemli Medical Centre in Zurich in Switzerland and is an international expert in areas of chronic illness particularly in cystic fibrosis and eating disorders and is a very dear close personal friend.

Admission and Initial Therapy of Severely Ill Anorexics Ueli Buhlmann

I will not present any really new statements, more a summary than anything else, so I will certainly agree with what’s been mentioned that it has been a battle and it will probably continue to be a battle. What I am talking about today is not just anorexia nervosa in general but I would like to share with you what we do in a rather small setting in a hospital on a combined paediatric and adolescent medicine ward when we have to deal with severely ill adolescents with eating disorder.

I am going to focus on severely ill adolescents. I must tell you that in Switzerland we still see a lot of kids that are severely ill. What Do I mean by severely ill? We see a lot of adolescents that come in early adolescence somewhere between 12 and 14 years of age of a body mass that is below 14 or with a pulse rate which is extremely low and really is of concern with very low temperature, all things that you find in the literature but you think we should no longer be in a position where we can wait as long as that before the kid will get treatment.

So what do we do when these kids come to our place. Usually they would have had some kind of contact with the medical system. They either have been followed by their paediatrician or by their family doctor having sort of managed for a long time to cover up a very low weight they reached. So patient of course will be in the centre of our work that we do. But we only work with the patients if the family is willing to participate in our programme as well. So these are key players that we are working with. And who is we? We move in with whole group of therapists, physician on one side, psychologist and family therapist, and we move in with nurses, physios and occupational therapists. And of course going from all those no care or just a standard follow up by a family doctor such a multi-disciplinary group is quite a shock and so before the meaning the patient we see the family in a first session when there are two goals: number one we as a treating team want to hear more about the history and not only know that from the parents but we also include the siblings and of course we want to hear if that’s possible if the patient actually speak up about their disease from their perspective.

In the second part of this first family session we show them how we work, what will happen, if the adolescent was to be admitted on our ward. From other side in terms of participating it’s the entire family who is invited to come. We really put this up as an indication to everybody because that’s very interesting to see who is showing up. Sometimes it’s just mum and the kids, sometimes really the family is showing up as an entire. From our side it’s usually one of our physicians the family therapist and the nurse who will be the one person who follows all the way through the hospital stay. The family after this first session goes home. Unless there is really an emergency or something comes up in a brief exam of a patient that would preclude us allowing her home overnight, if at all possible we send the family home so that then they can debate about what they heard usually it’s a very tense period because it’s the last opportunity for the patient to influence the parents once again its very hard on the parents but we actually encourage that process because we have to have this parents support otherwise our programme is more likely not to work.

We then admit the patient and in the first week we’ll do all the medical work-up meaning that we do really a lot of exams. We only recently have changed our approach to looking more closely into the details of the medicals, of the somatic conditions. And it’s just of the same purpose that’s been mentioned in the talk before, I think that we need data bases, as a basis for evaluation and when you are looking into the literature about anorexia nervosa there’s been a whole lot about the psychological, psychiatric issues, there’s a lot more and it’s not until a few years back that we learnt about the somatic problems that will probably last for a long time. One of the point being the bone mineral density, if these girls are really deficient in their nutrient intake for a long period of time they’ll be at risk for a low mineral density by the end of their adolescence.

We watch closer into gynaecological problems including the adolescent gynaecologist having a close look at what is going on doing like abdominal ultra-sound but also with of lab work. There is always the question about the CD scan or MRI of the brain, we not always do that is there’s a classical history in a girl with all the signs of an anorexia we probably will not do an MRI of the brain, we’ll do it certainly on the boys and in the cases where there is any doubt of the diagnosis. Then doing any of the lab work and the second goal of the first week is to introduce the patient to the details of our treatment plan. So what’s the plan. We work with contracts to all the different peers during that through all the phases of the treatment. And we divide the treatment in 3 parts. When I talk about severely ill kids most of them will come by a BMI the low 14 and a half or 14 and in our hospital this means that we need re-feeding through nasal gastric tubes. The longest period of time is what we would call control re-feeding. It’s a phase where we carefully monitor the kids while they are eating. And in the last phase we’ll work with them to finish the hospital stay, it’s a time where they go to their homes live with the family step by step progressing out again with their schools or with the work or slowly move out of the hospital when they finally reach their weight that we set as a goal.

The average calorie intake for the kids is around 2000 calories per day and we set as a goal a weight gain of 500 grams - half a kilo per week. When you calculate that kids come in in a really starving condition then this will end up with a first hospital stay anywhere between 3 - 4 months as average. So we really talking about a long hospital treatment. I would like to show you how we set the goal and how we work with the patients. This12 year old was admitted to hospital at 28.2 kg. It’s a BMI of 13. So this kid was severely ill. We calculate the BMI percentage, we set the goal and ask the patient that the weight that we measure on an irregular basis remains within +/- 500 grams between the initial weight and the goal weight. Initially with naso-gastric tube we didn’t have any problems, then she started to eat quite well and then lost quite a lot of weight. So first time she was below that lowest limit we added calories, added calories the second time until she was back in her channel. Patients have the same diagram so that they can follow their weight and what they are supposed to do by themselves.

Just a few words because it’s quite controversial about use of naso-gastric tube feeding. In children with very low weight we start with a low calorie amount of 800 then we’ll add 200 kcal per day to reach the goal of 2000 calories per day as average afterwards. We want to carefully monitor what’s going on in terms of balance, in terms of serum electrolytes and we also check the urine to be sure that kids are not just drinking water to gain weight. I have said a lot about somatic part of the treatment, in parallel the kids are carefully followed on a psychological treatment plan level. They have three session of individual therapy. In psychotherapy with these kids anything depending on the developmental stage of the adolescent can be anything from creative work to really speaking with the patient. I use a variety of technique. The family comes in once every two weeks and we have group session.

Once the patients reach the level when they eat by themselves they will have in addition physiotherapy and see the occupational therapist. In summary what we do in a rather classical setting on the combined paediatric and adolescent medicine ward for a long duration of first hospital stay we work with the family form the beginning, we have a multi-disciplinary approach that works very well, the team meets twice a week all the people involved really have a very clear line of where the patient is and what we want to do. We work with contracts sometimes difficult with the smaller children, we re-phrase our contract when we first start work with 11 year olds then probably have to adapt the language that used with this age group, but even with the smaller ones contracts work well.

We have a strong emphasis now on somatic development because we realised that there is a great risk if the patient’s average length of disease is for many years that is a high risk for a problem later in their lives and that’s all I wanted talk to you, thank you very much.

Chairman: We can open out briefly for comments and questions.

Question: If sexual abuse is part of the background of your patients who do you deal with that, do you deal with that within your programme or you go outside for it?

U.B. This would be one of the issues that I would expect to come up in the individual therapy sessions and so far we had very few cases where it’s been open. In these cases we dealt with it in our own programme so we didn’t go anywhere else.

Chairman: Thank you. This is again I think a very good way into our next paper, Elaine Yordan is a Professor of Clinical Paediatrics at the University of Connecticut in the United States, is a clinician and works in the areas of sexual abuse and will be talking on the topic of sexually abused adolescents with the history of prior victimisation.

Sexually Abused Adolescents with the History of Prior Victimisation   Elaine Yordan

Good afternoon. I wanted to show you here my setting the State of Connecticut, it’s very small and this I consider my home away from home (don’t tell my husband and son). Previous sexual victimisation is a risk factor for subsequent sexual assault. Those of us who counsel and treat adolescents who are victims of sexual abuse must keep in mind that a past history of sexual abuse places these teenagers at greater risk for sexual abuse, for sexual assault in the future.

Why do clinicians need to know if their patients have been a victim of forced sexual experience? In addition to obvious reason of needing to provide medical care and making sure the abuse is reported to child protection services healthcare clinicians need to make sure that the psycho-social sequelae of sexual abuse are recognised and dealt with appropriately before the adolescent begins to engage in risk-taking behaviours with potentially devastating outcomes such as unprotected sexual contact with multiple partners, substance abuse, delinquency, run away, school failure, drop out, pregnancy or suicide.

Adolescents sexual abuse whether current or in the past includes dating violence, permeates all aspects of modern society and every clinician who provides care for adolescent patients needs to know how to screen for the problem. When obtaining a psycho-social history or sexual history from an adolescents patients questions regarding past victimisation can be easily included as part of the routine screening. Getting a history of sexual abuse is not always easy and certainly we personally need to feel comfortable with this. We’ve been taught to incorporate questions about domestic, physical violence in our history-taking on the whole. We must also learn to include questions about sexual abuse, sexual assault, date rape as it is called in the United States. However simply asking the question, Have you ever been sexually abused? Often would not reveal the true history.

Many teens are unprepared to answer this question or they may not want to believe that they may have been abused. Questioning should be preceded by the explanation of the need to ask certain questions that may be very difficult but are necessary to understand their need. Questions should be formed around the types of behaviour rather than the term sexual abuse. Example include, have you ever been touched in the way that makes you feel uncomfortable and hurt? Have you ever been forced to perform sexual act that you didn’t want to? Were ever told to keep a secret or threatened if you did not? As a child were ever made to touch another person’s genitals or watch sexual activity of others? As a child were you given pornographic pictures, magazines or videos? If the psycho-social history reveals problems with family conflict, school failure or truancy, depression, suicide ideation or substance abuse the possibility of undisclosed past sexual abuse should be seriously entertained.

The sexually abused either a child or adolescent may have vague abdominal pain, pelvic pain very commonly seen by the gynaecologist, school phobias, advanced sexual talk, sexualised behaviour, secondary enuresis, secondary encopresis, defiance, panic attacks or passive behaviour. And with that in mind it’s also possible to realise that ironically some adolescents some may not show signs of immediate distress or dysfunction in relationship to sexual abuse.

It is very possible that symptoms may not become manifest until late adolescence or even adulthood. Statistically the reality is that only 30% of victims experience a single abuse episode. In one study adolescent female victims aged 12 to 18 years the abuse on average began when the girls were 10 years old and continued for more than 3 and a half years. More than 80% of the abuse was perpetrated by the father or a male dominant figure in the home. Numerous studies confirm the high frequency of multiple abuse. The relationship between prior and subsequent victimisation often coexists with other risk factor.

A very important risk factor is the absence of adequate guardianship. The situation leaves the adolescent with compromised defences against victimisation. Defencelessness make a young adolescent a more attractive target to a predator. Clearly children and adolescents who are well less supervised by parents because of impaired relationships are more vulnerable to multiple victimisations. In addition sexual abuse by a family member, often an adult male might create alienation from other family members who could serve as guardians against intrafamilial and extrafamilial sexual abuse. In betrayal a child comes to understand that someone who she trusted and upon whom she depended manipulated and hurt her deliberately. Further more another trusted person disbelieved was unable or even worse she was unwilling to protect her from harm. The worst circumstance for what I see clinically is the mother that does not believe the adolescent female when she discloses sexual abuse. Just splits them in their relationship.

If the abuse becomes more and more sexually intrusive, more coercion and threatening may be become necessary. The victim may feel as if she is responsible because she didn’t or felt she could not tell her mother or someone else immediately. Also she is prone to feel guilty because any physical or emotional pleasure she may have experienced as a result of this sexual abuse. If she is able to tell her mother and the mother disbelieves her the adolescent will feel further abandoned, unprotected and at the mercy of the predator’s sexual desires. Sexualisation of the adult-child relationship often takes place gradually over a period of time during which the offender rationalises his behaviour, for example by redefining the sexual abuse. I’ve heard this in my clinical practice.

The predator maintains the victim’s co-operation by a variety of coercive means that play upon naiveté, dependence, love and loyalty. These means include seductive pressure to establish guilt, verbal and physical threats, physical abuse, outright bribery and exploitation of the perceived reaction of others: should they be told, your mother’s never going to believe you. Several factor contribute to perpetuating the abusive situation: secrecy, helplessness, entrapment and finally accommodation, the means by which the victim emotionally tolerates the situation in which sexual abuse is followed by further sexual abuse. Symptoms resulting from betrayal include extreme dependence or clingyness in relationships because of the need to establish a trusting relationship. Sexual assault by a family member creates impaired attachments. The victim may show poor judgement about the trustworthiness of others because she has no model to appropriately establish trusting relationships. An adolescent and an adult survivor of sexual abuse is particularly vulnerable to later victimisation and may become involved in relationships that involve physical, emotional or sexual abuse of herself or her children.

Again I am sure all of  you if you deal with adolescents who’ve been sexually abused in your practices also hear from the mother or the family member that they themselves have been sexually abused and sometimes you get a history that it is multiple generations. She may also have absolute distrust for all male-female relationships perhaps resulting in deficient heterosexual relationships in the future. Survivors of sexual victimisation need to be aware understanding of the effect of these past experiences on their current behaviour they are at risk for being victimised again.

In the process of examining past practices it is often not surprising that women with patterns of frequent sexual activity may appear to themselves or others as could be called over-sexed. Their sexuality may however be of a function of not knowing how to select partners who desire a non-sexual relationship. Given that they may have been survivors of child sexual abuse they may need to re-learn strategies for expressing their need in relationships and for selecting partners with whom they can share sexual decision-making. In these instances learning how to perceive themselves as sexual beings and not sexual objects to communicate their sexual needs, to anticipate when contraceptive use is needed and to negotiate with partners about the type and frequency of behaviours in which to participate may be central to their effort to prevent re-victimisation.

Another risk factor is to the extent in which sexualisation follows sexual abuse may prompt sexualised behaviour. As a result of traumatic sexualisation the child receives emotional or tangible reward for behaviour that is not developmentally appropriate. For example, father-daughter incest may not be negative. She may be convinced that she has a special close relationship with her father, she may feel that she has power over her siblings and she may have privileges, the given privileges that they do not have. She may crave the attention that she is getting from this man whom she is every reason to trust, She may receive special gifts, she may enjoy feeling like an adult. She may conclude that the sexual behaviours are appropriate for children. This traumatic sexualisation results in a child’s sexuality being dysfunctional and inappropriately shaped. The sexualisation and stimulation that is experienced becomes a matter that may obsess the child and  prevent psychological development in other areas.

Another factor that should be considered is proximity to high crime areas. One plausible explanation of the connection between prior and subsequent assault is due to proximity to crime that people who live in dangerous communities are exposed to more predatory individuals and suffer more victimisation. Rape is only one of the many forms of sexual abuse perpetrated against girls. Unlawful sexual intercourse by force against an adolescent’s will is one of the most damaging.

Another risk factor for adolescent sexual abuse is the victimisation of another family member. This phenomenon has been termed “indirect victimisation”. The victimisation of the child’s family member is associated with increased risk for sexual abuse for that other child. Fearfulness engendered by exposure to victimised family member may result in characteristics that may make a child a more attractive target. Another plausible hypothesis for the existence of this phenomenon is that indirect victimisation may have a corrosive psychological impact on the child and her ability to protect herself. For example since people tend to view their own vulnerability as similar to those close to them exposure to a victimised family member might increase a child’ feeling of vulnerability and weaken their assumption that the world in a safe controllable place. Because feeling vulnerable or powerless has been suggested as a risk factor for child sexual abuse victimisation of a family member may in this way put a child at risk for sexual abuse.

Child prostitution and sex rings are additional situations in which adolescents are repetitively abused by adults. There are 3 types of sex rings: the solo, the transition ring and a syndicated ring. In the solo ring there is one offender and several victims. The perpetrator usually has a legitimate access to the victims. In transition rings there are several predators. The victims are usually adolescents. In the syndicated ring there is a highly organised system that may extend over geographic areas, across countries, across continents. In these situations children usually are abused in a group or at least aware of other children involved. The children may be manipulated to become competitive for the adults favour and special attention by receiving rewards for their various behaviours. As a child becomes older she may be used to obtain other children to bring them in to the ring. The children develop strong bonds with one another and their abusers. It is their family so to speak. As such they are unlikely to disclose their abuse to anyone. Children and adolescents in these situations may be prostituted or may participate in group sex with adult and peers, pornography may be developed from their activities.

The general public must be made aware that child sexual abuse like all forms of maltreatment is everyone’s responsibility, everyone’s problem. Beyond increasing the public’s recognition of the problem we must change the social environment that allows child sexual abuse to flourish. The goal is to create a culture that eliminates any tolerance for child sexual abuse. Eliminates the confusion over what society condones as appropriate interactions between adults and children. All parents need to be educated not only about sexual abuse but also a child’s normal sexual development. We must encourage broader parenting responsibilities beginning with early attachment and bonding between the parent and child. Parent education programmes should emphasise communication skill to create a contact in which secret or manipulation by another adult becomes difficult and not tolerated. Thank you.

Chairman: Thank you very much. I think in interests of the time we’ll hold questions to the end if we may. Our next speaker is Robyn Rosina who is going to talk on youth suicide and self harm. Robyn is with the adolescent service Royal Prince Alfred Hospital in Camperdown Sydney Australia and she has prepared her paper in conjunction with her colleague Gail Anderson of the adolescent medicine department Westmead hospital Sydney.

Youth Suicide Prevention - An Australian  Hospital Nursing Perspective Robyn Rosina

Youth suicide and self harm are major public health problems reaching epidemic proportions in Australia.  Suicide and deliberate self harm arouses the most poignant feelings in any health worker but particularly when it is a young person. This paper will assert that hospital nurses with their ongoing contact and caring relationship with young people are in pivotal positions to ensure care is best practice and evidence based.

The rarity of adolescent units has lead to nurses caring for young people in a variety of settings with varying nursing skills.  Nurses appropriately prepared in youth suicide prevention can provide effective interventions within a critical pathway of response.  Hospital nurses and nursing can take a leading role in youth suicide prevention with and within integrated approaches to care in general hospitals. Nurses within the hierarchy of hospital systems can deliver an effective acute care response to the epidemic of young people presenting to hospitals after a self harm attempt.

Youth suicide is currently the second leading cause of death of young people in Australia. In some studies Australia unfortunately has the highest rate of youth suicide in the world.  In a survey of 14 industrialised nations, 16.4 in every 100,00 young  Australians took their own life a rate of approximately one a day between 1987 and 1990. The social and financial costs of youth suicide to our community are huge.  The financial burden to Australia of youth suicide exceeds $100 million each year.

The increase youth suicide in Australia is only the tip of the iceberg of the psychological distress and disturbance among young people.  The disorder is apparent in nearly all developed countries and rising since World War II. The disorder includes drug abuse, depression, suicidal behaviour and suicide. Depression and drug use are common denominators in suicidal behaviour but when combined with a self, family or peer history of suicide there is higher risk of self harm.  Social factors are also associated  with youth self harm and suicide.  Youth and/or family unemployment, family breakdown and the availability of a fatal means of self harm often correlate with youth suicide. The link between drug use, depression, at risk behaviours, previous attempts and suicide has been well described in the literature. Drug use is associated with 81% of hospitalised cases of intentional injury. Unintentional injuries account for over 1600 deaths each year and 60,000 young male admissions to Australian Hospitals for injuries each year clearly linked with alcohol and drug use (Australian Institute of Health & Welfare, 1998).   There are links between depression, at risk behaviours, drug and alcohol use and deliberate self harm.  The same factors can be associated with unintentional injuries. One may suspect that some unintentional injuries may be suicide attempts and these young people may benefit from risk assessment and suicide prevention interventions. A false positive diagnosis of suicidal risk is better than missing a young person at risk of further attempts and completed suicide.

One of the strongest predictors of suicide is a previous attempt. Currently in Australia attempted suicide is most frequent in young people with a female to male ratio of 3:1.  Female overrepresentation is diminishing due to a rise in young male suicide attempts associated with drug use. Suicide attempts or parasuicides are a strong predictor of completed suicides with a risk of around 13% will complete the act - 60% of young people who kill themselves have made a previous attempt and many present to hospitals for treatment.

Young people present to hospitals in vast numbers increasing each year in Australia with intentional and unintentional injuries. In 1995 434 young people aged 15-24 died by suicide and for every suicide 10 young people are admitted to hospitals with intentional injuries (Australian Institute of Health & Welfare, 1998).  The problem is that many young people who present to hospitals with unintentional and intentional injuries can present with a myriad of diagnoses.  The concern is that the presenting diagnosis may mask the predictors of suicide illness or injury and not be addressed by the medical model of care in hospital nursing.

Clearly, the hospital admission provides a unique opportunity for nurses to intervene in the plight of these young people regardless of diagnosis. Interventions can include comprehensive psychosocial assessment and astute suicidal risk detection within a critical pathway of response.  Psychosocial and suicide assessment are not routine nursing practice in the care of young people in hospital. The information elicited from these assessments can ensure interventions and discharge planning is effective in meeting the community health care critical pathway.  The underlying problems that often result in the presenting problem can be addressed. For example depression and substance abuse in a young person admitted with injuries following a motor vehicle accident. The young man in this example would have an orthopaedic diagnosis.  Utilising astute assessment skills the underlying issues could be detected, and the opportunities of interventions attainable.

Strong predictors of suicidality are high risk taking behaviours that can be masked by a medical diagnosis of young people accessing health care for chronic illness. These conditions can include somatism, illness behaviour, trauma, substance abuse, motor vehicle accidents, accident recidivism, chronic illness, conduct disorders, delinquency, general acting out and aggression adding to the difficulty of detecting suicidal risk. The key is to be alert and recognise risk factors masked by other diagnoses such as chronic illness, depression, mental illness, aggression and risk taking behaviours in all young people in hospital. Assessment and interventions need to target all young people accessing health care rather than concentrating on those with a self harm diagnosis.  Suicide prevention targeting identified suicidal people will miss most of those who have a different diagnosis with suicide risk factors and higher risk of completed suicide.

The biomedical model is predominantly the driving paradigm of hospital nursing care of young people who self harm.  However it limits nursing to the medical phase of healing ignoring  underlying causes of the presenting problem. The pitfall of the biomedical paradigm is that it focuses on technology, technique, single causes and cures within an acute care model. Nursing becomes a technical aid to the medical phase of healing which is when young people decide to leave the hospital.  The narrow focus of the medical model impedes the holism of nursing theory and practice, comprehensive risk assessment and differential diagnosis.  The delay in suicide risk assessment prevents effective supervision of the young person creating legal vulnerability’s for nurses. Young people often leave hospitals when medically well with a medical follow appointment completely overlooking the underlying issues associated with the self harm attempt.

Young people in many cases do not wait for psychiatric or psychosocial assessment currently performed by other psychiatric services and leave the hospital when medical treatment for self harm is complete. At Royal Prince Alfred Hospital the most common time for presentation of young people who self harm is 11.00 PM on a Sunday night impeding the psychiatric services’ response.   Nurses trained in suicide prevention strategies can provide interventions improving the success of a critical pathway response to self harm attempts at whatever hour of presentation or discharge. Given that a previous attempt is the strongest predictor of further suicidal behaviour, it is crucial that a psychosocial and suicide risk assessments are done early in order to facilitate appropriate supervision and referral.   

Young people find compliance with follow up care particularly difficult.  Whether the venue or the time is inappropriate, failures in rapport with the new practitioner or it may be that a depressed person is not easily motivated to attend appointments.  75% of a large study sample did not receive a referral or did not comply with follow up arrangements after a self harm event.  Considering the significance of a previous suicidal attempt as a major risk factor of suicidal behaviour, preventing subsequent self harm should be a major focus of discharge planning when hospital staff organise the appointment the rate of compliance by the young person is higher.

Discharge planning for young people could include the following:-

1.      Details of previously discussed appointments and options if the appointment is not successful.  The arranged appointment details can be faxed to the community service provider to enable the service to follow up the young person if they fail to attend.

2.      A list phone numbers to call to seek another appointment, service enquires or further 24 hour assistance for the young person, family or peers to access in times of crisis.

3.      Information about medicare and accessing health care services.

4.      Details of relevant psychoeducation and self help seeking strategies.

5.      The young person could be assisted to make their own appointment prior to discharge and a community outreach visit could be arranged.

In summary, the hospital admission is a unique time for nurses to offer young people appropriate interventions 24 hours a day within a critical pathway of response.  An effective nursing response as asserted by this paper can improve the continuity of care between hospital and community services.  Nursing care in order to be best practice and evidence based needs to focus on five key areas of practice. These keys areas include early and ongoing psychosocial and suicide risk assessment within a critical pathway response, a safe level of supervision with ongoing risk assessment, the development of a therapeutic relationship with the young person, their peers and family, thorough defensible documentation and effective discharge planning.

Nurses and nursing need to be involved in policy development and the decision making in all of the five practice areas highlighted by this paper. Active involvement by nurses and nursing can ensure some control over their practice, expand nursing practice beyond the medical model, protect nurses from legal liability, ensure the integrity of the profession and most importantly contribute to national and international efforts in youth suicide prevention.

Chair person: Our next speaker is Pat Cox. Pat is currently a lecturer in social work specialising in child protection. She has worked with children and families for approximately 13 years and she now is engaged in research about child protection and particularly child sexual abuse and Pat is going to address the theme “sexual abuse - protecting young men and women from abuse”. Thank you.