DOI 10.1515/ijamh-2013-0339 Int J Adolesc Med Health 2014; 26(4): 567–574
Christine Ulke*, Annette M. Klein and Kai von Klitzing
Relational stressors as predictors for repeat aggressive and self-harming incidents in child and adolescent psychiatric inpatient settings Abstract: This study examined whether relational stressors such as psychosocial stressors, the therapist’s absence and a change of therapist are associated with repeat aggressive or self-harming incidents in child and adolescent psychiatric inpatient care. The study data were derived from critical incident reports and chart reviews of 107 inpatients. In multinomial regression analysis, patients with repeat aggressive or self-harming incidents were compared with patients with single incidents. Results suggested that a higher number of psychosocial stressors and a change of therapist, but not the therapist’s absence are predictors for repeat aggressive and self-harming incidents. There was a high prevalence of therapist’s absence during both, single and repeat, incidents. Repeat aggressive incidents were common in male children and adolescents with disruptive behavior disorders. Repeat self-harming incidents were common in adolescent females with trauma-related disorders. Patients with repeat aggressive or self-harming incidents had a higher number of abnormal intrafamilial relationships and acute life events than patients with single incidents. Interventions to reduce a change of therapist should in particular target children and adolescents with a higher number of psychosocial stressors and/or a known history of traumatic relational experiences. After a first incident, patients should have a psychosocial assessment to evaluate whether additional relational support is needed. Keywords: child and adolescent psychiatric inpatient care; critical incident; relational stressor. *Corresponding author: Christine Ulke, Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University of Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany, Phone: +49-341-9724-010, Fax: +49-341-9724-019, E-mail: [email protected] Annette M. Klein and Kai von Klitzing: Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University of Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany
Introduction Aggressive and self-harming behavior is a common reason why children and adolescents become psychiatric inpatients. When these behaviors pose a risk to patient and staff safety in inpatient settings, they are considered critical incidents. Prevalence of aggressive or self-harming incidents in inpatient settings varies between studies. In a clinical sample of a German study, the prevalence of self-harm was 59% for girls and 26% for boys (1). An Australian study reported that up to 84.8% of children and adolescent inpatients were engaged in an incident of physical aggression (2). In the Anglo-American literature, prevalence ranges between 17% and 61% for non-suicidal self-injury (3–5) and 20%–90% for overt aggressive behavior (5), making prediction of such incidents a core concern of clinical research. The literature on aggressive or self-harming incidents in clinical settings indicates that a few patients are often responsible for a disproportionate number of incidents (6, 7) and that previous episodes of aggressive or selfharming incidents are risk factors for subsequent incidents (8–10). Findings of an early-life exposure to stress (e.g., a history of abuse or parental neglect) (3, 11) and an exposure to psychosocial risk factors (1, 3) support the model of an altered stress reactivity (12) in patients with aggressive or self-harming incidents. Additionally, previous studies have found evidence for psychosocial risk accumulation in children and adolescents with problem behavior (13, 14). Most studies of risk factors for aggressive or selfharming incidents do not distinguish between patients with single and repeat incidents, yet action could be taken after a first incident. An analysis of single and repeat incidents of self-harm showed that therapist contact (performing a psychosocial assessment) was associated with a significantly decreased risk for a repeat incident, suggesting that the therapist-patient relationship has a moderating influence on repeat self-harming incidents (15). Further, we know from adult psychiatric literature that an increased risk for suicide has been associated with
Brought to you by | Western University Authenticated Download Date | 6/7/15 6:17 AM
568 Ulke et al.: Repeat critical incidents in inpatient care the discontinuity of care from a significant professional (16, 17). Children and adolescents are dependent on a stable therapist-patient relationship (18, 19) for a positive treatment outcome. They may not be able to distinguish the function of the therapist from the therapist as a person; the absence of a therapist may be perceived as abandonment, in particular if they experienced neglect in the past (20). In the literature, male gender, younger age and unstructured times of the day have been associated with aggressive incidents in inpatient settings (8, 21), raising the question whether the therapist’s absence (e.g., due to work schedules or vacations) may be a risk factor for repeat aggressive incidents. Conversely, female gender, older age (7, 22) and a previous inpatient stay (9) have been associated with self-harming incidents, raising the question whether a change of therapist may be a risk factor for repeat self-harming incidents.
The present study The goal of this study was to evaluate, among a sample of inpatients with single and repeat aggressive or self-harming incidents, whether there were increased frequencies of relational stressors (psychosocial stressors, therapist’s absence and change of therapist) in the groups of patients with repeat aggressive or self-harming incidents as compared with the group of patients with single aggressive or self-harming incidents. We hypothesized that children and adolescents with repeat aggressive or self-harming incidents have a higher number of psychosocial stressors than children and adolescents with single incidents (hypothesis 1). We further hypothesized that the therapist’s absence would be a significant predictor for patients with repeat aggressive incidents (hypothesis 2) and that a change of therapist would be a significant predictor for patients with repeat self-harming incidents (hypothesis 3). We expected more boys in the repeat aggressive and more girls in the repeat self-harming incidents group than in the group with single incidents.
Materials and methods Inclusion criteria and setting
10 patients. We provide psychiatric care for children and adolescents of the region and nationwide; the patient clientele is accordingly heterogeneous. The most common diagnostic groups are disruptive behavior disorders (conduct disorders, oppositional defiant disorders, attention deficit disorders), emotional disorders (anxiety and mood disorders) and trauma-related disorders (post-traumatic stress disorders, attachment disorders, borderline personality disorders). The average length of stay is 46.3 days per treatment episode; some patients have been admitted for several treatment episodes during the reported years.
Data collection The critical incident technique (CIT) (23) was used to collect the data. We utilized a semi-structured format, where the departmental guidelines of what and how to report served as a framework for participating staff members who completed reports after each critical incident. The reports commonly consist of: (i) the date, the time, the name of the patient; (ii) a description of the circumstances leading to the event; (iii) a detailed description of the behavior of the focal patient in the incident; and (iv) a description of the outcome/measures taken. In reports with multiple patients, data were collected for every patient. Some reports described more than one incident; in those cases, data were collected for each incident. Relational stressors (psychosocial stressors, therapist’s absence and change of therapist) and patient-related information were determined by review of staff schedules and patient charts. The retrospective study was approved by the Ethics Committee of Leipzig University and complies with the World Medical Association Declaration of Helsinki regarding ethical conduct of research.
Definitions and measures Critical incidents Critical incidents (incidents) were defined as events in the context of patient care that led to harm or could have led to harm to patients or staff. Aggressive and self-harming incidents were included. Aggressive incidents were defined as verbal aggression, physical violence towards staff, other patients or objects, and sexual assault. Following the classification of the CASE (Child and Adolescent Self-harm in Europe) group, self-harming incidents (e.g., self-cutting, drug ingestion, ingestion of objects) were defined as a deliberate act to harm oneself with or without suicidal intention and with a non-fatal outcome. Self-harming incidents also included acts that demonstrated suicidal thoughts, plans and intentions, such as writing a suicide note or threatening to jump off a high building.
Patients with repeat aggressive or self-harming incidents
Participants in this study were child and adolescent psychiatric inpatients admitted between January 2007 and May 2013 with at least one documented aggressive or self-harming incident. Our University clinic has an inpatient unit with 36 beds and a day treatment unit for
Patients with repeat aggressive or self-harming incidents constituted the groups of interest, which were compared to the reference group patients with single incidents. A repeat aggressive or self-harming
Brought to you by | Western University Authenticated Download Date | 6/7/15 6:17 AM
Ulke et al.: Repeat critical incidents in inpatient care 569 incident was defined as a repeated episode of an incident by the same patient during one treatment episode.
Relational stressors Relational stressors were defined as experiencing stressful environmental events and/or circumstances. These included psychosocial stressors, for example, in the family and school, as well as stressing events or circumstances during the treatment episode (clinical relational stressors). Psychosocial stressors were measured with the number of Axis V categories (abnormal psychosocial situations) of the ICD-10 Multi-axial Classification System (24), which classifies psychosocial stressors into nine categories (e.g., abnormal intrafamilial relationships, inadequate or distorted intrafamilial communication, acute life events) and several subcategories (e.g., the category abnormal intrafamilial relationships contains the subcategories lack of warmth in parent-child relationships, intrafamilial discord among the adults, hostility towards or scapegoating of the child, physical child abuse, sexual abuse within the family and other). The dichotomous rating of psychosocial stressors was based on our standard clinical routine in reference to the German Psychiatric Basic Documentation (BADO). For the purpose of this study, each category that was present counted equally to the number score of psychosocial stressors. In 13% of cases, the number of psychosocial stressors was reassessed using file analysis. The reliability of the ratings proved to be high with ICC = 0.814. Clinical relational stressors included therapist’s absence and change of therapist. Therapist’s absence was measured at the time and date of the index incident and was determined by review of staff schedules. The index incident was defined as the first critical incident of a patient’s most recent treatment episode. Change of therapist was determined by review (non-discrepancy or discrepancy of the treating physician) of admission and discharge documents of the most recent treatment episode and review (nondiscrepancy or discrepancy of the treating physician) of admission and discharge documents of the most recent and the prior treatment episode (within the past 12 months).
Statistical methods We used the Statistical Package for Social Sciences (SPSS) version 21 for statistical analysis (SPSS Inc., Chicago, IL, USA). A point-biserial
correlation test was used for testing the association between the number of psychosocial stressors and single or repeat incidents. To evaluate whether patients with repeat incidents were exposed to clinical relational stressors more often than patients with single incidents, we performed χ2-tests. Variables which were significantly associated with repeat versus single incident status, as well as age and gender, were included as predictors in a multinomial regression analysis where membership in the groups of patients with repeat aggressive or self-harming incidents versus membership in the group of patients with single incidents served as outcome variables. A p-value of
Christine Ulke*, Annette M. Klein and Kai von Klitzing
Relational stressors as predictors for repeat aggressive and self-harming incidents in child and adolescent psychiatric inpatient settings Abstract: This study examined whether relational stressors such as psychosocial stressors, the therapist’s absence and a change of therapist are associated with repeat aggressive or self-harming incidents in child and adolescent psychiatric inpatient care. The study data were derived from critical incident reports and chart reviews of 107 inpatients. In multinomial regression analysis, patients with repeat aggressive or self-harming incidents were compared with patients with single incidents. Results suggested that a higher number of psychosocial stressors and a change of therapist, but not the therapist’s absence are predictors for repeat aggressive and self-harming incidents. There was a high prevalence of therapist’s absence during both, single and repeat, incidents. Repeat aggressive incidents were common in male children and adolescents with disruptive behavior disorders. Repeat self-harming incidents were common in adolescent females with trauma-related disorders. Patients with repeat aggressive or self-harming incidents had a higher number of abnormal intrafamilial relationships and acute life events than patients with single incidents. Interventions to reduce a change of therapist should in particular target children and adolescents with a higher number of psychosocial stressors and/or a known history of traumatic relational experiences. After a first incident, patients should have a psychosocial assessment to evaluate whether additional relational support is needed. Keywords: child and adolescent psychiatric inpatient care; critical incident; relational stressor. *Corresponding author: Christine Ulke, Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University of Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany, Phone: +49-341-9724-010, Fax: +49-341-9724-019, E-mail: [email protected] Annette M. Klein and Kai von Klitzing: Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University of Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany
Introduction Aggressive and self-harming behavior is a common reason why children and adolescents become psychiatric inpatients. When these behaviors pose a risk to patient and staff safety in inpatient settings, they are considered critical incidents. Prevalence of aggressive or self-harming incidents in inpatient settings varies between studies. In a clinical sample of a German study, the prevalence of self-harm was 59% for girls and 26% for boys (1). An Australian study reported that up to 84.8% of children and adolescent inpatients were engaged in an incident of physical aggression (2). In the Anglo-American literature, prevalence ranges between 17% and 61% for non-suicidal self-injury (3–5) and 20%–90% for overt aggressive behavior (5), making prediction of such incidents a core concern of clinical research. The literature on aggressive or self-harming incidents in clinical settings indicates that a few patients are often responsible for a disproportionate number of incidents (6, 7) and that previous episodes of aggressive or selfharming incidents are risk factors for subsequent incidents (8–10). Findings of an early-life exposure to stress (e.g., a history of abuse or parental neglect) (3, 11) and an exposure to psychosocial risk factors (1, 3) support the model of an altered stress reactivity (12) in patients with aggressive or self-harming incidents. Additionally, previous studies have found evidence for psychosocial risk accumulation in children and adolescents with problem behavior (13, 14). Most studies of risk factors for aggressive or selfharming incidents do not distinguish between patients with single and repeat incidents, yet action could be taken after a first incident. An analysis of single and repeat incidents of self-harm showed that therapist contact (performing a psychosocial assessment) was associated with a significantly decreased risk for a repeat incident, suggesting that the therapist-patient relationship has a moderating influence on repeat self-harming incidents (15). Further, we know from adult psychiatric literature that an increased risk for suicide has been associated with
Brought to you by | Western University Authenticated Download Date | 6/7/15 6:17 AM
568 Ulke et al.: Repeat critical incidents in inpatient care the discontinuity of care from a significant professional (16, 17). Children and adolescents are dependent on a stable therapist-patient relationship (18, 19) for a positive treatment outcome. They may not be able to distinguish the function of the therapist from the therapist as a person; the absence of a therapist may be perceived as abandonment, in particular if they experienced neglect in the past (20). In the literature, male gender, younger age and unstructured times of the day have been associated with aggressive incidents in inpatient settings (8, 21), raising the question whether the therapist’s absence (e.g., due to work schedules or vacations) may be a risk factor for repeat aggressive incidents. Conversely, female gender, older age (7, 22) and a previous inpatient stay (9) have been associated with self-harming incidents, raising the question whether a change of therapist may be a risk factor for repeat self-harming incidents.
The present study The goal of this study was to evaluate, among a sample of inpatients with single and repeat aggressive or self-harming incidents, whether there were increased frequencies of relational stressors (psychosocial stressors, therapist’s absence and change of therapist) in the groups of patients with repeat aggressive or self-harming incidents as compared with the group of patients with single aggressive or self-harming incidents. We hypothesized that children and adolescents with repeat aggressive or self-harming incidents have a higher number of psychosocial stressors than children and adolescents with single incidents (hypothesis 1). We further hypothesized that the therapist’s absence would be a significant predictor for patients with repeat aggressive incidents (hypothesis 2) and that a change of therapist would be a significant predictor for patients with repeat self-harming incidents (hypothesis 3). We expected more boys in the repeat aggressive and more girls in the repeat self-harming incidents group than in the group with single incidents.
Materials and methods Inclusion criteria and setting
10 patients. We provide psychiatric care for children and adolescents of the region and nationwide; the patient clientele is accordingly heterogeneous. The most common diagnostic groups are disruptive behavior disorders (conduct disorders, oppositional defiant disorders, attention deficit disorders), emotional disorders (anxiety and mood disorders) and trauma-related disorders (post-traumatic stress disorders, attachment disorders, borderline personality disorders). The average length of stay is 46.3 days per treatment episode; some patients have been admitted for several treatment episodes during the reported years.
Data collection The critical incident technique (CIT) (23) was used to collect the data. We utilized a semi-structured format, where the departmental guidelines of what and how to report served as a framework for participating staff members who completed reports after each critical incident. The reports commonly consist of: (i) the date, the time, the name of the patient; (ii) a description of the circumstances leading to the event; (iii) a detailed description of the behavior of the focal patient in the incident; and (iv) a description of the outcome/measures taken. In reports with multiple patients, data were collected for every patient. Some reports described more than one incident; in those cases, data were collected for each incident. Relational stressors (psychosocial stressors, therapist’s absence and change of therapist) and patient-related information were determined by review of staff schedules and patient charts. The retrospective study was approved by the Ethics Committee of Leipzig University and complies with the World Medical Association Declaration of Helsinki regarding ethical conduct of research.
Definitions and measures Critical incidents Critical incidents (incidents) were defined as events in the context of patient care that led to harm or could have led to harm to patients or staff. Aggressive and self-harming incidents were included. Aggressive incidents were defined as verbal aggression, physical violence towards staff, other patients or objects, and sexual assault. Following the classification of the CASE (Child and Adolescent Self-harm in Europe) group, self-harming incidents (e.g., self-cutting, drug ingestion, ingestion of objects) were defined as a deliberate act to harm oneself with or without suicidal intention and with a non-fatal outcome. Self-harming incidents also included acts that demonstrated suicidal thoughts, plans and intentions, such as writing a suicide note or threatening to jump off a high building.
Patients with repeat aggressive or self-harming incidents
Participants in this study were child and adolescent psychiatric inpatients admitted between January 2007 and May 2013 with at least one documented aggressive or self-harming incident. Our University clinic has an inpatient unit with 36 beds and a day treatment unit for
Patients with repeat aggressive or self-harming incidents constituted the groups of interest, which were compared to the reference group patients with single incidents. A repeat aggressive or self-harming
Brought to you by | Western University Authenticated Download Date | 6/7/15 6:17 AM
Ulke et al.: Repeat critical incidents in inpatient care 569 incident was defined as a repeated episode of an incident by the same patient during one treatment episode.
Relational stressors Relational stressors were defined as experiencing stressful environmental events and/or circumstances. These included psychosocial stressors, for example, in the family and school, as well as stressing events or circumstances during the treatment episode (clinical relational stressors). Psychosocial stressors were measured with the number of Axis V categories (abnormal psychosocial situations) of the ICD-10 Multi-axial Classification System (24), which classifies psychosocial stressors into nine categories (e.g., abnormal intrafamilial relationships, inadequate or distorted intrafamilial communication, acute life events) and several subcategories (e.g., the category abnormal intrafamilial relationships contains the subcategories lack of warmth in parent-child relationships, intrafamilial discord among the adults, hostility towards or scapegoating of the child, physical child abuse, sexual abuse within the family and other). The dichotomous rating of psychosocial stressors was based on our standard clinical routine in reference to the German Psychiatric Basic Documentation (BADO). For the purpose of this study, each category that was present counted equally to the number score of psychosocial stressors. In 13% of cases, the number of psychosocial stressors was reassessed using file analysis. The reliability of the ratings proved to be high with ICC = 0.814. Clinical relational stressors included therapist’s absence and change of therapist. Therapist’s absence was measured at the time and date of the index incident and was determined by review of staff schedules. The index incident was defined as the first critical incident of a patient’s most recent treatment episode. Change of therapist was determined by review (non-discrepancy or discrepancy of the treating physician) of admission and discharge documents of the most recent treatment episode and review (nondiscrepancy or discrepancy of the treating physician) of admission and discharge documents of the most recent and the prior treatment episode (within the past 12 months).
Statistical methods We used the Statistical Package for Social Sciences (SPSS) version 21 for statistical analysis (SPSS Inc., Chicago, IL, USA). A point-biserial
correlation test was used for testing the association between the number of psychosocial stressors and single or repeat incidents. To evaluate whether patients with repeat incidents were exposed to clinical relational stressors more often than patients with single incidents, we performed χ2-tests. Variables which were significantly associated with repeat versus single incident status, as well as age and gender, were included as predictors in a multinomial regression analysis where membership in the groups of patients with repeat aggressive or self-harming incidents versus membership in the group of patients with single incidents served as outcome variables. A p-value of
