section disorders of personality development clinic of child and adolescent psychiatry
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School-based interventions to prevent suicidal behavior and risk behaviors among adolescents in Germany: Results from the European Research Consortium SEYLE R. Brunner, M. Kaess, P. Parzer, G. Fischer, J. Haffner, F. Resch and the SEYLE Consortium. Section Disorders of Personality Development - PowerPoint PPT PresentationTRANSCRIPT
School-based interventions to prevent suicidal behavior andrisk behaviors among adolescents in Germany:
Results from the European Research Consortium SEYLE
R. Brunner, M. Kaess, P. Parzer, G. Fischer, J. Haffner, F. Resch and the SEYLE Consortium
Section Disorders of Personality DevelopmentClinic of Child and Adolescent Psychiatry
Center for Psychosocial Medicine
Background
Begin of psychiatric disorders in childhood and adolescence
– Half of all psychiatric disorders emerge around the 14th year of life
– Median age of onset for anxiety disorders and impulse control disorders: 11 years of age
Kessler et al. 2005
Investigating in youth mental health is a best
buy...(but)
...mental health care systems are weakest where they need to be strongest.
Patrick McGorry, 2007
Overview
• Study I: Heidelberg School Study 2004/5– Prevalence and psychosocial correlates of suicidal behavior and
risk behavior in a representative sample of adolescent from the general population in Germany
• Study II: SEYLE Study 2010/11– School-based intervention study to reduce suicidal behavior and
risk behavior in adolescents: A randomized controlled study in 11 European countries
• Results from baseline evaluation in Germany and 7 other countries
• First results on the effectiveness
Epidemiology of suicidal behavior in adolescents
• Suicide is the third leading cause of death among children and adolescents between 10 and 19 years (USA), in Germany second most common cause
• Age of 15-19 years• 8.2 cases in 100.000• 5 times more common in boys
• Suicidal ideas: 10-19%• Suicidplans: 6-15%• Suicide attempts: 8%
Gould et al., 2003
Epidemiology of Nonsuicidal Self-Injury
(NSSI) in adolescents
• 6-7% of all students 15 years of age• Female – male ratio: 7 - 3:1 • Minority receive professional help
• Strong association with suicidal behaviour• Strong association with low self-esteem and substance
abuse– esp. in girls mit depressive symptoms, anxiety and impulsiveness
Hawton et al., 2002; De Leo & Heller, 2004
Heidelberg School Study 2005
• 15-16 year old students in Heidelberg and Rhein-Neckar district (116 of 121 schools)
• Anonymous questionnaire in the class rooms
• Approached: 6185• Returned: 6085 (98,4%)• Analyzed: 5832 (94,3%)
Brunner et al., Arch. Pediatr. Adolesc. Med., 2007
How often did you intentionally hurt yourself in the last year? (cutting, burning, ...)?
Report of the students (n=5522)
BOYS GIRLS
Never 89.9% 80.1%1-3 times a year 8.0% 14.0% (occasional
NSSI)>3 times a year 2.1% 5.9% (repetitive NSSI)
Definition and prevalence of occasional and repetitive forms of NSSI
Suicidality
Suicidal ideationBoys Girls
Never 90% 80%1-3 times 8% 14%4 and more times 2% 6%
Suicide attemptBoys Girls
Never 95% 89% One time 4% 8%2 times and more 1% 3%
NSSI and Suicide Attempt
NSSI Suicide attempt
Never Once Several times
n=5296 n=332 n=121
Never 89,3 41,6 20,7
1- 3 times a year 8,8 38,5 29,7
> 3 times a year 1,9 19,9 49,6
100% 100% 100%
N=5749, chi2(4)=1.3e+03, p<0.001/Cramer‘s V=0.34/Interaction Gender : chi2(4)=7.4, p=0.117
NSSI and YSR-scores1
YSR scales NSSI Anova
Never 1-3 times a year >3 times a year R2
n=4900 n=630 n=229 n=5759
Withdrawn 2.8 3.9 4.6 3.9%Somatic complaints 2.6 4.5 5.6 9.0% Anxious/depressed 4.9 8.5 12.0 14.5%Social problems 2.0 2.3 2.6 0.6% Thought problems 1.3 2.1 3.8 7.6%Attention problems 4.3 5.9 7.0 6.6%Delinquent behaviour 4.1 6.3 8.5 11.4% Aggressive Behaviour 8.2 11.5 14.1 8.0%
YSR: Youth Self-report
1Means of raw scores; 2Adjusted R2x100=explained variance
Prevalence of diagnostic criteria of borderline personality disorder (BPD)
Total (%) BPD (%)
1. Feelings of abandonment - -2. Instable relationships 3.9 34.03. Identity disturbances 3.1 36.24. Impulsivity 17.5 81.95. Self-injurious/suicidal behav. 6.1 85.1 6. Affective instability 17.0 88.37. Feelings of emptiness 9.0 80.98. Loss of anger control 7.5 59.69. Dissociative symptoms 18.6 59.6
Dimensional assessment by items of the Youth self-report, n=5832, mean age 15.2 y
54.39
24.66
11.45
5.252.64
1.01 0.38 0.15 0.07
020
4060
per
cent
0 1 2 3 4 5 6 7 8
Numbers of fullfilled diagnostic criteria
BPD-Symptomatology
n=5832, mean age 15.2 y
95.0
89.1
3.88.0
0.6 2.1 0.5 0.9
020
4060
8010
0P
er c
ent
none oncel 2-3 timesl >3 times
Report of the students
male female
99.598.6
0.3 1.1 0.1 0.2 0.1 0.2
020
4060
8010
0P
er c
ent
none once 2-3 times >3 times
Report of the parents
male female
Suicide attempts
Only 10-12% of the students with suicidal
behavior received professional help!
Study II: Aims of SEYLE Study„Saving and Empowering Young Lives in Europe“ (SEYLE)
• To reduce risky, self-destructive and suicidal
behavior in adolescents
• To evalute the effectiveness of different
intervention programs
• To implement the most effective intervention
program adapted to the individual countries
Participating centers: 10 European countries and Israel
Coordination: Karolinska Institute,Stockholm, Sweden
Supervision: Columbia University, New York, USA
Saving and EmpoweringYoung Lives in Europe (SEYLE)
Four Interventions
Gatekeeper-Training (n= 250)
Awareness-Training (n= 250)
Professional Screening (n= 250)
Control condition (n= 250)
t0
(baseline)
t1
(three months)
t2
(12 months after t0 )
Intervention
Recruitment and Procedure
11.000 adolescents aged between 14 and 16 years (n=1.000 per country)
Intervention programs (I)
Program 1: Gate-keeper training
Teachers are trained on how to recognize and refer students at-risk of suicide to professional services, how to help students with
depression and risk-behavior
Program 2: Awareness training
Educational program for students, teaching about mental illness and suicide; awareness about feelings and how to
manage stress and crisis situations; helping friends
raise willingness to seek professional help
Intervention programs (II)
Program 3: Professional Screening
Screening of students on self-destructive and risk-taking behavior via baseline evaluation.
Adolescents screened at-risk in accordance to the cut-off criteria are referred for professional clinical assessment and subsequent referral to mental health professionals
Program 4: Control condition (Minimal Intervention)
Educational posters in classrooms, basic information how to contact healthcare providers (self-referral)
37 schools of the Rhein-Neckar district had been approached
11 schools declined participation, 26 schools took part in the study
1857 students and their caretakers had been approached (written and informed consent)
The „Heidelberg“ sample
Approx. 70 % of the initially approached students were included
Schooltyp Interventions | HS RS GY |
Total--------------------------------------------------------------------------------------------------------- Gate-keeper | 178 73 79 | 330 Awareness | 134 104 130 | 368 ProfScreen | 114 140 169 | 423
Control condition | 97 132 94 | 323 ----------------------------------------------------------------------------------------------------- Total | 523 449 472 | 1,444
HS: Hauptschule, 9 years elementary schools
RS: Realschule, secondary school level 1 certificate
GY: Gymnasium, qualification for university entrance
Prevalence and gender differences of internet use
pathological usemaladaptive useadaptive use
Boys
11,8%
83,4%
4,8%
pathological use
maladaptive use
adaptive use
Girls
78,3
4,8%
16,9%
Young‘s Diagnostic Questionnaire (YDQ) asks symptoms according to the DSM-IV diagnostic criteria of „pathological gambling“
Suicidal behavior and internet use
Suicidal behavior and excessive internet usePaykel Suicide Scale
Baseline in 8 European countries (I)
Country Suicide attempts
last 2 weeks life time
Total
n % n % n %
Estonia 5 0.5 28 2.7 1,023 100
Germany 13 0.9 82 5.7 1,438 100
Hungary 0 0.0 24 2.4 1,007 100
Ireland 7 0.7 32 2.9 1,093 100
Israel 33 2.7 84 7.0 1,200 100
Italy 1 0.1 26 2.2 1,192 100
Romania 6 0.5 15 1.6 934 100
Spain 5 0.5 27 2.6 1,025 100
Total 70 0.8 318 3.6 8,912 100
Baseline in 8 European countries (II)
Country NSSI (more than 5 times)
NSSI (1-4 times) Total
n % n % n %
Estonia 79 7.7 261 25.3 1,033 100
Germany 149 10.4 354 24.8 1,430 100
Hungary 35 3.5 136 13.6 1,000 100
Ireland 47 4.4 173 16.2 1,071 100
Israel 101 8.5 284 23.9 1,191 100
Italy 40 3.4 209 17.5 1,193 100
Romania 21 1.9 210 18.7 1,126 100
Spain 66 6.4 232 22.6 1,025 100
Total 538 5.9 1,859 20.5 9,069 100
Baseline in 8 European countries (III)
Country Anxiety
(SAS)
Depression
(BDI)
Psychopathology
(SDQ)
Mean SD Mean SD Mean SD
Estonia 31.1 6.3 7.7 6.8 10.5 4.9
Germany 33.1 7.3 8.7 8.0 11.5 5.2
Hungary 35.1 4.7 6.9 6.3 9.6 4.6
Ireland 31.6 7.1 6.8 7.3 9.3 5.5
Israel 33.2 7.9 8.9 9.5 12.7 5.9
Italy 32.9 6.6 8.0 6.5 10.9 4.6
Romania 31.9 7.3 7.0 7.0 9.9 4.9
Spain 31.9 6.7 7.6 7.2 11.4 4.7
Difference of prevalence rates of NSSI and depressive symptoms
Evaluation of the referrals
Referral
Interview
ScreeningDrop-out
Drop-out
< Cut-off
> Cut-off
< Cut-off
> Cut-off
Professional Screening
- Baseline questionnaire
- Defined cut-offs
- Structured clinical interview by (trained psychologist and psychiatrists)
Professional Screening designed by Kaess, Parzer & Brunner 2009
Results of the screening (stage I)
• Eating behaviour 4.2 %• Substance abuse 47.0 %• Excessive use of media 15.8 %• Sensation seeking
& delinquent behaviour 11.1 %• School attendance 2.6 %• Peer victimization 8.3 %• Social relationships 6.4 %• Anxiety 8.4 %• Depression 20.6 %• NSSI 21.7 %• Suicidal behaviour 19.1 %
In total, 68.5 % of the sample was screened as being at-risk by the questionnaire!
Students took part in the interview: 95
Risk cases defined by questionnaire: 293 (out of 423)
Students contacted:259
Results of the interview (stage II)
Students could not be
contacted: 34
Students refused to take
part in the interview: 164
At-risk students
referred: 31
Students not at-risk (false positives): 64
Predictors after minimizing Bayes Information Criteria (BIC)
• Predictors for attending the interview– negative: excessive use of media– positive: peer victimization, suicidal
behavior
• Predictors for being referred to mental health care – positive: suicidal behaviour
Another predictor for attending the interview: Distance to professional institutions
Gender and response of intervention
Specific types of intervention programs as
– Awareness Program– Professional Screening
showed significant better response in female
students
Summary and Conclusions• High prevalence rates of NSSI and suicidal behavior in adolescents
– Striking differences between European countries
• Strong association with several risk behaviors
• Seeking for professional help very seldom
• Schools based intervention program can effectively reduce suicidal behavior– Open question which intervention program is the most effective one
• Early recognition and early intervention concepts are urgently needed– Role model: Orygen Mental Health Center
Thanks to…
… the Heidelberger SEYLE-Team
– Michael Kaess– Peter Parzer– Katja Klug– Gloria Fischer– Judith Frisch– Lisa Göbelbecker– Sarah Schneider– Nassrin Schönbach– Christoph Lenzen– Franz Resch
… and all members of the SEYLE-group