title: Child maltreatment and repeat presentations to the emergency department for suicide-related behaviors.
abstract: OBJECTIVE
  To identify factors associated with repeat emergency department (ED) presentations for suicide-related behaviors (SRB) - hereafter referred to as repetition - among children/youth to aid secondary prevention initiatives. To compare rates of repetition in children/youth with substantiated maltreatment requiring removal from their parental home with their peers in the general population.
  
  
  METHODS
  A population-based (retrospective) cohort study was established for children/youth with a first ED SRB presentation at risk for repetition in the Province of Ontario, Canada between 1 January 2004 and 31 December 2008. Children/youth legally removed from their parental home because of substantiated maltreatment (n=179) and their population-based peers (n=6,305) were individually linked to administrative health care records over time to ascertain social, demographic, and clinical information and subsequent ED presentations for SRB during follow-up. These children/youth were described and their repetition-free probabilities over time compared. To identify factors associated with repetition we fit multivariable, recurrent event survival analysis models stratified by repetition and present unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).
  
  
  RESULTS
  Children/youth with substantiated maltreatment (as noted) were two times more likely to have repetition than their peers after adjustments for social, demographic, and clinical factors (conditional on prior ED SRB presentations). A number of these factors were independently associated with repetition. No one factor distinguished between having a first and second repetition nor was more strongly associated with repetition than another.
  
  
  CONCLUSIONS
  The risk of repetition is higher in children with substantiated maltreatment (as noted) than their peers. No one factor stood out as predictive of repetition. Implications for secondary prevention initiatives include a non-selective approach, sensitive to family difficulties and the need to better contextualize repetition and harness data linkages.
authors.affiliation: The Suicide Studies Research Unit, The Keenan Research Centre at the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Ontario, Canada.
authors.forename: Anne E
authors.initials: AE
authors.lastname: Rhodes
authors.forename: Michael H
authors.initials: MH
authors.lastname: Boyle
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bethell
authors.forename: Christine
authors.initials: C
authors.lastname: Wekerle
authors.forename: Lil
authors.initials: L
authors.lastname: Tonmyr
authors.forename: Deborah
authors.initials: D
authors.lastname: Goodman
authors.forename: Bruce
authors.initials: B
authors.lastname: Leslie
authors.forename: Kelvin
authors.initials: K
authors.lastname: Lam
authors.forename: Ian
authors.initials: I
authors.lastname: Manion
mesh_terms: D000293:Adolescent; D002170:Canada / Q000453:epidemiology; D002648:Child; D002649:Child Abuse / Q000517:prevention & control / Q000523:psychology*; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000150:complications*; D012189:Retrospective Studies; D016728:Self-Injurious Behavior / Q000523:psychology*; D013406:Suicide, Attempted / Q000517:prevention & control / Q000523:psychology*; D055815:Young Adult