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Physicians Missing Self-Injury Behavior In Youths With Eating Disorders, Stanford/Packard Study Finds


STANFORD, Calif.
-- An alarming number of adolescents already battling eating disorders are also intentionally cutting themselves, and health-care providers may be failing to diagnose many instances of such self-injury, according to a new study from Stanford University School of Medicine and Lucile Packard Children’s Hospital.

The researchers found that 40.8 percent of patients with eating disorders in their study had documented incidents of intentionally harming themselves, most often by cutting and burning. What’s more, the study suggests that inadequate clinical screening might mean the count should be much higher.

“These are very high numbers, but they’re still conservative estimates,” said the study’s lead author,  Rebecka Peebles, MD, who was an instructor in pediatrics at Stanford when the research was conducted and is joining the faculty at Children’s Hospital of Philadelphia.

Peebles noted that clinicians aren’t routinely asking about this activity. “We ask 97 percent of children 12 years and up if they smoke cigarettes; we need to get that good with screening for self-injurious behavior,” she said.

The study is to be published online Sept. 28 in the Journal of Adolescent Health. Its senior author is  James Lock, MD, PhD, professor of psychiatry and behavioral sciences and of pediatrics. He is also psychiatric director of the Comprehensive Eating Disorders Program at Packard Children’s Hospital.

To conduct the study, the researchers examined the intake evaluation records of 1,432 patients, ages 10-21, who were admitted to the hospital’s eating disorders program from January 1997 through April 2008. Just over 90 percent of all the patients were female, three-quarters of them white, with a mean age of 15. Among the 40.8 percent identified to be physically harming themselves, the mean age was 16. Many of these patients had a history of binging and purging, and 85.2 percent of the self-injurers were cutting themselves.

The researchers also discovered that slightly fewer than half the charts showed that health-care providers had asked patients if they intentionally injured themselves. If patients aren’t asked, they are unlikely to volunteer such information, said Peebles.

Those who were questioned tended to fit previously published profiles of a self-injurer: older, white, female, suffering from bulimia nervosa, or with a history of substance abuse. “The question is, ‘Are we missing other kids who are not meeting this profile?’” Peebles said. “This is part of why we wanted to look at this. If you see an innocent-looking 12-year-old boy, you don't even think of asking about self-injurious behavior. We need to get much better about universal screening.”

Peebles noted that the profile itself might be flawed. If health-care workers only ask a certain type of patient about a behavior, the profile that emerges will necessarily reflect that bias, she said.

The study did not examine the reasons behind such acts but Peebles said her clinical experience suggested patients “are trying to feel pain.”

“Patients describe a feeling of release that comes when they cut or burn themselves,” she said. “They'll cut with a razor or a scissor blade. Sometimes we’ve even had kids who will take the tip of a paper clip and gouge holes. To burn themselves, they’ll heat up a metal object and press it to their skin, or they’ll use cigarettes.”

Physicians and other health-care providers at Packard’s Comprehensive Eating Disorders Program now question all new patients about self-injurious behavior. Studies have shown that between 13 and 40 percent of all adolescents engage in some form of self-injury, which is also associated with a higher risk of suicide.

“In clinical practice, kids are fairly open when you engage with them,” Peebles said. “They'll come in wearing long sleeves, or hiding the marks on their inner thighs. But then when you ask them, they are usually willing to discuss the behavior.”

The study’s other author is Jenny Wilson, MD, who was a resident in pediatrics when the study was conducted.

The study was funded in part by the Stanford Child Health Research Program. Information about the Departments of Pediatrics and of Psychiatry and Behavioral Sciences, which also helped to support this study, is available at http://pediatrics.stanford.edu and http://psychiatry.stanford.edu/.

Authors

About Stanford Children’s Health and Lucile Packard Children’s Hospital Stanford
Stanford Children’s Health, with Lucile Packard Children’s Hospital Stanford at its core, is an internationally recognized leader in world-class, nurturing care and extraordinary outcomes in every pediatric and obstetric specialty from the routine to rare, for every child and pregnant woman. Together with our Stanford Medicine physicians, nurses, and staff, we deliver this innovative care and research through partnerships, collaborations, outreach, specialty clinics and primary care practices at more than 100 locations in the U.S. western region. As a non-profit, we are committed to supporting our community – from caring for uninsured or underinsured kids, homeless teens and pregnant moms, to helping re-establish school nurse positions in local schools. Learn more about our full range of preeminent programs and network of care at stanfordchildrens.org, and on our Healthier, Happy Lives blog. Join us on Facebook, Twitter, LinkedIn, and YouTube.

Lucile Packard Children’s Hospital Stanford is the heart of Stanford Children’s Health, and is one of the nation’s top hospitals for the care of children and expectant mothers. For a decade, we have received the highest specialty rankings of any Northern California children’s hospital, according to U.S. News & World Report’s 2014-15 Best Children’s Hospitals survey, and are the only hospital in Northern California to receive the national 2013 Leapfrog Group Top Children’s Hospital award for quality and patient care safety. Discover more at stanfordchildrens.org.

About Stanford University School of Medicine
The Stanford University School of Medicine consistently ranks among the nation’s top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit http://mednews.stanford.edu. The medical school is part of Stanford Medicine, which includes Stanford Hospital & Clinics and Lucile Packard Children’s Hospital. For information about all three, please visit http://stanfordmedicine.org/about/news.html.