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Current Trends in Remediating Adolescent Self-injury an Integrative Review

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The Correlation between Oral Self-Harm and Ethnicity in Institutionalized Children

1

Section of Odontology and Oral Pathology, George Emil Palade University of Medicine, Chemist's, Science, and Technology of Târgu Mureș, 540139 Târgu Mureș, Romania

two

Department of Pedodontics, George Emil Palade University of Medicine, Pharmacy, Science, and Engineering of Târgu Mureș, 540139 Târgu Mureș, Romania

3

Faculty of Medicine, George Emil Palade Academy of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, 540139 Târgu Mureș, Romania

*

Author to whom correspondence should be addressed.

Received: fifteen Nov 2020 / Revised: 20 Dec 2020 / Accepted: 21 December 2020 / Published: 23 Dec 2020

Abstruse

Oral self-harm was described in institutionalized children who share a lack of emotional attention; often these children experience feelings such as neglect, loneliness, isolation or lack of connection with the earth. The aim of our paper was to behave a cross-sectional study in order to appraise the prevalence of this behavior and its correlation with ethnicity among children from 3 institutions located in the central office of Romania. We examined 116 children from three ethnic groups, Romanians, Hungarians and local Roma population aged between 10–14 years quondam. The oral soft tissues were evaluated by ane dentist who recorded the lesions of lips, buccal mucosa, commissures and tongue; information were statistically analyzed at a level of significance of p < 0.05. Nosotros found oral self-harm lesions in 18.1% participants, with statistically meaning higher odds in girls (p = 0.03). The results showed an clan between ethnicity and the development of these lesions (Chi-square p = 0.04). The most frequent lesions were located at oral commissures (35.48%), buccal mucosa (29.03%) and upper lip (xix.36%). Oral self-impairment lesions take a loftier incidence among institutionalized children in Romania. Identification of these cases in early stages is important, equally these weather are known to be aggravated during adolescence and adulthood.

i. Introduction

Self-mutilation is divers as a behavioral disturbance that consists of self-induced damage to body tissues, which might exist associated in some cases with a conscious intent to commit suicide. Also called cocky-harm, information technology includes any intentional injury to i's own trunk [1,2,iii,4]. Historically, the first institutions for abandoned children can be traced back in Europe since the Eye Ages; they came into prominence in the 19th century in Western Europe, today beingness common in different parts of the world such as Asia, Central and South America, the Centre East or Africa. In the United States, orphanages were documented in the first half of the 20th century [5].

At nowadays, worldwide there are betwixt 8–10 million children living in different types of institution [vi] and there is much scientific show that their psychological development is impaired past these life conditions [7]; furthermore, the trend of placing children in institutions appears to exist growing [eight,9]. According to information from literature, institutional intendance in Romania was associated with an harm of the physical development [x] and as well children who spent more than half dozen months in an institution had higher rates of autism symptoms, inattention or disinhibited social engagement [11]. Due to the demands of taking care of a large number of children, the caregivers rarely collaborate with children in a warm manner, every bit their activity is oftentimes limited to routine care, such as feeding or toileting [12]. Therefore, most institutionalized children experience poor caregiver-kid interaction and their physical, cerebral and social development is oft delayed. Moreover, scientific data showed that these results are caused mainly past the quality of caregiver-child relationships, rather than by the quality of medical care and nutrition [13]. The disability to live with their parents predisposes institutionalized children to low self-esteem and impaired psychosocial evolution (attention problems or lower intelligence caliber) [vii], which might represent confounding factors in the analysis of the correlation between cocky-impairment and institutionalization.

In institutionalized children, the relief of emotional pain could be expressed by self-harm, as the physical wounds they create on themselves is a sign of their emotional suffering [xiv]. The self-harm behavior has many causes, including stressful life events or mental disorders such as low or anxiety [15]. Adolescents use deliberate cocky-harm methods such as cutting, poisoning or overdosing, while children commonly scratch or bite themselves; this phenomenon may start during childhood and intensifies in adolescents and young adults, girls being considered more than vulnerable to this behavior than boys [16]. Among the etiological factors of deliberate self-harm the following weather were included: depression, low self-esteem and sense of persistent hopelessness, attempts to seek assist from others, poverty, abuse, attempts to resist suicidal thoughts and family dysfunction. The early detection of non-suicidal cocky-injury (NSSI) allows immediate intervention which might help these children stop this beliefs. Left undiagnosed for a long period of fourth dimension, NSSI becomes more frequent, severe and versatile, with negative consequences on the quality of life and more difficult recovery [17].

Oral cocky-harm (OSH) in institutionalized children occurs in connection with emotional, behavioral or even organic disorders. To engagement, virtually of the data comes from example serial presentations and there are little scientific information regarding the frequency of OSH amidst abandoned children without mental disorders or retardation. Therefore, the aim of our paper was to conduct a cross-sectional report in order to assess the frequency and type of OSH among institutionalized children from iii Romanian country centers. The zippo hypothesis to exist tested was that at that place is no statistically pregnant difference regarding the prevalence of oral self-inflicted lesions, according to gender and ethnicity in children at puberty.

2. Materials and Methods

2.1. Study Pattern and Participants

Our investigation was conducted between December 2019–February 2020 in the Clinic of Odontology and Oral Pathology from the George Emil Palade University of Medicine, Pharmacy, Scientific discipline, and Technology of Târgu Mureș, where at that place is a special program dedicated to dental medical intendance for institutionalized children, belonging to three state centers. The investigation was carried out after the approval obtained from the Ideals Committee of our academy (No. 520/21.11.2019), accompanied by a written consent for the utilise of personal data signed in each example by the legal representative of the kid (institution manager or legal guardian). Prior to enrolment in the study, children were also asked if they agreed to participate. Nosotros are located in the historical province of Transylvania, characterized by a multicultural and multiethnic population, represented mainly by Romanians, Hungarians and regional Roma. In society to address a source of bias related to the number of participants from each ethnicity, we decided to include close numbers in each grouping, according to age and gender. Moreover, all clinical examinations were carried out by one experienced dentist and data were recorded past ane dental specialist. In our report we included 116 children aged between 10–xiv years former, selected from a total of 167 children, based on awarding of inclusion criteria (status of institutionalized child for more than than v years, age x–14 years) and exclusion criteria (history of psychological counseling or psychiatric treatment, recordings of drugs or booze abuse, children with diagnosed neurologic or psychiatric disorders, known to exist etiological factors of self-harm behavior, such equally epilepsy, depression, anxiety or autism spectrum disorder) (Figure 1).

2.2. Clinical and Histopathological Examination

Ordinary dental examinations, with an emphasis on the health status of the lips, buccal mucosa and tongue (ulcerations, color change, surface aspect), were performed. In guild to discover whatsoever changes from normal texture, the area between oral commissures was carefully evaluated by palpation. Cases in which a chronic evolution was suspected, resembling premalignant lesions, were further investigated by exfoliative cytology, using Papanicolau stain. All children who presented OSH were farther referred to interdisciplinary evaluation by a psychologist and dental specialist.

2.3. Statistical Analysis

Statistical analysis was carried out using GraphPad Prism 7 for Windows (GraphPad Software, San Diego, CA, U.s.a.), past Fisher'due south exact test and Chi-square test. The continuous variables were expressed as hateful ± standard divergence and categorical variables as percentages and frequency distribution. The level of statistical significance was set at a p value < 0.05 (two-tailed).

3. Results

The distribution of the study group based on gender and ethnicity is presented in Table one.

The presence of OSH was noticed in 21 participants (18.ane%). According to Fisher'southward exact test, girls had statistically meaning higher odds of presenting OSH than boys (odds ratio (OR) = 3.268, 95% confidence interval (CI): 1.108–nine.643, p = 0.03) (Table 2).

The results of our study showed that the presence of self-inflicted oral lesions is influenced by ethnicity (Chi-square original p = 0.04). After applying the Bonferroni correction, the level of statistical significance was adjusted at p < 0.0167. Therefore, Romanians had statistically significant lower odds of developing oral self-injuries compared to Roma participants (OR = 0.15, 95% CI: 0.03–0.75, p = 0.0164), but at that place was no pregnant difference neither between Romanians and Hungarians (OR = 0.22, 95% CI: 0.04–ane.148, p = 0.07), nor betwixt Hungarians and Roma participants (OR = 0.71, 95% CI: 0.24–two.06, p = 0.6) (Table 3).

In Table 4 the types of encountered lesions are summarized, based on location and frequency.

About lesions were observed at the level of oral commissures (35.48%), followed by buccal mucosa (29.03%) and the upper lip (19.36%). The lowest value was obtained for the frequency of tongue lesions (3.23%). Suggestive clinical and histopathological aspects are presented in Figure 2 and Figure 3a,b.

iv. Give-and-take

In Romania at that place is a large number of institutionalized children and a lack of scientific information regarding the consequences of this policy on oral health. Moreover, central Romania is multicultural and dissimilar minorities among which Hungarians and local Roma population are the most numerous. This allows a better assessment of more variables, in the try to detect possible take chances factors for the development of OSH. The last few decades have been marked past increased scientific information on self-damage behavior, which could be the event of the interest of specialists or meliorate diagnostic methods. Although considered pathological, it was reported that a large number of individuals have experienced a self-harm behavior at least once or even for a period of time in their life [18,19]. To exist considered cocky-injury, a lesion must have the following characteristics: repetitive, socially unacceptable and to cause balmy/moderate tissue impairment [20]. Therefore, these lesions are commonly hidden, the exact prevalence in the earth is unknown and is believed to exist underestimated [21]. Recent studies reported different percentages depending on the group of population analyzed, ranging from iv% in adults, 17–38% in students, 7.7–22.8% in institutionalized patients with mental disorders to 69% in high-risk immature people (victims of sexual corruption or drug users) [22,23,24,25]. NSSI is a relatively common and insidious pervasive, often concealed habit that may start in childhood and increase in boyhood and young adulthood. Boyish girls seem more vulnerable and the central components of NSSI behavior are represented by negative emotion and saturnine cocky-derogation [26,27].

According to data from literature, ethnicity might have an influence on self-harm behavior [28]. This was confirmed by the results of our report, as the group of local Roma showed statistically pregnant higher odds of developing OSH lesions compared to Romanians. The influence of ethnicity upon self-injury behavior was farther confirmed by Toth et al. [29] who institute that Roma population from Hungary is characterized by higher odds of developing suicidal behavior compared to not-Roma ethnics. The authors mention that studies from the United kingdom and Hungary partially explain these tendencies by the loftier incidence of feet, depression and hostility from the bulk population. For the Roma population in particular, the family concept has an important social value and, therefore, the lack of cohesion with relatives experienced by institutionalized children could be a potent negative gene for the development of anxiety and low. These problems aggravate during adolescence and adulthood every bit a result of poverty, low educational level, and unemployment.

In a meta-analysis, published past Lang and Yao in 2018 [30], the estimated prevalence of NSSI in Chinese middle-school students was 22.37%, considered relatively high, females existence more than susceptible to this behavior (21.ix% compared to a prevalence of twenty.half dozen% reported in male students). The results of our written report are in accordance with this data, as out of the OSH overall prevalence of eighteen.1%, xiii.79% were attributed to female person participants and only 4.31% to male participants.

OSH is not a frequently encountered phenomenon in the daily clinical practise, merely information technology tin can correspond the first manifestation of a psychiatric disorder. AlSadhan et al. [31] found a higher prevalence of OSH among institutionalized children from Saudi Arabia, including gingival or mucosal lesions, cheek and lip biting. Traumatic lesions of the lips, accompanied past loss of tissue were recognized by many authors as the most frequent injuries of the oral mucosa. [32] This was explained past the proximity of incisors and canines, teeth with sharp cusps and incisal margins. In our report, the distribution of injuries is in accordance with scientific information, as the oral commissure and lips were afflicted in 35.48% and 32.26% cases, respectively, while the tongue was injured only in 3.23% cases. The frequent lesion of the oral commissure could be explained by the presence of caliculus angularis, a modest projection of keratinized mucosa, easily injured between upper and lower canine, associated with a decreased level of pain.

Based on the literature, children who self-impairment claim to have lilliputian to no pain while they are hurting themselves merely they feel tension and acrimony towards themselves or others. This was observed also by our investigators, every bit none of the children who presented with OSH complained about pain during examination. A drawback of our study is that during the oral examination no psychological assessment was performed and, therefore, the tension or anger could non be quantified. It is estimated that the incidence of habitual self-injurers is nearly one% of the population with a college proportion of females than males, the typical onset of cocky-harming acts is usually at puberty. This behavior lasts v–10 years but it can persist much longer without the proper treatment [33,34]. Institutionalized children prove an increased prevalence of oral habits and OSH, which indicate emotional stress. Moreover, foster caregivers frequently lack information on these subjects and are unable to provide the proper support for these children [31].

In a report from 2015, Tortorici et al. [35] reported that oral soft tissue injuries had an incidence estimated at 2.5% in the Caucasian population. In our study group, a chronic evolution was suspected in 6 cases with OSH (v.17%) and these were farther investigated using exfoliative cytology, the results confirming the beneficial evolution, with balmy inflammation. The seize with teeth of the lips and buccal mucosa can destroy the superficial epithelium and if this parafunction has a chronic evolution, it tin can cause keratinized shreds or erosive and desquamative areas. These lesions can be easily identified past clinical inspection and are often related to psychologically tense persons [36]. However, in some cases, the lesions were mistaken for serious medical weather and biopsies were required in order to dominion out a malignancy. Therefore, it is important to perform a thorough clinical examination and to translate the laboratory tests clearly [37].

4.1. Clinical Relevance

Identification of NSSI in the early stages is of utmost importance as scientific data confirm that upward to 70% of these persons experienced too suicidal attempts [33]. Data from literature suggests that early on age at which children engage in NSSI represents a risk factor for more episodes of NSSI during the lifetime with increased severity [17]. Equally self-injuries are conducted mainly in secret and may not be clearly visible, the periodic oral examination of these children might exist useful in early diagnosis. Although minor OSH does not atomic number 82 to a serious loss of tissue, it may affect oral health in the long run, with important social and emotional implications. Our results raise the question regarding efficient preventive measures, such equally ameliorate training of caregivers and policies focusing on the psychosocial well-beingness of institutionalized children. Measures aiming to raise subjective happiness and satisfaction with life at any age might decrease the prevalence of NSSI amongst institutionalized children [17].

4.2. Strengths and Limitations

According to our knowledge in that location were no studies addressing self-harm behavior of oral soft tissues in children from central Romania. However, our study encountered several limitations: the small sample size and cross-sectional design, which allowed a rapid and cost-effective evaluation of the prevalence of OSH, but is unable to provide a articulate association between investigated variables. Therefore, longitudinal studies on the full general population are required for a better understanding of these emotional disorders. Moreover, cognitive assessment of these children would have been useful in order to adjust confounding factors.

Author Contributions

Conceptualization, A.M.South. and M.M.; methodology, O.E.S.; software, A.M.P.; validation, A.Thou.Due south. and Chiliad.M.; formal analysis, M.Thou.; investigation, O.East.S. and R.E.V.; information curation, O.E.S. and R.E.V.; writing—original draft grooming, A.M.Due south., O.E.S., R.East.Five. and A.Thou.P.; writing—review and editing, M.M.; supervision, A.M.P. and K.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted co-ordinate to the guidelines of the Annunciation of Helsinki, and approved past the Ethics Committee of the George Emil Palade Academy of Medicine, Pharmacy, Science, and Technology of Târgu Mureș (protocol code 520/21.11.2019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Information Availability Statement

The data presented in this study are available on request from the respective author. The data are not publicly available due to privacy restrictions.

Conflicts of Involvement

The authors declare no disharmonize of interest.

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Figure one. Flow diagram illustrating selection of participants to the written report.

Figure 1. Flow diagram illustrating selection of participants to the study.

Children 08 00002 g001

Figure ii. xiv-yr-old female patient, with a large wound on her upper lip, non-bleeding area of 1 × two cm on the non-keratinized mucosa, surrounded by erythema that did not involve the vermilion border.

Figure two. xiv-twelvemonth-old female person patient, with a large wound on her upper lip, not-bleeding expanse of 1 × 2 cm on the non-keratinized mucosa, surrounded past erythema that did not involve the vermilion border.

Children 08 00002 g002

Effigy 3. (a) A 12-yr-erstwhile female patient with a white "patch" on the buccal mucosa, resembling leukoplakia; histopathological examination was performed in guild to obtain the correct diagnosis; (b) exfoliative cytology did non confirm the presence of a premalignant lesion. Intermediate squamous cells (reflecting the accelerate turnover) with slight inflammation (different shape of nuclei, stainability, irregular contour of the nuclear border) (Papanicolaou stain, ×forty).

Figure 3. (a) A 12-year-old female patient with a white "patch" on the buccal mucosa, resembling leukoplakia; histopathological exam was performed in lodge to obtain the right diagnosis; (b) exfoliative cytology did not confirm the presence of a premalignant lesion. Intermediate squamous cells (reflecting the accelerate turnover) with slight inflammation (dissimilar shape of nuclei, stainability, irregular contour of the nuclear edge) (Papanicolaou stain, ×twoscore).

Children 08 00002 g003

Table 1. Distribution of the study group according to gender and ethnicity.

Table 1. Distribution of the report grouping co-ordinate to gender and ethnicity.

Gender/Ethnicity Romanians Hungarians Roma Total
Female 20 (17.24%) 19 (16.38%) 24 (20.69%) 63 (54.31%)
Male 17 (14.65%) 15 (12.93%) 21 (xviii.11%) 53 (45.69%)
Total 37 (31.89%) 34 (29.31%) 45 (38.8%) 116 (100%)

Tabular array 2. The distribution of lesions according to gender.

Table 2. The distribution of lesions co-ordinate to gender.

Gender/Oral Lesion Oral Lesion Present Oral Lesion Absent Full
Female sixteen (xiii.79%) 47 (40.52%) 63 (54.31%)
Male 5 (4.31%) 48 (41.38%) 53 (45.69%)
Total 21 (18.1%) 95 (81.9%) 116 (100%)

Tabular array 3. The distribution of oral lesions co-ordinate to ethnicity.

Tabular array 3. The distribution of oral lesions co-ordinate to ethnicity.

Ethnicity/Oral Lesion Oral Lesion Nowadays Oral Lesion Absent Total
Romanian 2 (1.72%) 35 (30.17%) 37 (31.89%)
Hungarian 7 (half dozen.03%) 27 (23.28%) 34 (29.31%)
Roma 12 (10.35%) 33 (28.45%) 45 (38.eight%)
Total 21(18.1%) 95 (81.9%) 116 (100%)

Table 4. Frequency of oral cocky-inflicted lesions according to location.

Table 4. Frequency of oral self-inflicted lesions according to location.

Location of Lesion Number Frequency
Upper lip 6 nineteen.36%
Lower lip 4 12.90%
Tongue 1 three.23%
Buccal mucosa 9 29.03%
Commissures 11 35.48%

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