Evaluation of a school-based multicomponent behavioural intervention in deprived urban areas for children classified as overweight, obese or at risk for overweight

Gitte C Kloek
W A Martien
Jongert
Sanne I De Vries
Evaluation of a school-based multicomponent behavioural intervention in deprived urban areas for children classified as overweight, obese or at risk for overweight
10.1186/s13104-021-05513-yKloek et al. BMC Res Notes (2021) 14:100 This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article' s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article' s zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.OverweightObesityChildrenBody mass indexPreventionMulticomponent behavioural intervention
Objective: This study evaluated the effect of an after-school group-based medium-intensity multicomponent behavioural intervention programme for children aged 8-12 years classified as overweight, obese or at risk for overweight on body mass index standard deviation score (BMI SDS). In accordance with standardized protocols body weight and height were measured in 195 participants (88 boys, 107 girls) at baseline and at the end of the programme. A total of 166 children derived from a school-based monitoring system served as control group. Multivariate regression analyses examined the effect of the intervention and the independent factors associated with better outcomes in the intervention group.Results: Analysis of covariance showed a significant intervention effect on BMI SDS in favour of the intervention group (b-coefficient − 0.13 ± 0.03; p < 0.01) compared with the control group. Change in BMI SDS between baseline and follow-up in the intervention group was associated with baseline age (b-coefficient 0.03 ± 0.02; p = 0.04) but was independent from gender, ethnicity, baseline BMI SDS, time between baseline and follow-up, school year and attendance rate.

Introduction

Worldwide the growing incidence and prevalence of childhood obesity and overweight is a reason for concern [1]. Since 1980, the prevalence rates of childhood overweight have increased two to three fold in The Netherlands [2]. In 2009, 13-15% of the Dutch children were classified as overweight and 2% were obese [2], according to the International Obesity Task Force (IOTF) cut off values [3]. Although the prevalence of childhood overweight appears to be stabilizing at different levels in different countries it is still a public health issue, especially when ethnicity is taken into account [4]. In the Netherlands, children with backgrounds originating from Turkey and Morocco are at the highest risk: between 27 and 30% are overweight and between 6.5% and 8.4% are obese [5]. In The Hague, the third largest city in The Netherlands, an integrated approach for the prevention of childhood obesity was set up in 2006. The approach integrates a system of early identification and referral of children with overweight or obesity to appropriate care and support within multiple settings such as the community, schools, or paediatric primary care [6]. Behavioural interventions for treating overweight in children that combine changes in diet, physical activity and behavioural management strategies are promising means to lower body mass index standard deviation scores (BMI SDS) in participants [7][8][9][10][11]. According to Whitlock et al. [9] medium-(26 to 75 h) to high-(more than 75 h) intensity behavioural interventions have a significantly larger effect on weight outcomes than very low-intensity (under 10 h) interventions. The aim of the present study was to evaluate whether the WOWIJS programme, an afterschool group-based medium-intensity multicomponent behavioural intervention in deprived urban areas for children classified as overweight, obese or at risk for overweight, would be effective in preventing further increases in BMI SDS.

Main text

Methods

Intervention programme

Since 2010, the WOWIJS programme, Dutch acronym for 'WorkOut Wat Is Jouw Stijl' [Work Out What Is Your Style] is an ongoing after-school group-based multicomponent behavioural intervention for children aged 8-12 years with overweight, obesity, or at risk for overweight in The Hague, The Netherlands [12]. The intervention serves primary schools in more deprived areas of the city. Relatively many families in these deprived areas have low incomes and originate from four of the major ethnic groups in the Netherlands [13]. The children participate in weekly 90-min group sessions that include exercise training, nutrition education and lifestyle counselling during the school year. WOWIJS is located in the child's immediate environment, either at their own school or in a sports hall near their school. The group sessions are carried out by a team of professionals: a dietician, a physical education (PE) teacher, and a child psychologist.

Design and study population

The WOWIJS intervention programme is practice-based and was not designed as a controlled trial. In 2011 and 2012, the identification of children who were likely to benefit from the WOWIJS intervention programme was done by the school's PE teacher. Children with overweight, obesity without co-morbidities or children with a high risk of overweight in the near future were eligible for WOWIJS. Children were classified as 'high risk for overweight' if there was a known family history of overweight or obesity in older siblings. In 2011, 152 children from five primary schools and in 2012, 126 children from six primary schools started in the WOWIJS programme. Depending on the start date, the children took part in 30 to 50 group sessions during the school year. Baseline and follow-up measures were available from in total 195 (66%) out of 296 children. A logistic regression analysis showed that lost to follow-up was associated with a lower attendance rate of the program (p < 0.01). To evaluate the effect of the intervention, this study compared children in the intervention programme with overweight or obese children who were selected from a school-based monitoring system to follow developments in (over)weight in school children in The Hague. For the monitoring system, the PE teacher collected annual data on children's weight and height according to a standardized protocol. This study used data that were collected in 2011 en 2012 among 166 children who attended a primary school not participating in the WOWIJS programme but that was situated in an area with a comparable deprivation score, who were either overweight or obese and aged between 8 and 12 years in 2011 and who had participated in a follow-up measurement in 2012.

Measures

Demographic data were collected at baseline and attendance data for the group sessions were collected throughout the programme. Country of birth of the participants' parents determined the categorization by ethnic group. An attendance list was filled out for every group session to determine the overall attendance rate at the end of the programme. Anthropometric data were collected at the beginning and at the end of WOWIJS. Body weight (to the nearest 0.1 kg) and height (to the nearest 0.1 cm) were measured by a trained WOWIJS dietician using the same standardized protocols as in the monitoring system. Body weight was measured without heavy clothing and shoes. Body mass index (BMI, kg/m 2 ) was calculated as weight/height 2 . Overweight and obesity prevalence rates were defined according to the extended International Obesity Task Force (IOTF) cut-off points and genderand age-specific BMI SDS was calculated using the least square means coefficients corresponding to these IOTF cut-off points as a reference [14]. Change in BMI SDS at the end of the programme was calculated as BMI SDS at follow-up minus baseline BMI SDS. Participants were divided in four subgroups on the basis of their change in BMI SDS: BMI SDS increased, BMI SDS decreased by > 0 to < 0.25, BMI SDS decreased by ≥ 0.25 to < 0.5 and BMI SDS decreased by ≥ 0.5. These groups were chosen on the basis of previous studies where a minimum reduction in BMI SDS of at least 0.25 was required to improve body composition and cardio metabolic health [15,16].

Statistical analyses

Baseline characteristics and outcomes at follow-up of the children in the intervention group were compared with the control group. Chi-squared tests were used for categorical variables and t-tests were used for continuous variables. To estimate the effectiveness of WOWIJS on change in BMI SDS, a mixed model analysis of covariance with baseline value of BMI SDS, gender, age and time between baseline and follow-up measurement as covariates, was applied. The independent factors associated with better outcomes in WOWIJS participants were assessed using a two-level multilevel linear model to account for data clustering at the school level. All P values reported are two-sided with the significance level set to 0.05. Statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC, USA). Table 1 shows the characteristics of the study population. Age, BMI, weight status and evaluation period were significantly different between the intervention and control group. WOWIJS participants followed on average 27 (± 9) group sessions, with a minimum of 5 and a maximum of 49 lessons. The average attendance rate of the WOWIJS group sessions was 84% (± 13%).

Results

Comparing anthropometric changes at follow-up demonstrated a significantly smaller BMI increase and a greater BMI SDS reduction in the intervention group compared with the control group ( Table 2). Analysis of covariance showed a significant intervention effect on BMI SDS in favour of the intervention group (b-coefficient − 0.13 ± 0.03; p < 0.01).

The multilevel model showed that the change in BMI SDS between baseline and follow-up in the intervention group was only associated with baseline age (b-coefficient 0.03 ± 0.02; p = 0.04) and was independent from gender, ethnicity, baseline BMI SDS, duration of followup, school year and WOWIJS attendance rate ( Table 3). The variance attributable to school location was 5.3%.

Discussion

This study showed that the WOWIJS intervention improved BMI SDS in participants. WOWIJS participants had a more favourable BMI SDS reduction distribution compared with children in the school-based control group. Although the decrease in BMI SDS in the WOWIJS intervention group was modest, it is in accordance with findings from a recent meta-analysis that showed that behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years demonstrated a decrease in BMI SDS of 0.02 to 0.10 compared with a no treatment group [17]. Furthermore younger children had better outcomes on change in BMI SDS than older children. Reinehr et al. also reported better reduction of BMI SDS in younger children after  Table 2 Anthropometric changes from baseline to follow-up in the intervention group and school-based control group Highly successful Δ BMI-SDS ≤ − 0.50 13 (7) 9 (5) participation in a 1-year lifestyle intervention [18]. An explanation may be the social context that contributes to developing healthy lifestyles over time. Older children may experience more peer pressure for unhealthy behaviours than younger children [19] and therefore achieve less BMI SDS reduction. Our study possesses several strengths, including a multicomponent behavioural intervention designed according to evidence-based recommendations. These kind of interventions are efficient when it comes to paediatric obesity [9]. Overall group session attendance was high, therefore the received intervention dose of most participants meets the dose of a medium intensity behavioural intervention. Easy access to the intervention in the child's own school environment after school hours may have contributed to these high attendance rates. Furthermore the lost-to-follow up rate of 34% was lower than the up to 43% reported in a meta-analyses for randomized controlled trials that report dropout rates in paediatric obesity interventions [7].

In conclusion, BMI SDS in an ethnic diverse group of children classified as overweight, obese or at risk for overweight can be improved by participating in a school-based medium-intensity multicomponent behavioural intervention. Without the programme participants BMI SDS may continue to increase over time. The WOWIJS programme is a secondary obesity prevention programme and therefore fills a gap between primary prevention and tertiary preventive care treatment programs for obese children. The programme represents a realistic approach for the prevention of childhood obesity in a hard to reach populations in deprived urban areas. The ongoing WOWIJS programme now includes a smartphone application to stimulate physical activity and healthy food choices at home. This application may be attractive to the older participants in the programme and therefore it may increase their change on better outcomes. A new study should investigate the effectiveness of the extended programme on BMI SDS but also the long-term effects to determine the sustainability of the outcomes.

Limitations

• Long-term outcomes on change in BMI SDS after the end of the intervention were not assessed. • The school-based control group was not an exact match for the intervention group. Children were somewhat younger which may also explain the lower BMI at baseline. • Several children with a normal weight status were included in the intervention group because they were at high risk of overweight in the near future. They could not be matched with normal weight children in the monitoring system. • It is unknown whether the overweight children in the school-based control group participated in other behavioural interventions. • The follow-up period was shorter in the intervention group compared with the control group. However the length of the evaluation period was not associated with changes in BMI SDS.

Follow
-up measurement intervention group at the end of the program; follow-up measurement school-based control group in the next school year a Unpaired t-test or chi-squared test Intervention group (N = 195) School-based control group (N = 166) BMI-SDS ≤ 0 ≤ − 0.25 84 (43) 63 (38) Successful Δ BMI-SDS ≤ − 0.25 ≤ − 0.5 38 (19) 22 (13)

Table 1
1Characteristics of the intervention group and schoolbased control group at baseline Data as mean (SD) or N (%) NA not available for the school-based control group a Missing data n = 14 participants b Children at high risk for overweight in the near future c Number of days between baseline and follow-upCharacteristic
Intervention
group
(N = 195)

School-based
control group
(N = 166)

p-value

Gender (girls)
107 (55)
91 (55)
0.99

Age (years)
9.7 (1.2)
9.4 (1.1)
0.01

Ethnicity a

Dutch
3 (2)
NA

Surinamese
64 (35)
NA

Moroccan
49 (27)
NA

Turkish
40 (22)
NA

Other
25 (14)
NA

BMI (kg/m 2 )
23.0 (3.2)
22.4 (2.9)
0.03

BMI SDS
2.05 (0.58)
1.99 (0.50)
0.32

Weight status
< 0.01

Normal weight b
21 (11)
0

Overweight
98 (50)
116 (70)

Obese
37 (39)
50 (30)

Evaluation period (days c ) 196 (54)
306 (77)
< 0.01

Abbreviations BMI: Body mass index; BMI SDS: Body mass index standard deviation score; IOTF: International obesity task force; WOWIJS: Dutch acronym for 'WorkOut Wat Is Jouw Stijl' [Work Out What Is Your Style].

Table 3
3Independent factors and change in BMI SDS in the intervention group: multilevel regression analysis (N = 181) Mutually adjusted associations with change in BMI SDS in the intervention group, missing data n = 14 participants a Number of days between baseline and follow-up Intraclass Correlation Coefficient school level: 0.053Independent factors
Beta
95% CI
p-value

Gender

Girls vs boys
− 0.01
− 0.08 to 0.07
0.86

Age (years)
0.03
0.001 to 0.06
0.04

Ethnicity

Surinamese vs Moroccan − 0.01
− 0.15 to 0.13
0.86

Surinamese vs Turkish
− 0.01
− 0.15 to 0.13
0.88

Surinamese vs Other
0.02
− 0.10 to 0.14
0.76

BMI SDS baseline
0.02
− 0.04 to 0.08
0.49

Evaluation period (days a )
− 0.0004 − 0.0001 to 0.0001 0.38

School year

2012 vs 2011
0.03
− 0.05 to 0.10
0.47

Attendance rate (%)
− 0.11
− 0.40 to 0.18
0.45

AcknowledgementsWe would like to thank the WOWIJS programme manager, WOWIJS dieticians, and trainee dieticians for their assistance in recruitment and data collection. Furthermore we would like to thank the Municipal Health Service The Hague (GGD Haaglanden) for providing the school-based control group data set and Irene van der Meer for preparing the control group data set for this analysis.1Authors' contributions GCK managed the research project, performed the statistical analysis and drafted the manuscript. Both MWAJ and SIV supervised the project and critically reviewed the manuscript. All authors read and approved the final manuscript.FundingThis project was funded by The Netherlands Organisation for Health Research and Development (ZonMw project number 200005095409). The funding agency did not assist in the study design, analysis, interpretation or writing of the manuscript.Learn more biomedcentral.com/submissionsReady to submit your research Ready to submit your research ? Choose BMC and benefit from:? Choose BMC and benefit from:Availability of data and materialsThe data that support the findings of this study are not publicly available due to the original consent and ethics approval not containing approval from the participants in the WOWIJS intervention programme for data sharing. Data are however available from the authors upon reasonable request and with permission of the SHJG Foundation (non-profit foundation for youth health promotion in the Hague, The Netherlands).Declarations Ethics approval and consent to participateThis study was exempt from review by the Medical Ethics Committee Southwest Holland (reference number 17-032, as it does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act. Written informed consent to participate in the WOWIJS programme was obtained from participating children's caregivers. For the school-based control group an anonymised data set was used. To protect the children's privacy in the control group there was no access to personal data such as names or dates of birth or the school they attended.Consent for publicationNot applicable.Competing interestsMWAJ is treasurer of the non-profit SHJG Foundation. The SHJG Foundation takes charge of the implementation of the WOWIJS programme in the city of The Hague. GCK and SIV declare they have no competing interests.Author details
. World Health Organization. Ending Childhood Obesity. Geneva: WHO. World Health Organization. Ending Childhood Obesity. Geneva: WHO; 2016.

Increase in prevalence of overweight in Dutch children and adolescents: a comparison of nationwide growth studies in 1980. Y Schönbeck, H Talma, P Van Dommelen, B Bakker, S E Buitendijk, R A Hirasing, PLoS ONE. 61127608Schönbeck Y, Talma H, van Dommelen P, Bakker B, Buitendijk SE, HiraSing RA, et al. Increase in prevalence of overweight in Dutch children and adolescents: a comparison of nationwide growth studies in 1980, 1997 and 2009. PLoS ONE. 2011;6(11):e27608.

Establishing a standard definition for child overweight and obesity worldwide: international survey. T J Cole, M C Bellizzi, K M Flegal, W H Dietz, BMJ. 3207244Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard defini- tion for child overweight and obesity worldwide: international survey. BMJ. 2000;320(7244):1240-3.

Evidence that the prevalence of childhood overweight is plateauing: data from nine countries. T Olds, C Maher, S Zumin, S Péneau, S Lioret, K Castetbon, Pediatric Obes. 65-6Olds T, Maher C, Zumin S, Péneau S, Lioret S, Castetbon K, et al. Evidence that the prevalence of childhood overweight is plateauing: data from nine countries. Pediatric Obes. 2011;6(5-6):342-60.

Call for early prevention: prevalence rates of overweight among Turkish and Moroccan children in The Netherlands. P Van Dommelen, Y Schönbeck, R A Hirasing, S Van Buuren, Eur J Public Health. 255Van Dommelen P, Schönbeck Y, HiraSing RA, Van Buuren S. Call for early prevention: prevalence rates of overweight among Turkish and Moroccan children in The Netherlands. Eur J Public Health. 2015;25(5):828-33.

Percentage overgewicht Haagse jeugd 2007-2015 [Obesity prevalence in The Hague Youth. M Keetman, I Van Der Meer, De Wilde, J , Keetman M, Van der Meer I, De Wilde J. Percentage overgewicht Haagse jeugd 2007-2015 [Obesity prevalence in The Hague Youth 2007-2015].

. Epidemiol Bull. 514Epidemiol Bull. 2016;51(4):7-17.

Cochrane review: interventions for treating obesity in children. Evid Based Child. Oude Luttikhuis, H Baur, L Jansen, H Shrewsbury, V A O'malley, C Stolk, R P , Health Cochrane Rev J. 44Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Cochrane review: interventions for treating obesity in children. Evid Based Child Health Cochrane Rev J. 2009;4(4):1571-729.

Treatment of overweight and obesity in children and youth: a systematic review and meta-analysis. L Peirson, D Fitzpatrick-Lewis, K Morrison, R Warren, Usman Ali, M , Raina P , CMAJ Open. 31Peirson L, Fitzpatrick-Lewis D, Morrison K, Warren R, Usman Ali M, Raina P. Treatment of overweight and obesity in children and youth: a systematic review and meta-analysis. CMAJ Open. 2015;3(1):E35-46.

Effectiveness of primary care interventions for weight management in children and adolescents: an updated, targeted systematic review for the USPSTF. E P Whitlock, E A O'conner, S B Williams, T L Beil, K W Lutz, Rockville (MDAgency for Healthcare Research and Quality (US)Whitlock EP, O'Conner EA, Williams SB, Beil TL, Lutz KW. Effectiveness of primary care interventions for weight management in children and ado- lescents: an updated, targeted systematic review for the USPSTF. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Jan. https:// www. ncbi. nlm. nih. gov/ books/ NBK36 416/. Accessed 25 Feb 2021.

American Dietetic Association. Position of the American Dietetic Association: individual-, family-, school-, and community-based interventions for pediatric overweight. J Am Diet Assoc. 1066925American Dietetic Association. Position of the American Dietetic Associa- tion: individual-, family-, school-, and community-based interventions for pediatric overweight. J Am Diet Assoc. 2006;106(6):925.

Recommendations for treatment of child and adolescent overweight and obesity. B A Spear, S E Barlow, C Ervin, D S Ludwig, B E Saelens, K E Schetzina, Pediatrics. 120Supplement 4Spear BA, Barlow SE, Ervin C, Ludwig DS, Saelens BE, Schetzina KE, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(Supplement 4):S254-88.

The Hague: SHJG Foundation. Shjg Foundation, Wowijs, Web page in DutchSHJG Foundation. WoWijs [Web page in Dutch] The Hague: SHJG Foun- dation; 2021. https:// www. wowijs. nl/ wowijs/. Accessed 25 Feb 2021.

Cities in the Netherlands. Facts and figures on cities and urban areas. The Hague: PBL Netherlands Environmental Assessment Agency. K Nabielek, D Hamers, D Evers, Nabielek K, Hamers D, Evers D. Cities in the Netherlands. Facts and figures on cities and urban areas. The Hague: PBL Netherlands Environmental Assessment Agency; 2016.

Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatric obesity. T J Cole, T Lobstein, 7Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatric obesity. 2012;7(4):284-94.

What reduction in BMI SDS is required in obese adolescents to improve body composition and cardiometabolic health?. A L Ford, L P Hunt, A Cooper, J P Shield, Arch Dis Child. 954Ford AL, Hunt LP, Cooper A, Shield JP. What reduction in BMI SDS is required in obese adolescents to improve body composition and cardio- metabolic health? Arch Dis Child. 2010;95(4):256-61.

Which amount of BMI-SDS reduction is necessary to improve cardiovascular risk factors in overweight children?. T Reinehr, N Lass, C Toschke, J Rothermel, S Lanzinger, R W Holl, J Clin Endocrinol Metab. 1018Reinehr T, Lass N, Toschke C, Rothermel J, Lanzinger S, Holl RW. Which amount of BMI-SDS reduction is necessary to improve cardiovas- cular risk factors in overweight children? J Clin Endocrinol Metab. 2016;101(8):3171-9.

Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. E Mead, T Brown, K Rees, L B Azevedo, V Whittaker, D Jones, Cochrane Database Syst Rev. 6612651Mead E, Brown T, Rees K, Azevedo LB, Whittaker V, Jones D, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. Cochrane Database Syst Rev. 2017;6(6):12651.

Body mass index patterns over 5 years in obese children motivated to participate in a 1-y lifestyle intervention: age as a predictor of long-term success. T Reinehr, M Kleber, N Lass, A M Toschke, Am J Clin Nutr. 915Reinehr T, Kleber M, Lass N, Toschke AM. Body mass index patterns over 5 years in obese children motivated to participate in a 1-y lifestyle intervention: age as a predictor of long-term success. Am J Clin Nutr. 2010;91(5):1165-71.

Family, peer, and school influences on children's developing health lifestyles. S Mollborn, E Lawrence, J Health Soc Behav. 591Mollborn S, Lawrence E. Family, peer, and school influences on children's developing health lifestyles. J Health Soc Behav. 2018;59(1):133-50.

Publisher's Note. Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations.


Non-suicidal self-injury (Nssi) in adolescent inpatients: assessing personality features and attitude toward death

Mauro Ferrara
Arianna Terrinoni
†
Riccardo Williams
Non-suicidal self-injury (Nssi) in adolescent inpatients: assessing personality features and attitude toward death
R E S E A R C H Open Access
Background:Non-suicidal self-injury (NSSI) is a common concern among hospitalized adolescents, and can have significant implications for short and long-term prognosis. Little research has been devoted on how personality features in severely ill adolescents interact with NSSI and "attitude toward life and death" as a dimension of suicidality. Developing more specific assessment methodologies for adolescents who engage in self-harm without suicidal intent is relevant given the recent proposal of a non-suicidal self-injury (NSSI) disorder and may be useful in predicting risk in psychiatrically impaired subjects. Methods: Consecutively hospitalized adolescents in a psychiatric unit (N = 52; 71% females; age 12-19 years), reporting at least one recent episode of self-harm according to the Deliberate Self-harm Inventory, were administered the Structured Clinical Interview for DSM Mental Disorders and Personality Disorders (SCID I and II), the Children's Depression Inventory and the Multi-Attitude Suicide Tendency Scale (MAST). Results: Mean age onset of NSSI in the sample was 12.3 years. All patients showed "repetitive" NSSI (high frequency of self-harm), covering different modalities. Results revealed that 63.5% of adolescents met criteria for Borderline Personality Disorder (BPD) and that the rest of the sample also met criteria for personality disorders with dysregulated traits. History of suicide attempts was present in 46.1% of cases. Elevated depressive traits were found in 53.8%. Results show a statistically significant negative correlation between the score on the "Attraction to Life" subscale of the MAST and the frequency and diversification of self-harming behaviors. Conclusions: Most adolescent inpatients with NSSI met criteria for emotionally dysregulated personality disorders, and showed a reduced "attraction to life" disposition and significant depressive symptoms. This peculiar psychopathological configuration must be addressed in the treatment of adolescent inpatients engaging in NSSI and taken into account for the prevention of suicidal behavior in self-injuring adolescents who do not exhibit an explicit intent to die.BackgroundResearch on adolescent development has devoted efforts to the understanding of the roots of potentially self damaging behaviors, including suicide, eating disorders, substance abuse, sexual promiscuity, risk-taking, violence and aggression, delinquency and, more recently, self-harm or non-suicidal self-injurious behavior (NSSI). Literature data have shown that adolescence is a critical period for the onset of self-harm [1]. The prevalence of NSSI among adolescents in community based studies range between 13% and 28% [2-4]; in general, literature suggests a seemingly increasing prevalence of such behaviors in the teenager population[5,6].Not surprisingly, higher rates of self-harm are apparent in individuals receiving mental health treatment:

NSSI occurs in about 20% of adult psychiatric patients [7] and in 40-80% of adolescent psychiatric patients [8][9][10].

NSSI has also been described as one of the most diffuse and challenging clinical phenomena reported in adolescent inpatient samples [11,12]. A recent review study of discharge diagnoses indicated a threefold increase in NSSI among hospitalized adolescents from 1990 to 2000 [13].

Much debate concerns the psychopathological meaning of NSSI, due to its uncertain boundaries and heterogeneous manifestations. Overall, literature on psychopathological characteristics of NSSI in adolescence has considered separately two distinct controversial aspects: the relationship between NSSI and personality disorders, and the relationship between NSSI and the depressive-suicidal dimension. Moreover, adolescents with severe personality disorders are often assessed and treated in different clinical settings and with different approaches than those with mood disorders and suicidality.

Empirical findings show that the psychopathological dimension more consistently related to NSSI concerns personality functioning. In particular, a close link has been evidenced between NSSI and Borderline Personality Disorder (BPD) [14][15][16][17]. The majority of studies concern adult population. Indeed, epidemiological data show that 80% of adult BPD patients have exhibited at least one episode of self-harm [18]. In DSM-IV [19], self-harm has been represented under criterion 5 of BPD: keeping in mind the controversies about diagnosing personality disorders prior to adulthood and the fact that considering self-harm pathognomonic of BPD could lead to inappropriate management, the "DSM-5 Childhood and Adolescent Work Group" is now recommending the inclusion of the new diagnosis: Non-suicidal Self-Injury (NSSI). The proposed new diagnosis of NSSI applies to individuals engaging in intentional selfinflicted damage on 5 or more days in the last year, without suicidal intent and presenting a significant distress or impairment. The inclusion of the new diagnosis may reflect the clear cut relation between NSSI and childhood/adolescence, reduce the automatic assumption that an adolescent who engages in NSSI may have BPD and hopefully promote research to further clinical guidelines for treatment [20,21]. Since NSSI is a distinct aspect from BPD, it is important to fully articulate the relationship between NSSI and personality functioning in adolescence. The analysis of personality features of adolescent inpatient and outpatient populations exhibiting NSSI have so far confirmed the typical adult association between NSSI and BPD [21][22][23].

Substantial research attention has been given to the presence of specific forms of psychopathology associated with NSSI among hospitalized adolescent: it has been suggested [22] that most adolescent inpatients engaging in NSSI meet criteria for a DSM-IV Axis I diagnosis, with elevated rates of Major Depressive Disorder (MDD) (42%), Post-Traumatic Stress Disorder (PTSD) (24%), Substance Use Disorder (SUD) (60%). In a retrospective chart review using medical records, Jacobson et al. [23] found 67% of MDD in the total sample examined (NSSI and NSSI "plus suicide attempts" outpatients); Muehlenkamp et al. [24], using a similar methodology, examined how BPD symptoms relate to suicide attempts or NSSI within a population of adolescent outpatients, finding two BPD features ("confusion about self" and "unstable interpersonal relationships") as distinct predictors of "NSSI" and "NSSI + Suicide" group status, but not a strong variation in the impact of the single features on the different subgroups.

Although the inclusion of the new diagnosis makes clear the intention to consider NSSI and suicide attempts as distinct phenomena, several important questions are yet to be explained. First, NSSI and suicide attempts could co-occur with different modalities in different clinical populations: a sizable portion of selfinjurers (50% of outpatients; 70% of inpatients) reports having attempted suicide at least once [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. Some epidemiological and research data evidence that many suicides are not preceded by NSSI. In general population samples NSSI seems to have less severe consequences than attempted suicide and a different risk trajectory [5,6], but in adolescent inpatients who have attempted suicide a history of NSSI before the index episode is more likely than in those who have only suicidal ideation [25]. Data from ADAPT study show that in depressed adolescents receiving treatment over a 6 months follow-up, NSSI at baseline is an independent predictor of suicide attempt, even stronger than a history of suicide attempt itself [26]; Asarnow and colleagues identified similar findings in adolescents with treatment-resistant depression [27].

Second, although prior research has focused on the identifications of possible psychopathological links between NSSI, depression and suicidal ideation this crucial question remains unclear. Depressive symptoms seem to distinguish "NSSI-only" patients from NSSI patients who attempt suicide [23], thus implying a role for depressive conditions in the escalation from NSSI to suicidal behaviors. Moreover, self-harm has been found to be associated with depressive ideation, including feeling repulsed by life, having greater amounts of apathy, self-blame, and fewer connections to family members [28]. By definition, explicit suicidal ideation would not pertain NSSI subjects who, nonetheless, may end up in attempting suicide. Therefore, the individuation of instruments aimed in helping clinicians identify a suicide risk when there is not an explicit suicidal ideation seems a necessary step. Ideational factors related to feelings toward life and death has proved a useful construct in discriminating suicidal adolescents, non-suicidal adolescents and a psychiatric control group [29].

Given these considerations in this study we pursue two main objectives: 1) To describe the characteristics of NSSI and related psychopathology/personality functioning in a sample of NSSI adolescent inpatients;

2) To investigate whether characteristics such as depression symptoms and attitude toward life and death discriminate between NSSI subjects who have attempted suicide (NSSI -SA) and NSSI subjects who have not attempted suicide (NSSI only).

Methods

The participants for this study were consecutively admitted adolescents to a psychiatric inpatient unit ("Sapienza", University of Rome) that specializes in treating severe behavioral problems and psychotic episodes. A total of 114 adolescents were admitted in the study period (September 2009-September 2010), the majority of whom presented severe disruptive and/or personality disorders. All youths who presented NSSI over a 12-month period preceding admission were included. All adolescents with an attempted suicide as admission diagnosis were triaged to a separate unit and not included. Patients diagnosed with intellectual disabilities, pervasive developmental disorders, schizophrenia spectrum disorders or associated neurological conditions were excluded, given the relevance of such conditions for stereotypic self-injuries. The selected sample consisted of 52 adolescents (15 males and 37 females (age 12-19: mean = 15.50, SD = 1.72; age females: mean = 15.50, SD = 1.62; age males: mean = 15.2, SD = 2.03).

The great majority of the sample was made of ethnically white Italian. Of the remaining participants, 3 were Asian and 1 was unidentified. The distribution is reflective of the ethnic composition of the surrounding community.

As a standard assessment procedure, all subjects were interviewed and screened for DSM Axis I and Axis II diagnoses via the Structured Clinical Interview for DSM Mental Disorders and Personality Disorders (SCID I and II) [30]; the participants were administered the study measures, including the Deliberate Self-harm Inventory (DSHI), the Children's Depression Inventory (CDI) and the Multi-Attitude Suicide Tendency Scale (MAST). Youths and their parents signed informed consent for the evaluation. The study did not require any formal authorization, since the hospital's institutional review board did not consider the procedure as invasive.

The following instruments were administered sequentially for each patient, in a series of three sessions requiring 50 min each.

Instruments

The Deliberate Self-harm Inventory (DSHI) [31] was designed to measure non-suicidal deliberate self-harm; it is a self-report questionnaire that measures frequency, age of onset, duration, date of last occurrence, and severity of 17 types of self-harming behavior. The subject is required to report the relative frequency of each type of behavior on a 5-level scale: never-seldom-sometimes-often-always. The DSHI has adequate internal consistency (α = 0.82), temporal reliability (r = 0.92), and support for validity. For descriptive purposes we used the indexes of frequency = number of episodesper-month (seldom = episodic self-harm; sometimes to always = repetitive self-harm), types of self-harming behaviors (e.g., self-cutting, self-burning, etc.), diversification = occurrence of multiple types of self-harming behaviors measured on a three-level scale (0-1 types: minimum diversification; 2-4: moderate diversification; and 5-11: high diversification).

Children's Depression Inventory (CDI). This scale was developed by Kovacs [32] in order to assess the level of childhood depressive symptoms. It contains 27 items, each of which consists of 3 statements. For each item, the participant is asked to select the statement that best describes his/her feelings during the past 2 weeks. Scores range from 0 to 54. Higher scores indicate more severe depression.

The Multi-Attitude Suicide Tendency (MAST) [29] scale is a 30 item self-report measure of adolescent attitude toward life and death. The four types of conflicting attitudes identified are Attraction to Life (AL, 7 items), Repulsion by Life (RL, 7 items), Attraction to Death (AD, 7 items) and Repulsion by Death (RD, 9 items). The MAST was developed and initially validated in 2 studies involving high school and outpatient adolescents [28]. Another study [29] examined the construct validity and psychometric properties of this instrument in adolescent psychiatric inpatients and suggested that at least three of the MAST subscales may contribute to the assessment of suicidal behavior in adolescent psychiatric inpatients. Aspects concerning robustness and reliability of the Scale are included in Orbach [28].

Statistical methods

The ANOVA test, Binomial test and Mann Whitney Utest, correlations and linear regression methods were used when appropriate. For descriptive purposes, the results in univariate analyses are reported as significant at p < 0.05; SPSS software version 15.0 (SPSS Inc., Chicago, IL, USA) was used.

Results

No missing data were found for any of the participants originally recruited for the study. For all patients included in the study, the NSSI was classified as "repetitive", representing at least 5 lifetime self-harming behaviors on the DSHI. The average frequency of NSSI in the last three months is 2.9 (Table 1) (classified as "often" according to DSHI) The average number of selfinjuries types was 5. The DSHI evidenced that 60.5% of the subjects had "high diversification" self-harm ( Table  2) "Cutting" was the prevalent modality (80.8%), followed by "Severe scratching" (57.7%), "Interference with wound healing" (50.0%) and "Sticking pins, needles, staples into skin" (42.3%). The average age at the onset of NSSI was 12.3 years. Mann-Whitney U test evidenced no statistically significant differences (p = .689) for frequency and number of types of NSSI between NSSI subjects who had attempted suicide (NSSI-SA) and NSSI subjects who had not attempted suicide (NSSI only).

The sample mostly consisted of female subjects (F 71.2%; M 28.8%,). There were statistically significant differences indicating the association between female gender and NSSI (binomial test, p < 0.05).

Psychopathology and personality

Five subjects were diagnosed with an eating disorder (9.6%), 6 (11.5%) subjects with a substance abuse disorder and 10 (19.2%) subjects received a diagnosis for an anxiety disorder ( Table 3).

The sample shows a strong representation of BPD diagnosis with 63.5% of subjects meeting criteria for this personality disorder. A significant portion of the subjects were otherwise diagnosed with a Cluster B personality disorder: Histrionic personality disorder (N = 7; 13.5%), Narcissistic personality disorder (N = 3; 5.7%); 9 subjects were diagnosed with Passive-aggressive personality disorder (N = 9; 17.3%) belonging to Cluster C personality disorders. The impact of BPD diagnosis on NSSI was calculated by an ANOVA model having BPD vs other Axis II diagnoses as group predictor and both frequency and number of types derived from DSHI as dependent variables. No statistically significant effects were shown at the ANOVA either for frequency (mean for borderline group = 2.79; mean for non-borderline group = 2.63; SD = .87; F = .338; p = .536) and number of types of NSSI (mean for borderline group = 5.27; mean for non-borderline group = 4.22; SD = 2.77; F = 1.695; p = .20).

In order to evidence the possible relationship between the severity of depressive symptoms and NSSI, we performed several analyses. First of all, it should be highlighted that half of the patients of the sample (N = 28; 53.8%) had scores that were above the clinical threshold for depressive symptoms on the CDI (clinical cut-off > 19). Second, patients exceeding the cut-off for depressive symptoms at CDI were also significantly more likely to exhibit a greater number of types of NSSI than patients scoring in the non-depressive range of CDI (Mann-Whitney, p < 0.05). Finally, it was possible to evidence (see Table 4) a significant positive correlation between CDI scores and number of types of NSSI (r = 397; p < .01), while an only non significant positive correlation was found between CDI scores and frequency of NSSI (r = . 206; p = .148).

Attraction to life and death

Several analyses were also conducted to verify the relationship between attitude toward life and death, NSSI and suicide attempts. Results (see Table 4) show a statistically significant negative correlation between the AL     (Table 4). In order to verify whether the significant inverse association between AL scores and frequency and number of types of NSSI was mediated by CDI scores, we performed a linear regression model using frequency and number of types of NSSI as dependent variable and CDI and MAST-AL scores as predictors. The results evidence that the inverse association between AL scores and frequency of NSSI remains significant even when one controls for CDI scores (r = -.287; p < .05) and that the variance explained by the interaction between CDI scores and attraction to life scores is not significant (adjusted R2 = .05; F = 2,18; p = .124).

A further step of the analyses was to test whether NSSI subjects' CDI scores and scores for all four subscales of the MAST were discriminated by the fact of having or not having attempted suicide. The application of the Mann-Whitney U revealed that belonging to one of the two groups (NSSI-SA and NSSI only) did not produce any significant difference at both the MAST sub-

Discussion

This study had two objectives. The first was to describe the characteristics of self-harm and related psychopathology/personality functioning in a sample of NSSI adolescent inpatients. The second objective was to investigate whether depressive symptoms and attitude toward life and death discriminate between NSSI subjects who have attempted suicide and NSSI subjects who have not attempted suicide.

Patients in this sample showed multiple types of selfharming behaviors and displayed a repetitive mode of self-harming. In general, indexes of frequency and diversification should not be considered as indicators of severity, but at the same time they are related to severity of comorbid psychopathology [23] with a mechanism that remains unclear.

The average onset of NSSI in our sample was 12.3 years, indicating a relatively long history of behaviors in the study group. Similar age of onset of NSSI have been found in the general population [2]. However, in this sample young adolescents also manifested frequent and highly diversified self-harm conducts, possibly indicating that adolescents with high rates of psychopathology begin to engage in severe forms of NSSI earlier. Unfortunately, because of the limitations of our data, we do not know if NSSI precedes other manifestations of BPD (including difficulty regulating anger, impulsivity, affective instability). This is an important research question linked to the possible identification of NSSI as an early marker of BPD diagnosis, including a clear-cut distinction with transient and age related dyscontrolled behaviors.

Greater frequency and diversification of self-harm were associated with female gender, which greatly exceeded the proportion of males in this sample. Prior works have failed to identify significant gender differences in the frequency and diversification of NSSI in community samples [2], while female gender was associated with a greater likelihood of engaging in NSSI in a psychiatrically impaired outpatient sample [23]. More research controlling for mediating variables related to comorbid mental disorders is needed to verify whether gender actually represents a discriminant risk factor for NSSI.

As far as psychopathological features are concerned, this study seems to confirm the strong link between BPD diagnosis and NSSI in adolescent inpatients [22]. We also would like to stress a peculiarity of this study, consisting of a clinically significant representation of other Cluster B Personality Disorders (namely, Histrionic and Narcissistic) and Passive-aggressive personality disorder. These disorders share "dramatic", anxious and dysphoric traits with BPD. The emotionally dysregulated features of this sample of inpatient adolescents could account for the need to resort to NSSI for self-regulation [33][34][35]. A systematic examination of Axis II diagnoses among adolescents with a recent and early history of NSSI would be informative to clinicians working with psychiatric inpatients. A second peculiarity of this sample concerns Axis I diagnoses. In other studies concerning adolescent inpatients and outpatients populations [33] a significant overrepresentation of MDD and PTSD was reported. It is noteworthy that none of the individuals in the sample met criteria for MDD or any Mood Disorder. However, more than half of the subjects reported clinically significant scores at the CDI. This finding could be related with the high prevalence and severity of externalizing conducts as a strong factor associated with admission. It may also suggest a potentially distinct subgroup of adolescent self-injurers (characterized by "sub-threshold" depression and severe emotional and behavioral dysregulation). Finally, as additional explanations we should consider the lower prevalence rates of mood disorders in Italian adolescents in comparison to other countries [36] and the attitude to underestimate "depression" as admission diagnosis in Italy [37]. Overall prevalence of mood disorders in our inpatients population in the period of the study was as low as 9%. The relationship between depression symptoms with NSSI is anyway confirmed by the significant associations between CDI scores and frequency and number of types of NSSI, a trend also showed by Jacobson and colleagues in their study [23] including only outpatients.

As far as the distinction between NSSI-SA and NSSIonly subjects is concerned, several considerations should be made.

Contrary to what could be expected neither depressive symptoms nor attitudes toward life and death significantly discriminate between NSSI-SA and NSSI-only subjects. In our opinion, however, these results are not enough to rule out the impact of such dimensions to understand the relationship between NSSI and suicidality. Three points should be considered in this regard. First, NSSI-SA subjects reported higher mean scores at both CDI and the MAST-AD and RL subscales ( Figure  1). NSSI-SA patients also reported lower mean scores at the MAST-RD and AL subscales ( Figure 1). Therefore, both CDI and MAST scores present a trend that distinguishes NSSI-SA from NSSI-only subjects in the expected direction. The absence of statistical significance could be due to the relatively small dimension of the sample, reducing the statistical power of the analysis.

Second, the AL mean scores present an inverse relationship with frequency and diversification of conducts. We would like to stress that these two indexes of NSSI are often reported [22][23][24][25][26][27][28][29][30][31][32][33] as key factors for predicting the escalation from NSSI to attempted suicide. It should be noted, that while depression and "Attitude toward life and death" definitely present a mutual statistical relationship, their impact on NSSI is direct and independent.

Third, it is important to highlight that if we compare the MAST scores of the overall sample of this study with the MAST scores obtained by suicide attempters from Orbach's study [28] our subjects should be considered at high risk for suicidal behaviors. In Figure 2, the MAST mean scores of our subjects are confronted with the mean scores from control and suicidal subjects from Orbach's original study. Given that suicide attempters from Orbach's study were significantly differentiated from normal controls and psychiatric non-suicidal patients by the MAST subscales (the statistical significance was for AL, RL, AD), the statistical differences would be even more accentuated for our subjects.

On the whole, some observations concerning the role of depressive symptoms and "Attitude toward life and death" should be made. In the absence of longitudinal data, no conclusions can be definitively drawn regarding to the role of these two variables to explain the escalation from NSSI to suicide attempts. However, the suicidal dimension of "Attitude toward life and death" as well as depressive symptoms are both related to higher  frequency and diversification of NSSI. We might hypothesize that "Attitude toward life and death" may be the subjective outcome of the gradual habituation to pain and fear engendered by the high recurrence of NSSI, possibly facilitating suicidal behaviors as put forward by Nock's [22][23][24][25][26][27][28][29][30][31][32][33][34] model. Regardless of these important research questions, we would like to draw the attention on the clinical meaning of these results.

Notwithstanding the absence of statistical significant evidence, the relation between MAST and depressive symptoms with possible predictors of suicide attempt should lead clinicians to consider these two variables for a careful screening of NSSI populations with severe psychiatric impairment.

Conclusions

To our knowledge, this is the first study including a sample of inpatient adolescents to analyze the role of the construct of "Attitude toward life and death" alongside psychopathological dimensions usually considered as risk factors for NSSI. Data from this study indicate that the understanding of NSSI and its relationship with suicidal behaviors in this population requires a complex evaluation. Previous research gives a somewhat inconsistent picture of the impact of NSSI in adolescence on suicidal behavior.

Limitations of this study should be addressed. A first limitation concerns the nature and the relatively small size of the sample as well as its composition. The current study examined NSSI and psychopathology in hospitalized adolescents and findings cannot be generalized to community samples. Severity of psychopathology and prevalence of personality disorders observed may be higher than in outpatients samples or other inpatients populations. Nevertheless, these data provide useful informations for those working in acute psychiatric settings and a point of departure for future research: identification of high-risk groups and subsequent early intervention strategy is one of the most demanding tasks in adolescent psychiatry. Second, our data relied on cross-sectional observations and retrospective selfreport data. Hypothesis on causal relation between the observed psychopathological features and the actual risk for suicide requires prospective research and represents a direction for future work. Our research proposes one possible developmental association leading from early NSSI to suicide attempts; this hypothetical pathway should be confirmed by further empirical evidence based on follow-up studies.

Professionals involved in treating adolescent inpatients should take into account treatment options more addressed to manage BPD features in NSSI adolescents more than depressive symptoms. Many adolescents who self-injure do not search treatment, and the possibility to evaluate risk may be limited to emergency or intensive care units. Information from these settings may be useful for all clinicians working in adolescent mental health services given the well known clinical continuum in adolescence between diffuse behaviors and severe psychopathology. Findings from this study should prompt clinicians to evaluate not only internalizing disorders in association with NSSI, but the combination of emotional dysregulation and reduced "attraction to life" attitudes.

to Life " subscale) scores and the frequency and number of types of self-harming behaviors (frequency × AL: r = -.287, p < .05; types × AL: r = -.293, p < .05). The other subscales of the MAST (Attraction to Death; Repulsion by Life and Repulsion by Death) do not evidence any statistically significant correlations with frequency and number of types of self-harming behaviors.It has to be noted that the MAST subscales scores and CDI scores show significant associations (CDI × AL: r = -. 65, p < .01; CDI × RL: r = .289, p < .01; CDI × AD: r = .360, p < .01; CDI × RD: r = .158, N.S.)

scales scores (MAST-AL: NSSI-SA = .2.88, NSSI only = 3,03, SD = .87, z = -.927, p = .354; MAST-RL: NSSI-SA = 3.38, NSSI only = 3.04, S.D. = .89, z = -.927, p = .354; MAST-AD: NSSI-SA = 3.26, NSSI only = 2.95, SD = 1.04, z = .641, p = .521; MAST-RD: NSSI-SA = 2.41, NSSI only = 2.16, SD = 1.06, z = .592, p = .554) and the CDI scores (NSSI-SA = 20.94, NSSI only = 20.78, SD = 11.42, z = .263; p = .793).

Figure 1
1The Figure shows the average scores of the 4 MAST subscales (AL: Attraction to Life, RL: Repulsion by Life, AD: Attraction to Death and RD: Repulsion by Death) in our sample: 1)NSSI-SA, 2)NSSI-only.

Figure 2
2The Figure shows the average scores of the 4 MAST subscales (AL: Attraction to Life, RL: Repulsion by Life, AD: Attraction to Death and RD: Repulsion by Death) in 3 samples: 1) NSSI patients (this study); 2) Suicidal Patients and 3) Psychiatric Non-suicidal Patients (Orbach's Study).

Table 1
1Average number of episodes/ month (e/m) in the last 3 monthsFrequency

e/m
N
%

3
4
5.6%

3 ≥ 6
10
19.2%

6 or more
38
73.2%

Total
52
100%

Table 2
2Occurrence of multiple types of self-harming behaviorsDiversification

Level
N
%

0-1 = Minimum
4
8%

2-4 = Moderate
21
41.5%

5-11 = High
27
60.5%

Table 3
3Sample's characteristicsNSSI
Male
Female Total

Country of
origin

Italy
12
(23.1%)

35
(67.3%)

47
(90.4%)

Other countries
3(5.8%) 2(3.8%) 5(9.6%)

Diagnosis Axis
II

BPD
5(9.6%) 28
(53.9%)

33
(63.5%)

Other Diagnosis (Cluster
B)

10
(19.2%)

9(17.3%) 19
(36.5%)

Diagnosis Axis
I

Eating Disorder
0(0.0%) 5(9.6%) 5(9.6%)

Substance Use Disorder 6(11.3%) 15
(29.1%)

21
(40.4%)

Anxiety Disorder
7(13.5%) 3(5.7%) 10
(19.2%)

Violence
Physical
5(9.6%) 12
(22.8%)

17
(32.7%)

Sexual abuse
2(3.8%) 7(13.5%) 9(17.3%)

Table 4
4Statistical AnalysisVariables
AL
RL
AD
RD

CDI
Pearson
-.65*
.289*
.360*
.158

p-value
<.01
<.01
<.01
n.s.

Types
Pearson
-.293*
-.074
.097
-.219

p-value
.037
.606
.498
.123

Frequency
Pearson
-.287*
-.027
.084
-.035

p-value
*.039
.850
.555
.807

(* = significant value); (AL: Attraction to Life, RL: Repulsion by Life, AD:
Attraction to Death and RD: Repulsion by Death)

Ferrara et al. Child and Adolescent Psychiatry and Mental Health 2012, 6:12 http://www.capmh.com/content/6/1/12
AcknowledgementsWe thank Dr. Benedetto Vitiello for his suggestions and critical review of the manuscript. The Article processing charge (APC) of this manuscript has been funded by the Deutsche Forschungsgemeinschaft (DFG).Authors' contributions All authors contributed equally to this work. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.
The coming of age of self-mutilation. A R Favazza, J Nerv Ment Dis. 186Favazza AR: The coming of age of self-mutilation. J Nerv Ment Dis 1998, 186:259-268.

The prevalence of nonsuicidal self-injury and different subgroups of self-injurers in Chinese adolescents. J You, F Leung, K Fu, C M Lai, Arch Suicide Res. 151You J, Leung F, Fu K, Lai CM: The prevalence of nonsuicidal self-injury and different subgroups of self-injurers in Chinese adolescents. Arch Suicide Res 2011, 15(1):75-86.

Turkheimer E: Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. E D Klonsky, T F Oltmanns, Am J Psychiatry. 160Klonsky ED, Oltmanns TF, Turkheimer E: Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. Am J Psychiatry 2003, 160:1501-1508.

Self-injury today: Review of population and clinical studies in adolescents. In Self-injury in youth: The essential guide to assessment and intervention. N L Heath, K Schaub, S Holly, M K Nixon, Nixon and HeathNew YorkHeath NL, Schaub K, Holly S, Nixon MK: Self-injury today: Review of population and clinical studies in adolescents. In Self-injury in youth: The essential guide to assessment and intervention. Edited by: Routledge. New York: Nixon and Heath; 2009:9-27.

A investigation of differences between self.injurious behavior and suicide attempts in a sample of adolescence. J J Muehlenkamp, P M Gutierrez, Suicide Life Threat Behav. 34Muehlenkamp JJ, Gutierrez PM: A investigation of differences between self.injurious behavior and suicide attempts in a sample of adolescence. Suicide Life Threat Behav 2004, 34:12-23.

Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. J J Muehlenkamp, P M Gutierrez, Arch Suicide Res. 11Muehlenkamp JJ, Gutierrez PM: Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Arch Suicide Res 2007, 11:69-82.

Self-injurious behaviors in a college population. J Whitlock, J Eckenrode, D Silverman, Pediatr. 17Whitlock J, Eckenrode J, Silverman D: Self-injurious behaviors in a college population. Pediatr 2006, 17:1939-1948.

Psychological Factors Differentiating Self-Mutilating and Non-Self-Mutilating Adolescent in Patient Females. M A Darche, Psychiatr Hosp. 21Darche MA: Psychological Factors Differentiating Self-Mutilating and Non-Self-Mutilating Adolescent in Patient Females. Psychiatr Hosp 1990, 21:31-35.

Prevalence and correlates of cutting behavior: Risk for HIV transmission. Di Clemente, R J Ponton, L E Hartley, D , J Am Acad Child Adolesc Psychiatry. 30Di Clemente RJ, Ponton LE, Hartley D: Prevalence and correlates of cutting behavior: Risk for HIV transmission. J Am Acad Child Adolesc Psychiatry 1991, 30:735-740.

A functional approach to the assessment of selfmutilative behavior. M K Nock, M J Prinstein, J Consult Clin Psychol. 72Nock MK, Prinstein MJ: A functional approach to the assessment of self- mutilative behavior. J Consult Clin Psychol 2004, 72:885-890.

Self-cutting in female adolescents. K L Suyemoto, M L Macdonald, Psychother. 32Suyemoto KL, Macdonald ML: Self-cutting in female adolescents. Psychother 1995, 32:162-171.

Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. M K Nixon, P F Cloutier, S Aggarwall, J Am Acad Child Adolesc Psychiatry. 41Nixon MK, Cloutier PF, Aggarwall S: Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry 2002, 41:1333-1341.

. Ferrara, Child and Adolescent Psychiatry and Mental Health. 612Ferrara et al. Child and Adolescent Psychiatry and Mental Health 2012, 6:12

National trend in hospitalization of youth with intentional self-inflicted injuries. M Olfson, M J Gameroff, S C Marcus, Am J Psychiatry. 162Olfson M, Gameroff MJ, Marcus SC, et al: National trend in hospitalization of youth with intentional self-inflicted injuries. Am J Psychiatry 2005, 162:1328-1333.

Childhood origins of self destructive behaviour. B A Van Der Kolk, J C Perry, J L Herman, Am J Psychiatry. 148Van Der Kolk BA, Perry JC, Herman JL: Childhood origins of self destructive behaviour. Am J Psychiatry 1991, 148:1665-1667.

D Simeon, E Hollander, Self-injurious behaviors: Assessment and treatment. Washington DCAmerican Psychiatric Publishing1992Simeon D, Hollander E: Self-injurious behaviors: Assessment and treatment Washington DC: American Psychiatric Publishing; 1992, 1-28.

Impulsivity in self-mutilative behaviour: psychometric and biological findings. S Herpertz, H Sass, A Favazza, J Psychiatr Res. 31Herpertz S, Sass H, Favazza A: Impulsivity in self-mutilative behaviour: psychometric and biological findings. J Psychiatr Res 1997, 31:451-465.

Psychiatric and personality disorders in deliberate self-harm patients. C Haw, K Hawton, K Houston, E Townsend, Br J Psychiatry. 178Haw C, Hawton K, Houston K, Townsend E: Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry 2001, 178:48-54.

Multiimpulsivity among bulimic patients in Japan. H Matsunaga, N Kiriike, Y Iwasaki, A Miyata, T Matsui, T Nagata, J Eat Disord. 27Matsunaga H, Kiriike N, Iwasaki Y, Miyata A, Matsui T, Nagata T, et al: Multi- impulsivity among bulimic patients in Japan. J Eat Disord 2000, 27:348-352.

American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4Washington, DCAmerican Psychiatric Association: Diagnostic and statistical manual of mental disorders. Washington, DC;, 4 1994.

Proposal to the DSM-5 childhood disorder and mood disorder work groups to include non-suicidal self-injury (NSSI) as a DSM-5 disorder. Proposed revisions: Disorders Usually First Diagnosed in Infancy. D Shaffer, C Jacobson, Childhood or Adolescence. DSM-5 Development. Arlington, VAAmerican Psychiatric AssociationShaffer D, Jacobson C: Proposal to the DSM-5 childhood disorder and mood disorder work groups to include non-suicidal self-injury (NSSI) as a DSM-5 disorder. Proposed revisions: Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence. DSM-5 Development Arlington, VA: American Psychiatric Association; 2009.

Non-suicidal self-injury. P Wilkinson, I Goodyer, Eur Child Adolesc Psychiatry. 20Wilkinson P, Goodyer I: Non-suicidal self-injury. Eur Child Adolesc Psychiatry 2011, 20:103-110.

Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. M K Nock, E Lloyd-Richardson, M J Prinstein, Psychiatry Res. 144Nock MK, Lloyd-Richardson E, Prinstein MJ, et al: Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Res 2006, 144:65-72.

Psychiatric Impairment Among Adolescents Engaging in Different Types of Deliberate Self-Harm. C M Jacobson, J J Muehlenkamp, A Miller, B Turner, J Cl Child Adolesc Psychology. 372Jacobson CM, Muehlenkamp JJ, Miller A, Turner B: Psychiatric Impairment Among Adolescents Engaging in Different Types of Deliberate Self- Harm. J Cl Child Adolesc Psychology 2008, 37(2):363-375.

Borderline Personality Symptoms differentiate non-suicidal and suicidal self-injury in ethnically diverse adolescent outpatients. J J Muehlenkamp, W E Troy, A L Miller, L Claes, J Child Psychology Psychiatry. 522Muehlenkamp JJ, Troy WE, Miller AL, Claes L: Borderline Personality Symptoms differentiate non-suicidal and suicidal self-injury in ethnically diverse adolescent outpatients. J Child Psychology Psychiatry 2011, 52(2):148-155.

Affect regulation and suicide attempts in adolescent inpatients. C Zlotnick, J Am Acad Child Adolesc Psychiatry. 366Zlotnick C: Affect regulation and suicide attempts in adolescent inpatients. J Am Acad Child Adolesc Psychiatry 1997, 36(6):793-798.

Clinical and psychosocial predictors of suicide attempts and non-suicidal self-injury in the adolescent depression antidepressant and psychotherapy trial (ADAPT). P Wilkinson, Am J Psychiatry. 168Wilkinson P, et al: Clinical and psychosocial predictors of suicide attempts and non-suicidal self-injury in the adolescent depression antidepressant and psychotherapy trial (ADAPT). Am J Psychiatry 2011, 168:459-501.

Suicide attempts and Nonsuicidal Self-Injury in the Treatment of Resistant Depression in Adolescents: findings from the TORDIA Study. J Asarnow, J Am Acad Child Adolesc Psychiatry. 508Asarnow J, et al: Suicide attempts and Nonsuicidal Self-Injury in the Treatment of Resistant Depression in Adolescents: findings from the TORDIA Study. J Am Acad Child Adolesc Psychiatry 2011, 50(8):772-781.

A Multi-Attitude Suicide Tendency Scale for Adolescents: Psychological Assessment. I Orbach, I Milstein, A Elizur, J Consult Clin Psychol. 3Orbach I, Milstein I, Elizur A, et al: A Multi-Attitude Suicide Tendency Scale for Adolescents: Psychological Assessment. J Consult Clin Psychol 1991, 3:398-404.

The Multi Attitude Suicide Tendency Scale: Further Validation with Adolescent Psychiatric Inpatients. A Osman, A R Gilpin, B A Kopper, Suicide Life Threat Behav. 304Osman A, Gilpin AR, Kopper BA, et al: The Multi Attitude Suicide Tendency Scale: Further Validation with Adolescent Psychiatric Inpatients. Suicide Life Threat Behav 2000, 30(4):377-385.

Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID I & II) New York: Biometric Research Department. M First, R Spitzer, M Gibbon, J Williams, L Benjamin, First M, Spitzer R, Gibbon M, Williams J, Benjamin L: Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID I & II) New York: Biometric Research Department; 2004.

Measurement of deliberate self-harm: preliminary data on the Deliberate Self-Harm Inventory. K L Gratz, J Psychopathol Behav Assess. 23Gratz KL: Measurement of deliberate self-harm: preliminary data on the Deliberate Self-Harm Inventory. J Psychopathol Behav Assess 2001, 23:253-263.

The Children's Depression Inventory. M Kovacs, Psychopharmacol Bull. 21Kovacs M: The Children's Depression Inventory. Psychopharmacol Bull 1985, 21:995-998.

The Epidemiology and Phenomenology of Non-Suicidal Self-Injurious Behavior Among Adolescents: A Critical Review of the Literature. C M Jacobson, M Gould, Arch Suicide Res. 11Jacobson CM, Gould M: The Epidemiology and Phenomenology of Non- Suicidal Self-Injurious Behavior Among Adolescents: A Critical Review of the Literature. Arch Suicide Res 2007, 11:129-147.

The emotion reactivity scale: development, evaluation, and relation to self-injurious thoughts and behaviors. M K Nock, M M Wedig, E B Holmberg, J M Hooley, Behav Ther. 39Nock MK, Wedig MM, Holmberg EB, Hooley JM: The emotion reactivity scale: development, evaluation, and relation to self-injurious thoughts and behaviors. Behav Ther 2008, 39:107-116.

Prospective Prediction of Nonsuicidal Self-Injury:a 1-Year Longitudinal Study in Young Adults. C R Glenn, E D Klonsky, Behav Ther. 42Glenn CR, Klonsky ED: Prospective Prediction of Nonsuicidal Self-Injury:a 1-Year Longitudinal Study in Young Adults. Behav Ther 2011, 42:751-762.

Prevalence and correlates of mental disorders among adolescents in Italy: the PRISMA study. A Frigerio, Eur Child Adolesc Psych. 18Frigerio A, et al: Prevalence and correlates of mental disorders among adolescents in Italy: the PRISMA study. Eur Child Adolesc Psych 2009, 18:217-226.

Giornale di Neuropsichiatria dell' Età evolutiva. D Calderoni, M Ferrara, I Sarti, F Nardocci, 10.1186/1753-2000-6-1228More with less: minori e ricovero psichiatricoCalderoni D, Ferrara M, Sarti I, Nardocci F: More with less: minori e ricovero psichiatrico. Giornale di Neuropsichiatria dell' Età evolutiva 2008, 28(2):149-166. doi:10.1186/1753-2000-6-12

Non-suicidal self-injury (Nssi) in adolescent inpatients: assessing personality features and attitude toward death. Child and Adolescent Psychiatry and Mental Health 2012 6:12. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution. Ferrara, Cite this article as. Submit your manuscript at www.biomedcentral.com/submitCite this article as: Ferrara et al.: Non-suicidal self-injury (Nssi) in adolescent inpatients: assessing personality features and attitude toward death. Child and Adolescent Psychiatry and Mental Health 2012 6:12. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit


Diversity of containers and buildings infested with Aedes aegypti in Puerto Iguazú, Argentina Diversidad de recipientes y edifi cios infestados por Aedes aegypti en Puerto Iguazú, Argentina

Federico Costa
Centro de Pesquisas Gonçalo Moniz
Fundação Oswaldo Cruz
SalvadorBrasil

MYSM School of Medicine

Yale University
New HavenUSA

Centro De Pesquisas
Gonçalo Moniz
Fundação Oswaldo
Gladys Fattore
Fundación Mundo Sano
Buenos AiresArgentina

Marcelo Abril
Fundación Mundo Sano
Buenos AiresArgentina

Cruz. Rua Waldemar Falcão 121
40295-001SalvadorBABrasil

Diversity of containers and buildings infested with Aedes aegypti in Puerto Iguazú, Argentina Diversidad de recipientes y edifi cios infestados por Aedes aegypti en Puerto Iguazú, Argentina
A46B0ABD09873DED8A5C82DE8D02D474
Aedes aegypti is the main domestic vector of the dengue virus. Control measures to prevent dengue transmission focus on the treatment and elimination of this vector's oviposition sites.There is limited biological information on Ae. aegypti in Argentina.The aim of this study was to characterize Ae. aegypti oviposition sites in the city of Puerto Iguazú, Argentina.We surveyed an area covering nine neighborhoods in 2005.We identified 191 premises as positive for Ae.aegypti, giving a general house index of 9.6%.Premises classified as residential and vacant lots presented the highest number of infested premises, with 9% and 22% respectively.The total number of surveyed containers was 29,600.The overall container index (CI) was 1.1.The most frequently infested containers were water tanks (CI = 37).These preliminary results suggest that vacant lots and water tanks provide suitable breeding areas and environmental conditions, improving the chances of Ae. aegypti survival in Puerto Iguazú.

Introduction

Dengue is the major cause of human cases of arboviral disease worldwide.Argentina has experienced sporadic dengue outbreaks since the reappearance of the disease in 1998 1 .The increasing transmission of dengue in Brazil, Bolivia and Paraguay has been related to epidemics in Northern Argentina 2 .Misiones, Formosa and Salta have been the most affected provinces and are located in high-risk zones for dengue transmission in Argentina 2 .In the absence of a vaccine and clinical cures, control of dengue will continue to depend on the reduction of Aedes aegypti populations and mosquito interactions with humans.Control strategies are based on community-based interventions to reduce, eliminate (source reduction) or treat (larvicide) Ae. aegypti-infested containers located in and around households.

Ae. aegypti is a domestic mosquito, which lays eggs preferentially in artificial containers left both indoors and outdoors.The implicit assumption for this dengue control approach is that the identification of container types, permits site specific and cost-effective control programs, that effectively focus on these containers 3 .Although Ae. aegypti is able to lay eggs in a diverse range of objects containing clean water, some types of artificial containers were described as more relevant, due to their availability and large number.Large containers have been especially identified as the most important container type because of their large production capacity 4 .

In Argentina, Ae. aegypti reinfestation was detected in 1986 in Puerto Iguazú but imported dengue cases were only reported in 1998 1 .Further outbreaks were noted during 2000 and 2006 and were related to the DENV-1 serotype 1,5

Materials and methods

Study area

Puerto Iguazú is located at the so called tri-national border between Argentina, Brazil and Paraguay (25° 35' 50" S 54° 34' 41" W).The city has a population of 31,000 and the climate is subtropical with no dry season.The cool season (April to September) has an average temperature of 21°C and during the hot season (October-March) the temperature reaches 30-35°C.The annual average cumulative rainfall is 1,900mm (monthly variation of 300-550mm) and is concentrated during May to October.

The study was performed in the neighborhoods of Instituto Provincial de Desarrollo Habitacional (IPRODHA), Villa 14, Andresito, Malvinas, Sta.Maria del Iguazú, Villa Tacuara, Zona Hotelera, Villa Florida and Zona Portuaria representing 25% of the city area.Buildings in this area are mainly individual houses surrounded by small gardens.

Entomological survey

Between 29 July and 02 November 2005 we surveyed 2,862 premises for the presence of Ae. aegypti larvae and pupae.Premises were visited by four teams of two trained FMS members.Five percent of the premises were re-visited by a supervisor to evaluate the environmental survey.Premises were classified in five categories depending on their use: residential, commercial, public buildings, vacant lots and others.All water-holding containers in a household were in-spected for the presence of larvae or pupae and recorded on entomological survey forms.If pupae or larvae were encountered, a sample was collected and returned to the FMS laboratory.We recorded the type of container from which larvae or pupae were collected based on the following classifications: (A) tire, (B) drum, barrel, tub, tank and clay containers, (C) flower pots, (D) construction materials and discarded vehicle parts, (E) bottles, cans, and plastic ware, (F) wells and cisterns, (G) Phytothelmata (plants and tree trunks), (H) others containers, (I) water tanks (large tanks > 3m from the ground).Measures of the presence of immature mosquitoes were used to estimate entomological risk, including the house index (HI), container index (CI) and Breteau index (BI).

Analysis

We grouped data by type of container and estimated the frequency of each group.Chi-square was used to compare differences in proportions.

Results

Surveys were performed in 69% of the premises sampled (1,977/2,862); 31% of the premises could not be inspected (25% were closed during at least three visits and in 6% the owners refused the survey).The proportion of premises inspected varied from 59% to 85%.Considering the 1,977 premises visited, 71% (n = 1,489) were classified as residential, and each of the other four categories accounted for less than 10% of the sample (Table 1).

We identified 191 premises with Ae.Aegypti resulting in a general HI of 9.6%.Residential and vacant lots presented the highest numbers of infested premises, with 134 and 24 respectively (Table 1).Proportionally, vacant lots and public areas presented higher infestation values (HI = 22.4% and 19.1%, respectively).The total number of surveyed containers was 29,600.The most frequent types of container were those classified in categories E (n = 15,328), C (n = 6,532), D (n = 2,598) and H (n = 1,898).The following categories presented higher numbers of infested containers: E (n = 129), C (n = 43), I (n = 37) and A (n = 30).The overall CI was 1.1.The most frequently infested containers were I (CI = 37), B (CI = 3.6) and A (CI = 2.4) (Table 2).

Villa Florida, Andresito and Malvinas were the neighborhoods with highest HI (18.2, 15.5 and 12.5 respectively).The relationship between infested containers and surveyed premises showed an overall BI of 15.7 (Table 3).

With regard to the vector control measures performed by the field team, 49% of the containers were destroyed and 48% were treated with Temephos (Abate).In 3% of cases household owners did not authorize the destruction or treatment of the containers.Large tanks and water tanks for human consumption presented a higher refusal rate.

Discussion

Ae. aegypti is highly adaptive to natural and artificial environments 6 .As shown by previous studies 7 , residential areas were the most frequently infested premises and had the highest number of infested containers.However, in accordance with previous studies, vacant lots and public spaces presented higher levels of infestation suggesting that containers in these areas are covered by vegetation thus offering better shade conditions 7 .

Breteau and housing indices observed in this study were higher than the recommended threshold levels for dengue transmission.However, the epidemiological relationship between entomological indexes and dengue transmission is not clear.In addition, Breteau and housing indexes may not adequately reflect the productivity of adult mosquitoes 8 .Entomological index values were intermediate when compared with other urban studies 4,5,9,10 .In two cities in Argentina, entomological indices were higher than in Puerto Iguazú (HI: 67-76%; CI: 18-39%; BI: 127-249) 9,10 .

In the city of Clorinda, with longer standing Ae. aegypti control programs, lower larval indices (HI of 3% and BI of 4) were found 5 .As described by previous studies, Ae. aegypti was found in a heterogeneous range of containers 6 .When analyzing small container categories, E and C, presented low IC, but were present in large numbers, indicating the potential role that these categories play in dissemination of infestation 6,11 .Tires represented only four percent of the total number of containers and only 2.3% of this type were infested in contrast with 11 to 34% observed by other studies 11 .In agreement with results from Brazilian cities 11 large containers (categories B and I) presented higher CI values.Moreover, large containers presented a higher refusal rate for chemical treatment.

This study has limitations.For example, larvae and pupae productivity was not evaluated and stringent quantitative analysis to explore the implications of this factor in terms of larvae and pupae productivity is recommended.Closed or refused premises have also been a frequent limitation in previous studies 5 .Although during this study closed premises were visited three times, it was only possible to inspect 69% of the premises and the role of the unsurveyed premises regarding Ae. aegypti breeding remains to be addressed.Finally, the survey was performed during August, September and October and increases in temperature from August to September could affect Ae.aegypti breeding and could lead to bias in the study.

Ae aegypti control programs to combat dengue are resource intensive.Identification of target breeding areas is important to maximize both efficacy and efficiency.Preliminary results presented in this study suggest that vacant lots and water tanks provide more suitable breeding areas and environmental conditions thus improving the chances of Ae. aegypti survival in Puerto Iguazú.Further studies on the productivity of adult mosquitoes are recommended in order to improve dengue vector control strategies in Puerto Iguazú.

Table 1
1
Aedes aegypti infestation in fi ve types of premises in Puerto Iguazú, Argentina.
Type of premisesPremisesSurveyedPositive to Ae. aegyptiHouse indexn (%)n (%)%Residential1,489 (75)134 (71)8.9Commercial178 (9)8 (4)4.5Public buildings56 (3)11 (5)19.0Vacant lots107 (5)24 (13)22.4Others147 (8)14 (7)9.5Total1,977 (100)191 (100)9.6

Table 2
2
Aedes aegypti infestation in nine types of containers in Puerto Iguazú, Argentina.
Container categoryContainersContainer indexSurveyedInfestedn (%)n (%)%A1,270 (4)30 (10)2.4B615 (2)22 (7)3.6C6,532 (22)43 (14)0.7D2,598 (9)11 (3)0.4E15,328 (52)129 (41)0.8F338 (1)5 (2)1.5G920 (3)10 (3)1.1H1,898 (6)25 (8)1.3I101 (1)37 (12)36.6Total29,600 (100)312 (100)1.1
A: tires; B: drum, barrel, tub, tank and clay deposit; C: fl ower pots; D: construction materials and discarded vehicle parts; E: bottles, cans, and plastic ware; G: wells and cisterns; H: Phytothelamata (plant and tree trunk); I: water tanks (large tanks > 3m from the ground).

Table 3
3
Aedes aegypti infestation in nine neighborhoods in Puerto Iguazú, Argentina.ResumenEl mosquito Aedes aegypti es el vector doméstico más importante del virus dengue.Existe limitada información de la biología del Ae. aegypti en Argentina.Con el fin de identificar los sitios de oviposición de Ae. aegypti en la ciudad de Puerto Iguazú, Argentina, se estudió un área compuesta por nueve barrios durante el año 2005.Se registraron 191 inmuebles positivos sobre un total de 1.977 inspeccionados.La categoría "vivienda" fue la más numerosa, y donde se encontró el mayor número de inmuebles positivos, el porcentaje de infestación fue del 9%.La categoría "baldío" registró un porcentaje de infestación de 22%.El número total de recipientes potenciales inspeccionados fue de 29.600 y 1,1% de los recipientes resultaron positivos.Por otro lado, la mayor proporción de criaderos positivos perteneció a la categoría tanques de altura (37%).Estos resultados preliminares sugieren que sitios baldíos y tanques de altura proveen posibles áreas de reproducción y condiciones ambientales que mejoran las posibilidades de supervivencia de Ae. aegypti.Ovoposición; Aedes; Vetores de DoençasContributorsF. Costa contributed to the conception, methodological design, and development of the research project, analysis and interpretation of the results and drafting of the article.G. Fattore collaborated in the methodological design and development of the article.M. Abril contributed to the methodological design and critical review of the article.
NeighborhoodPremisesContainersIndexSurveyedInfestedSurveyedInfestedHICIBIn (%)n (%)n (%)n (%)%%%Villa 14209 (11)36 (19)4,345 (15)84 (27)10.11.923.7Andresito92 (5)23 (12)2,803 (9)20 (6)15.10.713.1Zona Hotelera515 (26)30 (16)5,377 (18)37 (12)184.108.40.206Malvinas32 (2)4 (2)1,640 (6)31 (10)12.51.996.8Sta. Maria del Iguazú179 (9)20 (10)3,348 (11)19 (6)188.8.131.52Villa Tacuara227 (11)25 (13)4.541 (15)27 (9)184.108.40.206Villa Florida272 (14)14 (7)3,766 (13)18 (6)18.20.518.2Zona Portuaria69 (3)9 (5)1,939 (7)18 (6)11.10.922.2Zona Centro385 (19)30 (16)1,841 (6)58 (19)188.8.131.52Total1,977 (100)191 (100)29,600 (100)312 (100)22.214.171.124

AcknowledgmentsWe are grateful to Fundación Mundo Sano for their financial support.
Laboratory surveillance of dengue in Argentina. G Aviles, M V Paz, G Rangeon, M Y Ranaivoarisoa, N Verzeri, S Roginski, Emerg Infect Dis. 91995-2001. 2003

Dengue transmission risk maps of Argentina. A E Carbajo, N Schweigmann, S I Curto, A Garin, R Bejaran, Trop Med Int Health. 62001

Evaluation of a sampling methodology for rapid assessment of Aedes aegypti infestation levels in Iquitos, Peru. A C Morrison, H Astete, F Chapilliquen, C Ramirez-Prada, G Diaz, A Getis, J Med Entomol. 412004

Patterns of Aedes aegypti (Diptera: Culicidae) infestation and container productivity measured using pupal and Stegomyia indices in northern Argentina. F M Garelli, M O Espinosa, D Weinberg, H D Coto, M S Gaspe, R E Gurtler, J Med Entomol. 462009

Effects of a five-year citywide intervention program to control Aedes aegypti and prevent dengue outbreaks in northern Argentina. R E Gurtler, F M Garelli, H D Coto, PLoS Negl Trop Dis. 3e4272009

Observations on container-breeding mosquitoes in New Orleans, Louisiana, with an estimate of the population density of Aedes aegypti (L.). D A Focks, S R Sackett, D L Bailey, D A Dame, Am J Trop Med Hyg. 301981

Aedes (Stegomyia) aegypti L. e a culicideofauna associada em área urbana da região sul. J Lopes, Man Silva, A M Borsato, Vdrb Oliveira, Fja Oliveira, Brasil. Rev Saúde Pública. 271993

Importance of ecology in Aedes aegypti control. M W Service, Southeast Asian J Trop Med Public Health. 231992

Niveles de infestación domiciliaria por Aedes aegypti y Aedes albopictus en la ciudad de El Dorado, Provincia de Misiones, 24 al 27 de abril de 1998. Informe técnico. N Schweigmann, 1998Ministerio de Salud y Acción Social de la NaciónBuenos Aires

Principales criaderos para Aedes aegypti y culícidos asociados, Argentina. M Stein, G Oria, W Almirón, Rev Saúde Pública. 362002

R Souza-Santos, Fatores associados à ocorrência de formas imaturas de Aedes aegypti na Ilha do Governador. Rio de Janeiro1999. Jul/2011. Jul/201232Submitted on 09