during adolescence , children undergo rapid physical , mental , and emotional changes , and thus become prone to risk - taking behaviors such as voluntary poisonings .
voluntary poisoning has been defined by the world health organization multicenter study on parasuicide as an act with a nonfatal outcome in which an individual deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage .
the significance of the event may vary by age , but the risk assessment in emergency units is usually identically . according to the annual report of the american society of toxicology centers , the children in the 10 to 19 years age group presenting to the hospital with intentional ingestions can be divided into 3 categories : voluntary abuse , intentional misuse , and suicide attempt .
there is a tendency to underestimate the importance of voluntary poisoning in adolescent because usually it is not fatal .
a triple assessment must be carried out in voluntary poisoning : somatic , psychological , and social .
the initial somatic examination will assess the immediate severity of the poisoning in order to apply an appropriate treatment ( possibly cure ) .
the psychological evaluation should begin as early as possible , as soon as the patient 's state of consciousness permits .
this evaluation should analyze the history and identify risk factors leading to relapse and the existence of underlying conditions , particularly depression .
the social assessment must be carried out with the participation of a social care team , comprising the patient 's familial , scholar , and educational context .
there is a little literature describing the epidemiology of acute poisoning and intoxication among adolescents .
the aim of this study was to analyze the epidemiological profile and to identify the triggering factors of voluntary intoxications and poisonings in adolescents admitted at  st .
we performed an observational cross - sectional retrospective study on a group of 219 adolescents with voluntary poisoning , admitted at regional center of toxicology in  st .
mary  children 's emergency hospital , iasi during 2014 . in our patients , poisonings included pharmacological drugs , alcohol intoxication , chemical substances , and maladaptive effects of illicit drugs .
we assessed the following factors : sociodemographic data , educational status , the substance used , the motivation for overdose , psychiatric problems , and the outcome of poisoning . during admission
, these patients had received psychosocial assessment by a psychiatrist , a psychologist , and a social worker .
diagnosis of depression was established by the psychiatrist according to standard dsm - iv criteria for major depressive disorder , through structured clinical interview , questioning both the teens and their parents or other caregivers . the psychiatric examination in children with coma
the patients who could not be subjected to psychological and psychiatric examinations at the time of their admittance , according to the toxicology department 's protocol , were excluded from the study .
we refer to poisoning as the consumption of some substances with an intentional aim to self - harm ( e.g. , pharmaceutical drugs ) .
similarly , we refer to intoxication as excessive ingestion of some substances otherwise not harmful in habitual behavior ( e.g. , alcohol ) .
all statistical analyses were performed using statistical package for social science ( spss ) , version 19 for windows .
the results have been reported as mean    standard deviation for normally distributed variables .
groups comparison for categorical data was performed by chi - squared test and relative risk ( rr ) was calculated .
the mean age was slightly lower in girls , but not statistically significant ( 16    2.05 years in boys and 15.5    0.7 years in girls ) .
poisonings were more prevalent in summer and autumn , approximately 60% of all events . the agents used to commit poisoning , in order of frequency , were pharmaceutical drugs , alcohol , illicit drugs , caustics , and insecticides  raticides ( table 1 ) .
we noticed that pharmaceutical drugs were the most involved in self - poisoning , 34.7% of total cases , mainly in girls ( 56.3% vs. 15.5% ; p  =  0.0001 ) , with an rr 3.63 times higher than in males .
regarding the poisoning with a single type of medicine , we found that the most frequently involved were paracetamol ( acetaminophen)23.1% ( 12 ) of cases , benzodiazepines19.2% ( 10 ) of cases , antiepileptics15.4% ( 8) of cases , and antibiotics13.5% ( 7 ) of cases .
others drugs involved in self - poisoning were hydrazide and ibuprofen ( 4 cases each ) ; tricyclic antidepressants ( 2 cases ) ; and antipsychotics , iron salts , anti - parkinson agents , mineral supplements , and calcium salts ( 1 case of each ) .
we encountered mild , as well as severe cases of acetaminophen poisoning , the median ( min  max range ) of liver transaminase being 543  ui / l ( 721866  ui / l ) for alanine aminotransferase and 214  ui / l ( 46428  ui
acute ethanol intoxication was encountered in 32.4% of cases , especially in males ( 77.4% ) , with an rr 3.05 times higher than in females , and in rural areas ( table 1 ) .
the average blood alcohol level at admission in the emergency unit was slightly higher in boys ( 3    0.77 g vs. 2.5    0.61 g in girls ) .
the highest alcohol level encountered was 5.07 g to a 17-year - old teenager admitted with alcoholic coma .
acute voluntary illicit drug intoxications were not only important ( 20.5% ) , but also more common in boys , with an rr 3.55 higher than in girls .
the most common drugs were those involving so - called  ethnobotanical substances  ( 68.8% ) , while the frequency of high - risk drugs intoxications was lower ( 31.2% ) . in our study , 7 teenagers were chronic users of ethnobotanics .
self - poisoning with caustics and insecticides were rare , but potentially serious , and both were more common in women .
drugs voluntary poisoning was more frequently encountered in rural areas ( 38.1% vs. 28.8% ) , but without statistical significance ; however , voluntary illicit drugs intoxications were significantly more common in urban areas ( 30% vs. 15.1% ; p  =  0.009 ) , with an rr 1.99 times higher than in rural areas . regarding ethanol , caustics , and insecticides  raticides poisoning
the most common given reasons for poisoning were family and school conflicts , with 24.7% of cases and 13.2% of cases , respectively .
we noticed that both family and school conflict triggered voluntary poisoning in girls more often than in boys , but the differences were not statistically significant ( table 2 ) .
the desire for group integration was significantly more frequently invoked in boys ( p  =  0.001 ) , with rr over 4 times higher than in girls ( table 2 ) . less frequently identified reasons for poisoning were conflict with partner , curiosity , defiance , demonstration purpose , festive events , victim of aggression , and the failure of attempts to lose weight in 2 girls ( table 2 ) . in 16% of cases , teens came from dysfunctional families , 4% were cared by their grandparents and 6.4% of cases were institutionalized children .
suicidal purpose was confessed only in 6 cases in girls and in 2 cases in boys .
no triggering factor has been identified in a large percentage of the cases , especially in boys ( 20.7% vs. 8.7% ; p  =  0.023 ) .
eight teenagers committed self - poisoning twice , 4 teens did it for the 3rd time , and 1 case was admitted at his 4th attempt .
we found that voluntary poisoning rr was slightly higher in boys presenting emotional and/or conduct disorder ( rr  =  1.33 ) or adjustment disorder ( rr 1.5 times higher than in girls ) .
it was noticeable that an important percentage of adolescent girls had severe depression ( 23.3% vs. 6.9% ; p  =  0.001 ) with an rr more than 3 times higher than in boys .
suicidal ideation or autolysis was more frequently encountered in girls and even though the percentage differences were not statistically significant ; it was noticed an rr 3.38 and 2.82 times , respectively , higher than in boys .
many patients had no psychiatric disorder , but the percentage of boys who did not have any mental disorder at the time of examination was significantly higher than that of girls ( 52.6% vs. 34% ; p  =  0.008 ) ( table 3 ) .
it was found that most teenagers who presented with voluntary poisoning had no school problems ( 71.7% ) .
yet some of them faced dropout ( 12.8% ) , absenteeism ( 9.13% ) , repeaters ( 4.1% ) , or expulsion ( 5 cases ) ( table 4 ) .
nevertheless , it has to be noted that 8.4% of teenagers initially presented an extremely serious condition , being admitted in various stages of coma ( glasgow score < 8) .
clinical manifestation associated with voluntary poisoning were traumatic cranial and brain injury by falls in 8 cases and 7 cases presented self - harm signs ( sectioning veins ) .
self - poisoning , the most common method of self - inflicted injuries and attempts to suicide among adolescences , represents a public health problem in industrialized countries .
therefore , it is important to identify the risk factors and predictors in order to insure proper preventive care .
we analyzed the adolescents admitted in a regional center of toxicology , where patients are sent from the northeast part of romania .
this is the first study that analyses the epidemiological issue of voluntary poisoning and intoxication in a representative cohort for this region . according to the literature ,
one of the main risk factors in self - poisoning is female gender , due to the facts that girls consider suicide more frequently during adolescence .
however , a slightly predominance of boys is observed in our study . according to the literature ,
instead , the use of drug and alcohol intoxication was found especially in boys . in our study ,
other studies recorded a greater percentage of self - poisoning involving medicines , reaching 84.5% or even 97.8% . also , many patients presented with polydrugs poisonings . the drugs most frequently involved in self - poisoning are different from one country to another and from one toxicology center to another , depending on drugs prescription , their availability and accessibility , and the purpose of poisoning . similarly to the results of a recent prospective study conducted in france , we found that the most common pharmaceutical drug involved in single - drug self - poisoning was acetaminophen .
studies carried out in united states also report analgesics ( acetaminophen and nonsteroidal anti - inflammatory ) as most commonly involved in intentional poisoning attempts , followed by sedative / hypnotic and antipsychotic drugs .
literature data suggest that substance use is a powerful independent risk factor for self - inflicted injury and suicidal behavior .
some studies underline the importance of including alcohol intoxication and maladaptive effects of drugs in the spectrum of adolescent poisoning , given that they can be an important cause of death .
ethanol poisoning was one of the most frequent cause of intoxication . considering that this study included only hospitalized cases
, we may think that the frequency of ethanol intoxication is even higher among teenagers , because the mild forms were not admitted .
some studies performed in other countries show that the child 's age for his first alcohol ingestion has declined in recent years .
thus , a french investigation showed that 59% of children ages 11 , 72% of children ages 13 , and 84% of those ages 15 have already drunk alcohol at least once . in our cohort ,
the ethanol intoxication was more frequent in rural areas due to alimentary behaviors , parents examples , and the greater availability of ethanol products , especially in autumn , in this region . in our study , the most common acute voluntary drug intoxications were those involving the improperly called ethnobotanic substances .
the products dubbed ethnobotanic are used for their psychoactive and physiological effects which resemble that of classic drugs ; they contain chemical substances or mixtures of vegetal and chemical substances and are sold on the internet and smart shops / head shops .
they are commonly consumed as cigarettes or joint and are known as novel psychoactive substances ( designer drugs ) .
. the socioeconomic status in middle - income countries like romania may be the reason for the more frequent use of ethnobotanic substances compared with other countries .
studies suggested that an authoritative parenting or rejecting  neglecting parenting style associated with lack of affection ( inflexible families ) generates risk for suicidal thoughts and attempts in adolescence .
these studies also identified some other familial risk factors , such as absenteeism , parental separation events , and migration background .
an important percentage of adolescents in our study came from dysfunctional families or were raised by their grandparents , as their parents work in other countries .
growing up without their parents became an important issue in the determinism of children behavioral disorders in the last decade in romania . also , school failure itself is not a triggering factor , but the association with academic pressure , personal dissatisfaction due to school results and lack of social / family support may cause suicidal behavior .
underlying psychiatric illness confers a significant risk for committing self - harm and can promote the transition to a suicidal act and to relapse .
the presence of a psychiatric disorder multiplies by a factor of 11 to 27 the risk of suicidal attempt over the general population . in our study , around half of the children had mental health issues .
out of these , a third accounted for depression , making them extremely susceptible to suicidal attempts .
depression was found in 31% of girls , with a 3 times higher rr for voluntary poisoning in girls than in boys .
the rates of depression increase greatly during adolescence to reach a prevalence of around 1% in boys and 2% in girls .
our results are similar with those in the literature , indicating that females are at risk for traditional suicidal ideation / depression measures , whereas risk - taking behaviors ( alcoholism or drug abuse ) are more common in males . in our patients ,
suicidal ideation was assessed by a psychiatrist communicating with the patients , taking into account the adolescents psychosocial factors and history and encouraging them to share their feelings and concerns .
children diagnosed with depression or suicide ideation were transferred into the psychiatric clinic for treatment , after the acute episode .
it is important to follow these patients and to give a specific treatment , in order to avoid repeated episode of suicidal attempts .
only a few patients of the study group confessed the suicide attempt . for a lot of them ,
poisoning had only a demonstrative purpose , or it was meant as a call for help or a resumption of dialog , but the passage to an act should not be neglected .
some authors opined that it is hard to distinguish between suicide attempter 's adolescents and at - risk adolescent , suicide attempts being  one point on a continuum of adolescent problem behaviors .
 physiological counseling and personal approach in accompanying patients to overcome suicidal ideation should be a priority to the healthcare providers .
it included only children with voluntary poisoning admitted in a tertiary hospital from the northeast part of romania ; mild poisoning cases who did not need hospital care were excluded , as well as patients without a psychological and psychiatric examination . due to these limitations
, we can not estimate a rate of adolescent poisoning and the presented result are not representative of all self - inflicted poisoning cases among adolescents in romania .
the incidence of alcohol and ethnobotanic substances intoxication is higher in general population , if we consider also the less dramatic cases , but without differences in terms of gender or demographic distribution from severe cases .
further detailed studies on screening and surveillance , with focus on the circumstances of poisoning and motives , are needed .
we found that self - inflicted poisonings with pharmaceutical drugs were more common in girls and the use of drug and alcohol intoxication was found especially in boys .
family or school conflicts and emotional and/or conduct disorders were the most important triggering factors of voluntary poisoning .
triggering factors and adolescents with suicidal risk should be identified in order to avoid fatal events .
familial factors have to be carefully considered , because they play an important role in the process of personality development in adolescents .
 abstractself - poisoning is an important medical and social problem in adolescents.we performed an observational cross - sectional retrospective study on a group of 219 adolescents admitted for voluntary intoxications at  st . 
 mary  children 's emergency hospital , iasi during 1 year period . epidemiological aspects and triggering factors have been analyzed . 
 data collected from the patients files were centralized in an spss 18.0 database and processed with confidence interval of 95%.we found that pharmaceutical drugs have been usually involved ( 34.7% ) , mostly in girls ( 56.3% vs. 15.5% ; p  =  0.0001 ) . 
 the most frequently cited reason for poisoning was family conflict , with a relative risk ( rr ) 1.43 times higher in girls , as well as scholar conflict ( rr  =  1.39 ) . 
 a great percentage of the monitored girls presented severe depression ( 23.3% vs. 6.9% ; p  =  0.001 ) , with an rr more than 3 times higher than in the case of boys . 
 all cases evolved favorably , no death having been recorded , even if 18 teenagers initially presented an extremely serious condition , being admitted in various stages of coma ( glasgow coma scale score < 8).we found that self - inflicted poisonings with pharmaceutical drugs was more common in girls and the use of drug and alcohol intoxication was found especially in boys . 
 the most common pharmaceutical drug involved in self - poisoning was acetaminophen . 
 psychological disorders and family or school conflicts are the most important triggering factors of voluntary poisoning . 
 risk factors should be identified after stabilizing the patient , and actions should be taken in order to prevent a fatal recurrence . 