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 .