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RES E A R C H A R T I C L E Open Access
The Ottawa Self-Injury Inventory: Evaluation
of an assessment measure of nonsuicidal
self-injury in an inpatient sample of adolescents
Mary K Nixon
1*†
, Christine Levesque
2†
, Michèle Preyde
3†
, John Vanderkooy
4†
and Paula F. Cloutier
5†
Abstract
Background: The Ottawa Self-Injury Inventory (OSI) is a self-report measure that offers a comprehensive assessment of
nonsuicidal self-injury (NSSI), including measurement of its functions and addictive features. In a preliminary investigation
of self injuring college students who completed the OSI, exploratory analysis revealed four function factors (Internal
Emotion Regulation, Social Influence, External Emotion Regulation and Sensation Seeking) and a single Addictive Features
factor. Rates of NSSI are particularly high in inpatient psychiatry youth. The OSI can assistin both standardizing assessment
regarding functions and potential addictive features and aid case formulation leading to informed treatment planning.
This report will describe a confirmatory factor analysis (CFA) of the OSI on youth hospitalized in a psychiatric unit in
southwestern Ontario.
Methods: Demographic and self-report data were collected from all youth consecutively admitted to an adolescent
in-patient unit who provided consent or assent.
Results: The mean age of the sample was 15.71 years (SD = 1.5) and 76 (81 %) were female. The CFA proved the same
four function factors relevant, as in the p revious study on college students (χ
2
(183) = 231.98, p = .008; χ
2
/df =
1.27; CFI = .91; RMSEA = .05). The model yielded significant correlations between factors (rs = .44-.90, p < .001).
HigherNSSIfrequencywasrelatedtohigherscoresoneachfunctionfactor(rs = .24-.29, p < .05), except the
ExternalEmotionRegulationfactor(r = .11, p > .05). The factor structure of the Addictive Features function was
also confirmed (χ
2
(14) = 21.96, p > .05; χ
2
/df = 1.57; CFI = .96; RMSEA = .08). All the items had significant path
estimates (.52 to .80). Cronbach’s alpha for the Addictive Features scale was .84 with a mean score of 16.22
(SD = 6.90). Higher Addictive Features scores were related to more frequent NSSI (r = .48, p < .001).
Conclusions: Results show further support for the OSI as a valid and reliable assessment tool in a dolescents,
in this case in a clinical setting, where results can inform case conceptualization a nd treatment planning.
Keywords : Nonsuicidal self-injury, Assessment, Functions, Addictive features, Youth
Background
Early adolescence is the peak period of onset for non
suicidal self-injury (NSSI) [1] providing, if detected, an
opportunity for early intervent ion as the youth is at risk
of developing a repetitive maladaptive coping strategy.
In clinical practice, there are curre ntly no routine
standardized self report mea sures used to inform the
understanding a nd treatment of N SSI despite it s high
prevalence rates in clinical populations [2, 3]. The
majority of NSSI measures remain research tools.
Having a mea sure of N SSI that is valid and clinically
useful can inform case conceptualization and treat-
ment planning.
While the clinical interview provides important infor-
mation and the opportunity to develop a therapeutic
alliance, many youth may not share the extent of their
NSSI due to shame or difficul ty expressing themselves
fully in one on one questioning. Many find that
self report measures are helpful to share information
they would otherwise be reluctant to disclose [4]. In
* Correspondence: Mary.Nixon@viha.ca
†
Equal contributors
1
Queen Alexandra Centre for Children’s Health, 2400 Arbutus Rd, Victoria, BC
V8N 1V7, Canada
Full list of author information is available at the end of the article
© 2015 Nixon et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26
DOI 10.1186/s13034-015-0056-5
addition, clinicians may not be able to provide as com-
prehensive questioning specific to NSSI nor necessarily
have the time to do so in the first assessment interview.
Many aspects of NSSI have been poorly understood in
terms of its functions and other characteristics. The
Diagnostic and Statistical Manual of Mental Disorders,
5
th
Edition (DSM-5) [5] has included criteria for NSSI to
the section “requiring further study” indicating that
NSSI requires more research and proposing that NSSI
does not solely exist as a symptom of borderline person-
ality disorder.
Theories regarding the reasons or functions of NSSI
have been postulated for several decades with an under-
standing that NSSI may serve more than one function
[6]. Klonsky [7] completed a comprehensive review of
theoretical und erstandings of the functions of NSSI and
research to date in the field. Seven main categori es
of functions of NSSI were derived from this review:
affect regulation, self-punishment, antidissociation, inter-
personal influence, interpersonal boundaries, sensation-
seeking, and anti-suicide. The most commonly endorsed
reason for NSSI is affect regulation with the intent to
relieve negative affective states such as tension, depres-
sion, and/or anger. This category was the most highly
endorsed function in a study of hospitalized adolescent s
where the mean number of en dorsed reasons per indi-
vidual, regardless of category of function, was approxi-
mately eight [8]. In a paper entitled “Why do people
hurt themselves?”, M. Nock provides an integrated the-
oretical model of the development and maintenance of
NSSI. Distal risk factors such as genetic predisposition
to high emotional/cognitive reactivity, intra and inter-
personal vulnerability factors, responses to stress and
specific NSSI vulnerability factors in the generation of
NSSI are illustrated in how they may interact. This
model helps to consider those at more risk for develop-
ment of NSSI and incorporates the role and underpin-
nings of the potential functions of NSSI [9].
There remains some controversy regarding whether
NSSI can become an addictive behaviour despite many
youths self reporting this anecdotally and several studies
providing evidence of addictive features. In a clinical
study of youth with NSSI to study addictive features,
Nixon Cloutier and Aggarwal [8], showed that 97.6 % of
a clinical sample of 42 repetitive self injuring adolescents
endorsed at least three dependence items on a seven-
point criteria scale for addictive features of NSSI. This
scale was adapted from the Diagnostic Statistical Manual
of Ment al Disorders IV TR (substance dependence cri-
teria) [10]. Schaub, Holly, Toste, and, Heath [personal
communications, 2006], in a university sample of self-
injurers, showed that 31 % endorsed at least three of the
addictive features using the same seven-item scale. More
recently, Moumne, Heath, Schaub, and Nixon [personal
communications; 2014] found that of 137 out of 710
high school students surveyed that endorsed lifetime
presence of NSSI, 20.4 % reported three or more Addi-
tive Features on the OSI addictive features scale. Those
with addictive features had higher frequency, more
methods and more locations of NSSI. Opposing the
concept that NSSI has the potential as an addictive be-
haviour, Victor, Glenn, and Klonsky [11] found in com-
paring drug users and self injuring adolescents that
cravings occurred primarily while experiencing negative
emotions for NSSI with cravings of drug users being
higher than that of self injurers.
In re views o f N SSI asses sment tools [12, 13] there
appears to be significant va riability in functions that
are mea sured between a ssessment tools. Despite the
number of self-report measures asses sing NSSI func-
tions (e.g., Inventory of Statements About Self-Injury
[14], Functional Ass essment of Self-Mutilation [15])
none, e xcept the OSI, assess potential addictive fea-
tures in addition to functions of NSSI. The OSI is a
self-report measure that offers a comprehensive a s -
sessment of NSSI, including both mea surement of it s
functions and potential addictive features. The inventory
was developed based on a comprehensive literature re-
view, clinician feedback and input from adolescent psychi-
atric inpatients with NSSI. It contains a number of scales
including an indication of frequency of recent NSSI
thoughts and acts, reasons for starting and reasons for
continuing to self injure (i.e., functions), addictive features,
level of motivation to stop the behaviour and other char-
acteristics of the nature of NSSI. Youth also respond to
questions regarding what has or has not helped in terms
of previous treatment (s).
The OSI has been previously validated in a commu-
nity sample of self-injuring university students [16].
Explorator y fa ctor analyses revealed four function
factors (Internal Emotion Regulation, Social Influence,
External Emotion Regulation, and Sensation Seeking)
and a single Addictive Features factor. Convergent
evidence for the functions fa ctors scores was demon-
strated through significant correlations with the Func-
tional Assessment of Self-Mutilation measure [15], a
known tool for assessing the functions of NSSI. Con-
vergent evidence w a s also noted for indications of
psychological well being, ris ky behaviours, and con-
text and frequency of NSSI. Convergent e vidence for
the Addictive Features scores was demonstrated
through associations with NSSI frequency, feeling
relieved following the act of NSSI, and the inabi lity to
resist urges to self injure. The conclusions of this pre-
liminary research were that the OSI is a valid and
reliable asse ssment tool that can be used in both re-
search and clinical settings and t hat further research
is warranted.
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 2 of 7
The purpose of this report is to describe a confirma-
tory factor analysis of the functions and addictive scales
of the Ottawa Self-Injury Inventory (OSI) on youth hos-
pitalized in a child and adolescent psychiatric inpatient
unit in Ontario, Canada. These analyses were performed
on data collected for a study on the characteristics of
youth who accessed inpatient psychiatric care regarding
nonsuicidal self-injury and suicidal behaviour [3]. Com-
prehensive, accessible and user friendly measures such
as the OSI fill a gap in the practice of assessment and
offer clinicians a means to obje ctively assess the behav-
iour in a standardized fashion.
Methods
Subjects
Participants were youth (14 to 18 years old) consecu-
tively admitted between July 2012 and January 2013 to
the Child and Adolescent Inpatient unit who gave con-
sent and completed the OSI. The inpatient unit provides
in-patient crisis, assessment, stabilization and treatment
where the mean length of stay is approximately 5 days.
Procedures
Youth provided informed consent. Exclusion criteria
were an unstable psychiatric condition (e.g., psychosis
interfering with the ability to provide informed consent),
intellectual disability or pervasive developmental disabil-
ity which was determined by nursing staff. Consenting
youth completed the OSI while in hospital. Research
Ethics Board (REB) approval was obtained from the
Grand River Hospital, Kitchener-Waterloo, Ontario and
the University of Guelph, Guelph, Ontario.
Measures
The study included self-reported measures of demo-
graphics and a standardized measure of NSSI. Data were
collected post day two of admission. Youth with a brief
one day admission or held overnight were not included.
Ottawa Self-Injury Inventory (OSI) [16]: This self re-
port inven tory is an in-depth mea sure of occurrence,
frequency, level of motivation to stop, types and func-
tions and potential addictive features of self-injury. The
functions of NSSI are endorsed by indicating the degree
to which 31 items (e.g., “to release unbearable tension”,
“to get care and attention from others”) correspond with
their rea sons for engaging in NSSI, ranging from 0,
never a reason,to4,always a reason). Seven questions
were modified from the DSM-IV-TR criteria for sub-
stance dependence to incorporate NSSI as opposed to
substance use . These were used to assess addictive fea-
tures (e.g., “Despite a desire to cut down or control this
behaviour, you are unable to do so”) with a range
response options from 0 ( never)to4(always) for each
addictive feature. The OSI has been shown to be valid
and reliable with excellent internal consistency scores
of 0.67 to 0.87 in a university sample of young adults
[16] and is appropriate for use with clinical samples of
adolescents.
Data analysis
Demographic data was analysed with descriptive statis-
tics using Statistical Package for the Social Sciences
(SPSS) Version 21 [17]. Confirmatory factor analysis was
used to verify the factor structure of the OSI using
AMOS 20 [18]. In order to optimize the sample size,
missing values were estimated using Expectation
Maximization. None of the items had more than 5 %
missing values, indicating that this option was appropri-
ate for use [19].
Results
In the original sample [3], 322 children and youth were
admitted during the study period and assessed by nurs -
ing staff for possible inclusion in the study: 102 youth
declined to participate or complete the sur vey, or there
were difficulties in obtaining guardian consent, 25 youth
were discharged or on pass before they could be asked
about the study or before the RA could make contact,
72 did not meet inclusion criteria (48 were considered
not appropriate due to psychosis, developmental delay
or violent behaviour, 16 were re-admissions, 6 were ex-
cluded due to age, one had language difficulties, and one
due to extreme fatigue affecting their ability to complete
the questionnaires). Ninety-four participants with a life-
time pre valence of NSSI who completed the functions
section of the OSI were included in this analysis. Almost
half (45.8 %) of the youth reported daily or weekly NSSI
and seventy-three percent (n = 69) reported co-occurring
suicidal ideation and/or behaviour. The mean age was
15.71 (1.5) ran ging from 11 to 20 years of age. Eighty-
one percent of participants were female, 16 % were male,
and one participant was bi-gender. Most youth were at-
tending high school (n = 74), four were in middle school,
and 7 were in college or university. Approximately three
quarters of the sample (n = 42) self reported having symp-
toms of depression.
Confirmatory factor analysis of function scores
A confirmatory factor analysis (CFA) was conduc ted to
confirm the factor structure of the initial functions of
the OSI (“Why did you start to self injure?”). The model
was composed of four factors (Internal Emotion Regula-
tion, Social Influence, External Emotion Regulation, and
Sensation Seeking). Correlation paths between the factors
were allowed. Bootstrapping (5000 samples) was used to
managethepresenceofmultivariatenon-normaldata
within the subsample [20]. The fit of the model was
deemed inadequate (χ
2
(246) = 402.12, p < .001; χ
2
/df = 1.64;
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 3 of 7
CFI = .76; RMSEA = .083). Upon further inspection, two
items (to diminish feelings of sexual arousal and to
get care and attention from other people)fromthe
social influence factor did not have significant path
estimates and were therefore removed from the
model. In addition, inspection of the modification in-
dexes revealed that one item ( to stop me from think-
ing about idea s of killing myself ) had significant
correlated errors with another item (to stop me from
acting out ide as of killing myself). This item was also
removed from the model. The fit of the final model
was deemed satisfactory (χ
2
(183) = 231.98, p = .008; χ
2
/
df = 1.2 7; CFI = .91; R MSEA = .05). All the items in
the final model had significant path estimates (stan-
dardized f actor loadings are presented in Table 1 ).
This model also yielded significant correlations be-
tween each fac tors (see Table 2). G reater NSSI fre-
quency wa s related to higher scores on each function
factor (rs=.24–.29, p < .05), except for the Exte rnal
Emotion Regulation factor (r =.11, p >.05).
Confirmatory factor analysis of addictive features
Ninety one of ninety four participants completed the
Addictive Features items. The same analytic strategy as
described previously for the function items was con-
ducted on the seven Addictive Features items of the
OSI. The fit of the model was deemed satisfactory
(χ
2
(14) = 21.96, p > .05; χ
2
/df = 1.57; CFI = .96; RMSEA
= .08). All the items had significant path estimates,
ranging between .52 and .80 (standardize d factor
loadings are presented in Table 3). Cronbach’salpha
for the Addictive Features scale was .84 with a mean
score of 16.22 ( SD = 6.90).
Higher Addictive Features scores were related to more
frequent NSSI (r = .48, p < .001). In addition, no signifi-
cant correlation wa s found between the Addictive
Features factor and feeling of physical pain when self-
injuring (r = .05, p > .0 5). Lastly, significant positive
correlations between the Addictive Features factor
and each of the obtained function factors of the OSI
were obtained (rs=.30– .4 4, p <.01).
Table 1 Standardized factor loadings and descriptive statistics for NSSI function factors
Motivations Internal Emotion
Regulation
Social
Influence
External Emotion
Regulation
Sensation
Seeking
To produce a sense of being real when I feel
numb and “unreal”
.64
To relieve feelings of sadness or feeling “down” .63
To distract me from unpleasant memories .62
To punish myself .60
To stop feeling alone and empty .56
To experience physical pain in one area, when
the other pain I feel is unbearable
.56
To stop me from acting out ideas of killing myself .50
To stop my parents from being angry at me .56
To stop people from expecting so much from me .55
To change my body image and/or appearance .53
To show others how hurt or damaged I am .50
To avoid getting in trouble for something I did .46
To get out of doing something that I don’t
want to do
.38
To belong to a group .29
To release frustration .89
To release anger .80
To release unbearable tension. .62
To experience a “high” like a drug high .71
To provide a sense of excitement that feels
exhilarating
.69
For sexual excitement .31
To prove to myself how much I can take .26
α .78 .66 .82 .53
Mean scores (SD) 17.78 (7.11) 5.47 (4.93) 8.62 (3.49) 3.69 (3.39)
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 4 of 7
Discussion
The current study provides additional support for the psy-
chometric properties of the OSI’sfunctionsandAddictive
Features scales in a clinical sample of adolescents. The ori-
ginal factor structure obtained in a university sample [16]
was confirmed. The four-factor model (Internal Emotion
Regulation, Social Influence, External Emotion Regulation,
and Sensation Seeking) of NSSI functions and the single
Addictive Features factor were replicated in this clinical
sample, with few exceptions. Within the Internal Emotion
Regulation factor, the item “to stop me from thinking about
ideas of killing myself” had significant correlated errors
with the item “to stop me from acting out ideas of killing
myself”. This is not a surprising finding as the two items
are connected when there is active planning of a suicide
attempt, in that experiencing suicidal ideation commonly
precedes the act of suicide. Under the Social Influence
factor there were two items that did not have significant
path estimates (i.e., did not relate significantly to their
factor), namely, “to diminish feelings of sexual arousal”
and “to get care and attention from other people”. It is
unclear why this would be, however, these items may be
under-reported or less commonly reported in adolescent
inpatients. Inpatient samples have typically higher rates
and frequency of NSSI [21] and are likely to have func-
tions endorsed related to managing symptoms associated
with major mental health disorders such as mood and
anxiety problems. Additional research is recommended to
investigate this further.
Convergent evidence was found for scores on both
functions and Addictive Features on the OSI through
significant correlations with theoretical and empirical
constructs. Specifically, greater NSSI frequency was re-
lated to higher scores on each function factor, except for
the External Emotion Regulation factor. This finding fur-
ther supports the notion that frequent NSSI can be both
negatively (Internal Emotional Regulation) and positively
(Sensation Seeking) reinforcing in a clinical sample as
previously found in a non clinical population [16]. The
mean score in this clinical sample was double that ob-
tained in the university sample (16.22 vs 8.05) indicating
that the measure is sensitive enough to detect differ-
ences between samples. These finding s indicate that
clinical samples might have more addictive features of
NSSI than community samples however further research
is required.
An interesting finding is that Social Influence as a
function factor was correlated with frequency of NSSI in
this clinical sample while this was not the case in Martin
and colleagues [16], where the population was somewhat
older and also community based. There may be several
reasons for this finding. Firstly, adolescents as opposed
to young adults are expected to have fewer and less de-
veloped coping strategies [22]. Second, the adolescent
period is particularly stressful in regards to interpersonal
issues, more spe cifically the impact of peer influence
and peer victimization including online bullying [23].
Thirdly, clinical samples typically have greater frequency
of NSSI than non-clinical samples and triggers or rea-
sons for NSSI such as social influence factors are likely
to also be reinforces of the behaviour leading to more
frequent NSSI.
There are several study limitations that should be
mentioned. First and foremost, the sample size limit s
generalizability of the results and research should repli-
cate these findings with large samples. Second, there
were fewer males than females who participated in the
study. However, the gende r proportions obtained are
representative of the ratio of females to males admitted
to adolescent inpatient care [2, 8]. Further research on
Table 3 Standardized factor loadings and descriptive statistics
for NSSI Addictive Features
Items Addictive
Features
The self-injurious behaviour occurs more
often than intended?
.64
The severity in which the self-injurious
behaviour occurs has increased
(e.g., deeper cuts, more extensive
parts of your body)?
.80
If the self-injurious behaviour produced
an effect when started, you now need
to self-injure more frequently or with
greater intensity to produce the
same effect?
.74
This behaviour or thinking about it
consumes a significant amount of
your time (e.g., planning and thinking
about it, collecting and hiding sharp
\objects, doing it and recovering from it)?
.60
Despite a desire to cut down or control
this behaviour, you are
unable to do so?
.68
You continue this behaviour despite
recognizing that it is harmful to you
physically and/or emotionally?
.59
Important social, family, academic
or recreational activities are given
up or reduced because of this behaviour?
.52
α .84
Mean scores (SD) 16.22 (6.90)
Table 2 Intercorrelations between the function factors
12 3 4
1. Internal Emotion Regulation - .68*** .90*** -.76***
2. Social Influence - .44*** -.87***
3. External Emotion Regulation - -.59***
4. Sensation Seeking -
Note. *** p < .001
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 5 of 7
males in clinical populations who engage in NSSI is
required. Third, as this was a secondary analysis of sur-
vey data obtained from a clinical sample, we were unable
to fully explore convergent and discriminant validity
with the data being limited to what was obtained in the
original sample [3].
Conclusions
This current study provides additional support for the
psychometric properties of the OSI’s functions and
Addictive Features scales. Further research on larger
clinical and community samples is warranted. Clinicians
can use a self report method that is comprehensive and
validated in an adolescent clinical population. In a recent
study of adolescents with self harm [4], the investigators
found that self repor t was able to detect previously un-
detected NSSI in a clinical setting, suggesting that while
self report questionnaires do not replace clinical assess-
ment, they may enha nce detection rates in youth. While
the purpose of this study was to confirm a preliminary
factor analysis, further research clinically in terms of en-
hancing detection is indicated.
Several recent studies [24, 25] have reviewed treatment
interventions that show promise in youth with NSSI. As
Brent and colleagues [25] emphasize in their summary,
results for both suicide attempts and NSSI should be
reported separately. An assessment tool such as the OSI
could give both baseline and outcome information spe-
cifically on NSSI and its associated functions and fea-
tures. Ougrin and colleagues [24] in their systematic
review and meta analysis of therapeutic interventions for
suicide attempts and self harm in adolescents indicate
that that largest effect sizes are for dialectical behavior
therapy (DBT), cognitive behavioural therapy (CBT) and
mentalization based therapy (MBT), but that no modal-
ity has had its efficacy independently replicated. They
highlight that research is lacking in indentifying variables
that are most important to match youths with NSSI and
their families to inte rventions that may have the most
benefit. With the ability to assess functions based on
four factors (Internal Emotion Regulation, Social Influ-
ence, External Emotion Regulation, and Sensation Seek-
ing) and the extent of Addictive Features, the OSI may
assist in selecting more specific treatment modalities.
For example, for those with the Internal Emotional
Regulation function most highly endorsed, assessment
for mood and anxiety disorders would be important and
the components of DBT and or CBT may be most indi-
cated whe reas those with the Social Influence function
most highly endorsed and related attachment issues
MBT may be more beneficial. For those with significant
Addictive Features endorsed, managing treatment expec-
tations and using a harm reduction approach with
motivational interviewing may be most helpful. More
research in these areas is needed as the treatment of
NSSI in youth continues to lack standardized a ssess -
ment and knowledge about what might be the most
effective treatment s depending on the nature of the
behavior [26].
Measure
The OSI can be downloaded free of charge if used for
public institutions and for research purposes at http://
www.insync-group.ca/publications/OSI_clinical_Octo-
ber_20051.pdf (Additional file 1).
Additional file
Additional file 1: The Ottawa Self-Injury Inventory.
Abbreviations
NSSI: Nonsuicidal self-injury; DSM: Diagnostic and Statistical Manual of
Mental Disorders; OSI: Ottawa Self-Injury Inventory; CFA: Confirmatory factor
analysis; SD: Standard deviation; RMSEA: Root Mean Square Error of
Approximation.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MKN drafted the manuscript, conceived the design and study of secondary
analysis of data from existing clinical sample. CL performed the statistical
analyses and help draft the manuscript. MP conceive d and designed the
original study and help ed draft the manuscript. JV conceived and designed
the original study. PC helped draft and critically edit the manuscript. All
authors read and approved the final manuscript.
Author details
1
Queen Alexandra Centre for Children’s Health, 2400 Arbutus Rd, Victoria, BC
V8N 1V7, Canada.
2
University of Ottawa, 136 Jean-Jacques Lussier, Ottawa,
ON K1N 6 N5, Canada.
3
College of Social and Applied Human Sciences,
University of Guelph, 50 Stone Road East Mackinnon 138, Guelph, ON N1G
2 W1, Canada.
4
Homewood Health Centre, 150 Delhi St, Guelph, ON N1E
6 K9, Canada.
5
Mental Health Research, Children’s Hospital of Eastern Ontario,
401 Smyth Rd, Ottawa, ON K1H 8 L1, Canada.
Received: 27 March 2015 Accepted: 10 June 2015
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