Highlights in Child Mental Health Research: May 2020

Highlights:

• This narrative review discusses the considerable impact of the COVID-19 pandemic (and its associated containment measures) on child and adolescent mental health.

• While the COVID-19 pandemic may offer some potential benefits for children and families (e.g., increased cohesion between family members; increased time with caregivers; growing and developing as a person), the negative effects may overshadow these advantages.

• The researchers consider the potential risks to child mental health with regards to the 3 main phases of the pandemic. The phases are (p. 2):

1. “Preparation” – Governments implement containment and mitigation measures (e.g., social distancing, economic shutdowns, hygiene strategies).
2. “Punctum maximum” – The curve (i.e. number of new cases) and mortality rate reach their maximum levels.
3. “Return to normality” – Society recovers from the pandemic, which includes ensuring that services are re-organised and re-established.

• During phases 1 and 2, the key factors that may increase the risk of children’s mental health problems include:
  • Restrictions to leisure and stress-reducing activities (e.g., playground closures, sporting club closures).
  • Limits to social interactions due to social distancing measures (e.g., minimal or no contact with peers or family members; school closures).
  • Stigma towards those children or families that have become infected.
  • Increased pressures on the family unit, including financial which is a well-documented risk factor for poorer child mental health.
  • Increased levels of parental mental health problems and substance misuse.
  • Heightened levels of domestic and family violence and child maltreatment.
  • Containment measures (e.g., isolation, quarantine), which can negatively-impact on mental health (e.g., post-traumatic stress symptoms).
  • Concerns about the impact of the virus itself on oneself or others.
  • Limited access to health and support services, including in relation to mental health.

• During phase 3, potential risk factors for child mental health problems can include:
  • Economic problems and unemployment, which may create increased pressures for parents, children, and families.
  • Increased demand and pressure on mental health services as they work to address both the previous limitations to their service and the pandemic’s ongoing mental health effects. This can occur against a background of wider limitations in access to healthcare.
  • Ongoing increased risks of domestic and family violence and child maltreatment, which may be exacerbated by economic factors.

• Those children who were already experiencing vulnerability pre-pandemic are considered to be at highest risk of mental health problems. These groups will require special attention by practitioners and service providers, and include:
  • children from low-income families
  • children with disabilities
  • children who have experienced adversity
  • children with pre-existing mental health problems
  • children who are refugees.

• The pandemic may offer practitioners the opportunity to develop innovative strategies for delivering mental health services to children and families, as well as to up-skill. One example is the development of skills in telehealth delivery.
• Future research will be critical for: 1) understanding the pandemic’s effects on child mental health, 2) identifying factors associated with risk and resilience, and 3) understanding how we might reduce the pandemic’s long-term effects. This could inform responses to similar future events.

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Highlights:

• This study explored the changes that have occurred in the barriers to mental health care for Australian children and adolescents over time.
• The study used data from two surveys of children and adolescents (aged 4 to 17 years old) performed in 1998 and 2013-2014. The nationally-representative surveys included over 4,000 participants in 1998 and over 6,000 participants in 2013-2014.
• Barriers were assessed by adolescents (aged 11-14 years) and parents over the time period.
• Parents endorsed the top barriers to child and adolescent mental health care at both time-points as:
  • Preferring to rely on themselves (i.e. self-reliance). This decreased over the 16-year-period from around 66% to around 35%.
  • Being uncertain of where they could get help.
  • Costs of mental health care.
• Adolescents endorsed the top barriers to mental health care at both time-points as:
  • Preferring to rely on themselves. This remained unchanged over time.
  • Being concerned about what other people may think (i.e. stigma). This also remained unchanged over time.
• The researchers concluded that despite considerable investment in mental health treatment and awareness-raising strategies, the main barriers to care for Australian children and adolescents appear to have remained largely the same over time.
• Schnyder and colleagues (2020, p. 1) suggest that “the decrease in self-reliance [in parents] may reflect a positive shift in beliefs about the potential benefits of treatment” associated with strategies that have aimed to strengthen mental health literacy and decrease stigma.
• The researchers highlight that their findings demonstrate an ongoing need for mental health supports and treatments that are free or minimal in cost.

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Highlights:

• This study developed practice guidelines for conducting psychosocial assessments with Aboriginal and Torres Strait Islander people who present to hospital with self-harm and thoughts of suicide.
• The guidelines aim to “address an important gap in the evidence-base for clinically effective and culturally responsive assessment of self-harm and suicidal thoughts by Aboriginal and Torres Strait Islander people in hospital settings” (Leckning et al., 2020, p. 1).
• The researchers developed the guidelines using the Delphi method. This method involved 28 experts responding to three rounds of statements about best practice.  Statements that were rated by at least 90% of the expert panel as “essential or important” were used to develop the resulting principles and recommendations (Leckning et al., 2020, p. 1).
• The 28 experts had clinical experience, community-based experience, and lived experience in the mental health and/or prevention of suicide of Aboriginal and Torres Strait Islander people. 11 experts identified as Aboriginal and 1 as Torres Strait Islander.
• Especially relevant to child mental health practitioners is the section of the guidelines dedicated to children and young people (see p. 23 of the guidelines), which considers that this is a “high-risk group with specific developmental and socio-cultural needs” (Leckning et al., 2020, p. 7).
• Researchers will now focus on developing a strategy for implementation and a framework for evaluation with an aim of strengthening the evidence and improving outcomes.

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Read the best practice guidelines here

Highlights:

• This article provides new guidelines and practice recommendations to support practitioners in the assessment, diagnosis, and treatment of individuals with co-existing attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).
• The article will be of interest to healthcare professionals and allied health practitioners who work with children and their families.
• Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) in 2013, ADHD and ASD were not recognised as being able to co-occur.
• While guidelines exist for ADHD and ASD as separate disorders, there has been a relative lack of understanding and guidance regarding the identification, assessment, and treatment of these conditions when these co-occur. Hence these guidelines were developed to address this gap in the evidence-base and to assist practitioners.
• Co-existing ADHD and ASD can lead to an intensification of difficulties over and above that which might occur in either condition in isolation.
• The recommendations were developed through consensus of a panel of expert professionals from the United Kingdom.
• Guidance and practice recommendations are provided for (p. 2):
  • Identification and assessment, including the need for a multi-faceted approach that incorporates multiple sources of information.
  • The use of rating scales and clinical interviews.
  • The use of objective assessments.
  • Assessment outcomes, including assessment reports and their content.
  • Interventions for children with co-morbid ASD and ADHD, including psychoeducation, parent/caregiver interventions, behavioural interventions, CBT (Cognitive Behavioural Therapy), and school-based interventions.
  • Pharmacological treatments.

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Highlights

• This study investigated how parenting stress and family resilience might influence the association between adverse childhood experiences (ACEs) and children’s mental health. It also explored the potential impact of these factors on the association between ACEs and outcomes related to attention-deficit/hyperactivity disorder (ADHD).
• The study used data of over 44,000 children (aged 6 to 17 years) from the 2016-2017 National Survey of Children’s Health (NSCH) conducted in the United States.
• Family connection and resilience was measured using responses of parents/carers to questions about the likelihood of the family responding to problems using positive strategies (e.g., discussing what to do as a family; working together to problem-solve).
• Key findings included:
  • Around 7% of children exposed to ACEs had a mental health condition and around 10% had ADHD.
  • Consistent with past research, children with a higher ACEs score were more likely to have a mental health condition. They were also more likely to have ADHD. This finding persisted even after adjusting for the effect of social-demographic factors.
  • “Parenting stress mediated 57% of the total effect of ACEs on any mental health condition” (p. 104). That is, parenting stress appears to be a potential risk factor through which ACEs may have a negative impact on child mental health outcomes.
  • ACEs had a larger effect on mental health and ADHD outcomes in children with lower levels of family-level connection and resilience (compared to those with higher levels of family connection and resilience). That is, family resilience was a protective factor that buffered the negative impact of ACEs on children’s mental health.

The study highlights the importance of clinicians, service providers, and policy-makers targeting parental mental health (including parenting stress) and family functioning (including family relationships) when seeking to support the mental health of children who have experienced adversity.

Read the Abstract here