Highlights in child mental health research: May 2024

This month’s highlights include:

Exploring bonding and attachment in Aboriginal families

This qualitative study investigated the experiences and understandings of Aboriginal and culturally skilled non-Aboriginal mental health professionals about bonding and attachment relationships in Aboriginal families. The study found that their concepts of bonding and attachment differed from Western views, as they also included community and kinship, culture, connection to country and spirituality.

School refusal behaviour in children and adolescents

This narrative review of ten studies from Europe and North America explored how school refusal behaviour affects the psychological wellbeing of children and adolescents (4-18 years) and how it relates to common mental health conditions. The findings suggest that school refusal is associated with different mental health challenges, including autism, attention-deficit/hyperactivity disorder, anxiety and depression. School refusal as an avoidance strategy was associated with children and young people experiencing negative emotions linked to social or academic situations.

Social media use and adolescents’ mental health and wellbeing

This review examined the relationship between the use of social media (risks and opportunities) and adolescents’ mental health and well-being. Younger adolescents (10-15 years old) who were heavy social media users (more than 2 hours per day) were more likely to develop emotional and behavioural problems, depression and anxiety symptoms compared to older age groups and those who spent less time on social media. The findings also suggested that social media can provide opportunities to support positive mental health through providing a medium for social supports, facilitating identity development and easy access to online professional help.

School-based screen-and-treat strategy for children experiencing PTSD following disasters

This paper describes the ‘screen-and-treat’ strategy that was used after the severe floods in Queensland in 2011 and explores the outcomes for children in the community that were most affected. As part of this strategy, school children in the disaster affected areas were screened for PTSD symptoms and eligible children were offered treatment. The trauma-focused cognitive behavioural therapy intervention was delivered to 19 children experiencing PTSD. At the post-treatment assessment, 2 (11%) of the 19 children who received treatment met the diagnostic criteria for PTSD. At 12-months post treatment, none of the children met the diagnostic criteria for PTSD and only 4 children met the diagnostic criteria for anxiety.

Life course predictors of child emotional distress during the COVID-19 pandemic

This paper investigated the factors that contributed to child emotional difficulties during the COVID-19 pandemic in a longitudinal Australian study of families across generations. Parental life course factors (specifically internalising difficulties, lower conscientiousness, social skills problems, poorer relational health and lower trust and tolerance) were associated with children experiencing emotional distress during the pandemic.

Why is this important?

• There is limited published research evidence on the bonding and attachment relationships in Aboriginal and Torres Strait Islander families. Understanding these relationships is key to child development and supporting children and families in culturally safe ways.
• Bonding and attachment relationships are a focus of the Attachment Theory that frame child development in terms of parent-child relationships and the ways in which children can be supported to develop within a secure base. They represent a Western perspective on relationships.
• This paper investigates the experiences and understandings of Aboriginal and culturally skilled non-Aboriginal mental health professionals with regard to bonding and attachment relationships in Aboriginal families.

What did they do?

• The authors conducted eight interviews with community and psychology professionals using the yarning method and thematically analysed the data. The professionals either identified as Aboriginal people or were non-Aboriginal people with extensive experience working with these families in the field.
• The interviews explored how the participants defined bonding and attachment and their perspectives on how well the attachment theory reflects Aboriginal family dynamics.

What did they find?

• This qualitative study found that the understandings of the Aboriginal professionals on kinship, family and community systems differed from Western views of bonding and attachment. Collectivist culture, connection to Country and spirituality were described as essential elements of bonding and attachment relationships.
• The researchers identified 6 themes in how participants described bonding and attachment in Aboriginal families:
  • intergenerational trauma (can affect parenting styles and be triggered in specific parenting situations)
  • colonisation (can be experienced by Aboriginal parents as ongoing when they adopt Western views of parenting, fearing oversurveillance by the child protection services)
  • collectivist culture (differs from attachment theory in that it views children’s wellbeing within the context of caring relationships beyond their genetic parents)
  • connection to Country (considers various ways in which relationships to community, place and Country impact on bonding and attachment relationships)
  • self-determination (refers to the need for structures and supports that are Aboriginal designed, led and delivered to support Aboriginal families)
  • rejection of deficit framework (is about views of Aboriginal people as resilient rather than vulnerable).
• Culturally safe, accessible and appropriate services can be a protective factor that supports healing and the prevention of intergenerational trauma for Aboriginal communities.

What does this mean for practice?

• The experiences of intergenerational trauma and system failure affect the way Aboriginal people understand and experience attachment relationships.
• Programs and services to support Aboriginal parents must consider their cultural views on supporting parent-child relationships and child development. These should consider kinship and community systems as part of attachment relationships.

Why is this important?

• The study explored how school refusal behaviour affects the psychological wellbeing of children and adolescents (4–18 years) and how it relates to common mental health conditions.
• School refusal behaviour is a type of school attendance problem that affects children and adolescents. These children can have difficulty going to school regularly and face negative impacts on their mental health and coping skills (e.g. emotional distress, severe antisocial behaviour).

What did they do?

• The authors searched five academic databases for peer-reviewed literature published between 2019 to 2023.
• They conducted a narrative review of 10 observational and experimental studies from Europe and North America that reported on the school withdrawal statistics for children and adolescents with diagnosed mental health challenges, including neurodevelopmental or psychiatric conditions.

What did they find?

• The findings suggest that school refusal is associated with different types of mental health challenges, including autism, attention-deficit/hyperactivity disorder, anxiety and depression.
• In adolescents, some temperamental traits (e.g. fear, anger, nervousness, lack of interest, guilt, shame and increased sensitivity to negative stimuli) were associated with decreased school attendance.
• School refusal as an avoidance strategy was associated with children and young people experiencing negative emotions linked to social or academic situations.
• Key risk factors for school refusal included:
  • individual risk factors such as emotional and behavioural problems, lack of communication skills, low self-concept, exposure to cyberbullying, specific affective profiles and excessive technology usage
  • familial risk factors such as poverty, family frequent relocations, parental neglect, domestic violence, parental unemployment and parental mental health issues
  • risk factors related to the school environment such as bullying and socialisation difficulties.

What does this mean for practice?

• By recognising that school refusal is linked to a series of risk factors and mental health challenges, practitioners can seek to tailor therapeutic interventions to the needs of children and young people.
• For some children, school attendance may be improved through support to develop social skills, emotional self-regulation and problem-solving specific to the school settings. This may enable children to better cope with their emotions, support academic performance and engagement in social relationships.

Why is this important?

• Social media use is common among young people, but this can involve some risks for their mental health.
• This review examined the relationship between the use of social media (risks and opportunities) and adolescents’ mental health and well-being.

What did they do?

• The authors conducted an umbrella review of reviews and meta-analyses, published between 2015 to 2023, about social media use in children and young people.
• 24 articles were analysed thematically presenting a narrative synthesis of results.
• They explored mental health outcomes including wellbeing (i.e. happiness, friendship, hope, optimism, life satisfaction), ill-being (i.e. shame, psychological distress, depressive or anxious symptoms) and mental health issues (i.e. depressive or anxiety disorder, eating disorder, deliberate self-harm).

What did they find?

• Most included reviews (n=19) were published since 2020 and commonly focused on young people aged 10-19 years old (37.5%).
• The authors explored three key factors that impacted the relationship between social media use and mental health: individual demographic and psycho-socio characteristics, individual use of social media, and platforms’ content/design.
• Gender, age and time spent on social media were the key determining factors for social media use having implications for mental health.
• Younger adolescents (10-15 years old) who were heavy users of social media (more than 2 hours per day) were more likely to develop emotional and behavioural problems, depression and anxiety symptoms compared to older age groups and those who spent less time on social media. This was linked to their limited social and mood regulation skills, and social, psychological and biological changes they were undergoing.
• Better emotional regulation and social skills were protective factors for the challenges posed by social media use, particularly deliberate self-harm.
• Social media can also provide opportunities and support positive mental health through social supports, facilitating identity development or access to online professional help.

What does this mean for practice?

• Practitioners should consider asking adolescents about their social media usage for early detection of possible negative mental health impacts. They could also support families with guidance about how to develop digital competencies to promote safe and healthy social media usage.
• Although social media use can affect mental health, it can also be a way to reach young people. Mental health practitioners may need to consider how to offer psychological support using social media so they can better reach young people and support adolescents with reliable mental health information, especially those who may have eating or mood disorders or self-harm behaviours.

Why is this important?

• Exposure to natural disasters can lead to 1 in 10 children developing posttraumatic stress disorders (PTSD), however few children access available support.
• This paper describes the ‘screen-and-treat’ strategy (described below) that was used after the severe floods in Queensland in 2011 and explores the outcomes for children in four Lockyer Valley primary schools (the community that suffered the most).

What did they do?

• The researchers conducted the study in 2011-2012, as part of a government-funded post-disaster service response.
• Two months after the flooding, 150 children aged 7-12 years were screened at schools for PTSD, anxiety and depression. 80 children were identified for further assessment; of those 48 were offered treatment and 19 parents gave their consent for children to participate.
• The trauma-focused cognitive behavioural therapy (CBT) intervention was delivered by 7 clinical psychology trainees from local universities and 2 experienced clinicians. The intervention was free, delivered in the children’s schools and targeted parents (2 x 90 min sessions, weekly) and children (8 x 90 min sessions, weekly plus an additional session 2-4 weeks post intervention). The intervention consisted of 2 strengths-based, manualised CBT protocols with a trauma focus: ‘My Story of the Flood: What parents need to know and how they can help’ and ‘My Story of the Flood’.
• Clinical assessment of child mental health was conducted pre-treatment, immediately post-treatment and 6- and 12-months after treatment.

What did they find?

• Of the 19 children who participated in the intervention, 17 met the diagnostic criteria for PTSD pre-treatment and 16 met the diagnostic criteria for an anxiety disorder.
• At the post-treatment assessment, 2 (11%) of the 19 children who received treatment met diagnostic criteria for PTSD. At 12-months post treatment, none of the children met the diagnostic criteria for PTSD and only 4 children met the diagnostic criteria for anxiety.
• There were no differences in outcomes for children seen by trainees compared to experienced clinicians.

What does this mean for practice?

• Delivering a free, trauma-informed screen-and-treat method to treat PTSD, anxiety or depression in schools could be an effective way to support children who have been exposed to natural disasters.
• In a post-disaster situation, postgraduate trainees can be a valuable and capable workforce.

Why is this important?

• There is not much known about the long-term implications of complex stressors and extensive social restrictions on the mental health of families who were living in Australia during the COVID-19 pandemic in 2020/2021.
• This paper investigated the factors that contributed to child emotional difficulties during the COVID-19 pandemic in a longitudinal Australian study of families across generations.

What did they do?

• This was a longitudinal study using data from the Australian Temperament Project Generation 3 Study (ATPG3). Data from 549 parents (60% mothers) of 934 children (1-9 years old) was included.
• The parents completed a brief online survey about the impacts of the COVID-19 pandemic in 2020 and 2021. They had previously completed assessments as part of the ATPG3 study about their experiences during their own childhood, adolescence and young adulthood. These assessments included individual factors (e.g. internalising and externalising problems), relational factors (e.g. parental attachment, parent social support and parent-child relationships) and contextual factors (e.g. parent education, separation and stressful life events).
• The authors examined the relationships between:
  • parent/child emotional distress during the COVID-19 pandemic
  • pre-pandemic infant behaviour problems
  • parental life-course factors, i.e. child, adolescent and young adult precursors of child emotional distress
  • pre-pandemic, one-year postpartum precursors of child emotional distress.

What did they find?

• Parents reported that their children had low levels of negative mood states during the pandemic.
• Parental life course factors (specifically internalising difficulties, lower conscientiousness, social skills problems, poorer relational health and lower trust and tolerance) were associated with parents reporting that their child experienced emotional distress during the pandemic.
• Pre-pandemic parental factors from the postpartum period (specifically internalising difficulties, lower parental warmth, lower cooperation and fewer behavioural competencies) were predictive of parents reporting their child as experiencing emotional distress.

What does this mean for practice?

• It is important to consider an intergenerational perspective regarding the mental health impacts of future pandemics or other stressors. This means investments in whole of family emotional and relational health.