Highlights in child mental health research: October 2023

This month’s highlights include:

• Family factors, child emotion regulation and internalising symptoms

This meta-analysis study analysed the relationship between family factors, child emotion regulation and internalising symptoms from 49 studies. Child emotion regulation mediated the relationship between some family factors (parent emotion regulation, psychopathology, psychological control and unsupportive emotion socialisation), and child internalising symptoms. This study supports a theoretical model that family factors (particularly family relationships, attitudes towards emotional expression, and child observation and modelling of parental emotional regulation and behaviours) can impact on children’s emotional development and mental health symptoms.

• Online program for child and adolescent anxiety

This study assessed the impact of BRAVE, an Australian online cognitive behavioural therapy program for children and adolescents. Both children and adolescents experienced improvements in anxiety symptoms after the first 3-4 sessions. For children, small improvements in anxiety-related functioning were observed in those who completed at least 6 sessions. However, there was no change to life interference for adolescents. Adolescents may need additional supports such as other types of interventions and/or parental assistance to improve anxiety-related functioning.

• Mental health and wellbeing interventions for care-experienced children and young people

The authors conducted a systematic review of the contextual factors that influence implementation and acceptability of interventions that support the mental health and wellbeing of children and young people (aged ≤25 years old) in out-of-home care. Evaluation of 64 interventions were included. The majority were from UK, Ireland and the USA. Factors that influence the implementation of programs were found to be: 1) lack of system resources; 2) intervention burden; 3) interprofessional relationships; 4) care-experienced young people’s feelings of systematic disenfranchisement; and 5) carer identity, including feeling expertise and history of parenting is not valued. Most of the barriers to implementation exist at the organisational and system level. Future interventions should consider addressing resource allocation, work culture and stakeholder values.

• The global prevalence of ADHD in children and adolescents

This review summarised the current evidence from 13 meta-analytic systematic reviews, to estimate the global prevalence of attention deficit hyperactivity disorder (ADHD) among children and young people. The review found the global prevalence of ADHD in children and adolescents to be 8%, with boys (10%) twice as likely to experience the disorder than girls (5%). The most common types of ADHD were inattentive and hyperactive, followed by the combined type. Practitioners should be aware that almost 1 in 10 children and young people are affected by ADHD and look out for the relevant signs and symptoms.

Why is this important?

• Understanding the factors and mechanisms that influence the development of child internalising symptoms can help to improve interventions and supports that promote mental wellbeing in childhood and prevent mental ill health later in life.
• There is established evidence that parental factors influence children’s internalising symptoms and the development of emotion regulation. However, the mechanisms that underpin this relationship are not well understood.
• Theoretical models suggest that child emotional regulation may mediate the association between family factors and a child’s internalising symptoms. However, this relationship has not been systematically tested.

What did they do?

• Authors conducted a meta-analysis of 49 studies to understand the relationship between child emotion regulation, family factors and child internalising symptoms. Included studies measured family factors as an influencing factor, child emotional regulation as a mediating factor and child internalising symptoms as an outcome.
• The meta-analysis included 24,524 participants across 16 countries. The mean age of children included in the meta-analysis was 11.3 years.

What did they find?

• There was evidence that child emotion regulation mediated the relationship between some family factors and internalising symptoms.
• Family factors that were mediated by child emotion regulation included: parent emotion regulation (parents’ ability to regulate their own emotions), parent psychopathology (parents’ internalising symptoms), psychological control (parental behaviours that negatively influence child emotions, including the use of guilt and conditional affection), unsupportive emotion socialisation (intolerance of child emotions including discouraging emotional expression), family conflict (e.g. parent-parent and parent-child conflict), parental aversiveness and secure attachment.
• The mediation effects were strongest for parent emotion regulation, psychopathology, psychological control and unsupportive emotion socialisation. Child emotion regulation accounted for 27-41% of the total effect of the relationship between these family factors on internalising symptoms.
• There was no evidence of child emotion regulation mediating the relationship between supportive emotion socialisation (validating child emotions and expressions, modelling regulation) and internalising symptoms.
• There was no significant association between behavioural control (parents’ use of rules, guidelines and monitoring to manage behaviours) and internalising symptoms in children, and child emotion regulation was not found to mediate this relationship.

What does this mean for practice?

• This study supports the theoretical model that describes three main processes within the family that can impact on children’s emotional development and mental health symptoms:
  • child observation and modelling of how parents and other family members regulate their own emotions
  • how parents react to and talk about children’s emotions and
  • the emotional environment of the family, including family relationships and display of emotions.
• Positive child and adolescent outcomes can be supported by interventions targeting modifiable parenting behaviours that promote healthy emotion regulation development and mental health.

Why is this important?

• Anxiety can lead to functional impairments that can interfere with the daily lives of children and adolescents. Online mental health programs can be helpful for children and young people as they help overcome some important barriers to help-seeking (including cost and ease of access).

What did they do?

• This study explored the impact of an internet-delivered Cognitive Behavioural Therapy (iCBT) program on anxiety symptoms and anxiety-related life interference. It used a pre-post study design, including a group of 1,198 children (mean age 9.6 years) and 721 adolescents (mean age 13.6 years) with elevated or clinical levels of anxiety symptoms.
• BRAVE is an Australian online iCBT program tailored to children and adolescents focussing on reducing different types of anxieties (separation anxiety, generalised anxiety, specific phobia and social anxiety). It consists of 10 interactive sessions 30-60 min each that include question and answer activities, quizzes and homework activities to facilitate skill rehearsal and retention.

What did they find?

• Following iCBT, both children and adolescents experienced improvements in anxiety symptoms after the first 3-4 sessions.
• After completing 3-5 sessions of iCBT, children had no change and adolescents had a small increase in life interference at home (compared to outside of the home).
• Small improvements in anxiety-related functioning were observed in children who completed at least 6 sessions. For adolescents, there was no change to life interference after completing the iCBT course.

What does this mean for practice?

• Anxiety symptoms in children can be reduced following an online program, and with a relatively low number of sessions (e.g., 3-5 sessions).
• Improvements in anxiety-related functional impairments are likely to require more prolonged program durations in children (at least 6-8 sessions). However, adolescents may need additional supports such as other types of interventions and/or parental assistance to improve anxiety-related functioning.
• Self-help iCBT can be useful to improve anxiety and life interference for some children and young people. However, improvements in anxiety symptoms may not translate to improvements in functioning, especially for adolescents.

Why is this important?

• Children and young people in out-of-home care experience higher levels of mental health difficulties than the general population. Interventions that aim to support their mental health are effective in some contexts but not others. There is limited research into the contextual factors that influence implementation and acceptability of these interventions.

What did they do?

• The authors conducted a systematic review of process evaluations of interventions that support the mental health and wellbeing of care-experienced (currently or previously in care) children and young people (aged ≤25 years old).
• They looked at evidence from mental health and wellbeing intervention evaluation studies published between 1990-2022 and reported on the contextual factors that influence implementation and acceptability of these interventions.
• They also conducted stakeholder consultations with children and young people, and with care practitioners to refine the review, and to interpret the findings.

What did they find?

• The authors identified evaluation reports that described 64 interventions as eligible for the review. Most interventions (9) were from UK and Ireland, followed by the USA (6), and Australia (1).
• Factors that facilitate and inhibit intervention implementation included system resources and culture, and the interaction between stakeholders and interventions.
• 5 key themes of contextual factors that influence implementation were identified for intervention delivery: 1) lack of system resources (including organisational and wider social care system; 2) intervention burden (time, cognitive, and emotional burden from participation and implementation); 3) interprofessional relationships (with health and social care professionals); 4) care-experienced young people’s dissatisfaction with interventions leading to disengagement; and 5) carer identity, including feelings of expertise and history of parenting is not valued.
• Children and young people reported often feeling disempowered within interventions, lacking a voice, and feeling they are to blame when the intervention didn’t work.
• Child support workers regarded high workloads, unsupportive workplace cultures as barriers to intervention participation and attendance at training sessions.

What does this mean for practice?

• Process evaluation is necessary to understand the contextual factors that contribute to implementation and program success.
• While interventions and programs for mental health in out-of-home care tend to focus on addressing knowledge, skills and relationships, this review found that most of the barriers to implementation exist at the organisational and system level. Future interventions should consider addressing resource allocation, work culture and stakeholder values.
• Program funders and policy makers should consider how workforce and system-level factors can influence program implementation, and ensure sufficient resources and support are available for new program implementation or adaptation to new contexts.
• Practitioners can support the mental health and wellbeing of children and young people in care with a focus on relationship-building. This includes child-caregiver relationships, other meaningful relationships for the child, and interprofessional relationships across health and social care professionals.

Why is this important?

• Many individual studies and reviews indicate that there is a high prevalence of attention deficit hyperactivity disorder (ADHD) in children and adolescents, however prevalence across the world is unknown.
• ADHD is a complex neurodevelopmental disorder that begins in childhood and can impact across the lifespan. Common symptoms of ADHD include difficulties in concentration, distractibility, hyperactivity and/or impulsivity.

What did they do?

• The authors reviewed international meta-analyses and systematic reviews of observational studies that reported on the prevalence of ADHD in children and adolescents.
• The review aimed to estimate the global prevalence of ADHD and ADHD sub-types in children. Studies were included if they were published in the English language.
• In total, 13 review studies were included (collectively drawing from 588 primary studies) from regions across the global including Africa, China, India, Spain, Iran and USA.

What did they find?

• The review indicated that the global prevalence of ADHD in children and adolescents was 8%. Overall, the reported prevalence rates for ADHD across studies ranged from 3.4% to 14% and there was significant variation in studies.
• The prevalence of ADHD was higher for boys (10%), than girls (5%).
• The estimated prevalence of ADHD sub-types were inattentive 3%, hyperactive 3%, and combined type 2.4%.

What does this mean for practice?

• Practitioners should be aware that almost 1 in 10 children and young people are affected by ADHD and look out for the relevant signs and symptoms.
• A greater focus should be given in practice to early identification, prevention and treatment of ADHD.