Highlights in child mental health research: August 2023

This month’s highlights include:

• Paternal depression and risk of depression in offspring

This systematic review and meta-analysis aimed to establish greater clarity about the relationship between paternal depression and the risk of future depression in their offspring. The review included 7,153,723 father-child dyads and found significant association between paternal and offspring depression. Exposure to paternal depression was found to increase offspring’s risk of depression by 42%. The study authors concluded that a family-focused approach that looks beyond maternal issues is important to adequately address child mental health.

• Anxiety and social outcomes in autistic children and adolescents

This systematic review and meta-analysis aimed to understand the association between anxiety and social outcomes among autistic children and young people and how other factors influence this relationship. 20 studies, including 2,321 participants, were included in the review. The review findings suggested a tendency for social competence to decrease as anxiety increases in autistic children and young people, although the association weakened with older age. However, there was significant unaccounted for variation in the findings across studies.

• Australian child and adolescent mental health services: 2015–2020

This study sought to better understand the Australian child and adolescent mental health services (CAMHS) between 2015-16 and 2019-20. Inpatient CAMHS was found to cost more per day compared to adult mental health inpatient services but produce lower rates of significant improvement and higher rates of no-improvement following an episode. In 2019-20, CAMHS patients also had lower lengths of stay and higher readmission rates for inpatient episodes than general adult and older persons mental health services.

• Maternal psychological stress and mother-infant bonding

This systematic review aimed to comprehensively examine the relationship between maternal psychological distress during pregnancy and postpartum and mother-infant bonding challenges. 99 studies with 119,498 mothers were included in the review’ most studies were from high-income countries. Strong associations were found between increased maternal psychological distress and mother-infant bonding challenges. Depression saw the strongest association, although anxiety, stress, psychological distress, or post-partum blues also had moderate to strong associations.

Why is this important?

• Previous research about the association between paternal depression and the risk of future depression in offspring was not definitive.
• This paper aimed to establish greater clarity on this relationship, with the purpose of informing mental health (MH) interventions.

What did they do?

• Authors conducted a systematic review of 7,153,723 father-child dyads across 16 studies, published between 2002-2021. Eight studies were conducted in Europe, 6 in the United States, one in Australia and one in Taiwan. Most (12) were classified as of high quality.
• A meta-analysis and subgroup analysis were conducted.

What did they find?

• A significant association between paternal depression and an increased risk of depression in their offspring was found in 11 out of 16 studies. The strength of the association was largely similar across the included studies. Meta-analysis found that exposure to paternal depression increased offspring’s risk of depression by 42%.
• In the sub-group analysis, the authors found that exposure to paternal depressive disorders increased offspring risk of depression by 65%, whereas exposure to paternal depressive symptoms increased risk of depression by 12%. There were also stronger associations found in children exposed to long-term paternal depression than those exposed to shorter early periods of paternal depression.
• Sub-group analysis also found a higher risk of offspring depression in studies that did not take into account maternal substance use, compared to those studies that did adjust for these maternal factors.
• Other relevant confounding factors (e.g., parental education, parental age, household income, pregnancy complications) were not consistently adjusted for across the studies reviewed.

What does this mean for practice?

• Addressing paternal MH concerns early (e.g. in the perinatal and early childhood years and before depressive symptoms reach the severity of a depressive disorder) can reduce the chances of offspring developing depression.
• Conventional gendered approaches that focus on maternal issues, or only on the individual treatment of children, underestimate the influence of other family factors. A family-focused approach that considers the health and wellbeing of parents collectively is important to adequately address child MH.
• The underlying factors contributing to the association between paternal and offspring MH are not yet clear. It is possible that maternal substance use and depression may compound the effects of paternal depression, however the direction of the relationship and the influence of other confounding factors require further examination.

Why is this important?

• The prevalence of anxiety in autistic children and young people (CYP) is well researched, however how anxiety in this population affects their social outcomes is not yet clear.
• The authors aimed to develop an understanding of the association between anxiety and social outcomes among autistic CYP and how other factors influence the relationship.

What did they do?

• 20 studies involving 2,321 participants were included in this review. All studies included participants under 18 years of age with an autism diagnosis and standardised, neurotypical measures for anxiety and social competence.
• A meta-analysis of the studies and a sub-group analysis were conducted.

What did they find?

• Anxiety was found to have a significant, though small, negative impact on social competence for autistic CYP. This suggests a tendency for social competence to decrease as anxiety increases in this population.
• The authors found significant variation in the included studies’ findings.
• The association between social competence and anxiety became weaker with older age.
• Other factors assessed, including the presence of co-occurring intellectual disabilities, gender, type of social competence measure used and quality of the study, were not found to significantly impact on the relationship between social competence and anxiety, nor account for the variation between studies.

What does this mean for practice?

• People working with autistic CYP should be aware of the potential challenges this group may face regarding both anxiety and social competencies.
• Young autistic children may require more support with social competency than their older counterparts.
• There are likely to be multiple factors influencing social outcomes for autistic CYP that were not addressed in this study. The authors suggest that social acceptance, stigma reduction and support for autistic identity could be an important anxiety prevention measure to reduce potential social misunderstandings or rejection; however, this suggestion was not based directly on the study findings. The authors also propose that future research should consider how masking behaviours and age-related changes (e.g., schooling) may affect social outcomes.

Why is this important?

• This study aimed to better understand child and adolescent mental health services (CAMHS) across the Australian states and territories between 2015-16 and 2019-20.
• CAMHS are mental health services focused on those under 18 years of age, although general services may also provide care to children and adolescents.

What did they do?

• The authors analysed data from the Australian Institute of Health and Welfare and the Australian Bureau of Statistics.
• Analysis focused on expenditure, outpatient services, key performance indicators, and comparisons with mental health services for other age groups between 2015-16 and 2019-20.

What did they find?

• Between 2015-16 and 2019-20, total CAHMS expenditure increased by an average of 3.6% each year.
• In 2019-20, CAMHS patients had shorter lengths of stay for inpatient episode admissions (8.8 days on average) and higher rates of being readmitted within 21-days (19.5%) compared with general adults (11.7 days, 14.9%) and older persons accessing mental health services (35.1 days, 7.6%).
• In 2019-20, 12–17-year-old CAMHS patients were the most likely of all age-groups to have contact with community CAHMS and contact with community CAHMS increased by a larger annual average than any other age-group (at 4.9%) between 2015-16 and 2019-20. The 0–4-year-olds group were the least likely to have contact with CAMHS, followed by 5–11-year-olds.
• ‘Mental disorders not otherwise specified’ was the most common diagnosis across CAMHS outpatients. Childhood-specific emotional, behavioural or developmental disorder were the principal diagnosis for 0-4- and 5–11-year-olds, while depressive episodes, anxiety disorders and eating disorders were principal outpatient diagnosis for 12–17-year-olds.
• The number of CAMHS public hospital beds increased by an annual average of 3% between 2015-16 and 2019-20. However, in 2019-20 CAMHS bed numbers remained significantly lower than beds for either general adults or older persons accessing mental health services (5.5-per-100,000 compared to 31.9 and 22.1 respectively).
• In 2019-20, CAMHS inpatient users reported lower rates of significant improvement post-admission than for all ages (57.7% vs 72.2%) and higher rates of no improvement (32.8% vs 22.9%). Conversely, following outpatient episodes more CAMHS users reported significant improvement compared to all ages (52.4% vs 50.7%) and CAMHS users had lower rates of significant deterioration following an outpatient episode (5.7% vs 6.4%).

What does this mean for practice?

• Inpatient CAMHS was found to cost more per day than adult inpatient services but produce lower rates of significant improvement and higher rates of no-improvement following an episode. The reasons behind this were not explored in this study. However, the authors theorised that influences may include increased complexities managing familial discord when treating young people and young people presenting with conditions that may not respond well to inpatient treatments.
• Young people’s response to, and the availability of, family/carer support at home may influence their response to inpatient care. It may also be affected by the shorter lengths of stay and the lower availability of beds.

Why is this important?

• Maternal psychological distress during pregnancy and postpartum has been linked to poor mother-infant bonding. This study aimed to comprehensively examine this relationship and the extent to which they are associated.
• Mother-infant bonding refers to how a mother feels about their emotional bond with their infant. Mother’s self-identified bonding challenges can predict poorer outcomes for both mothers and offspring.

What did they do?

• Researchers analysed 99 studies comprising 119,498 mothers, published between 1988 and 2020 (83% were published since 2011). Most were from high-income countries.
• Studies were included if they reported the association between a standardised measure of mother-infant bonding and one or more measures of psychological distress (including depression, anxiety, stress and postpartum blues).
• The researchers conducted a meta-analysis and sub-group analysis of the association between maternal psychological distress and mother-infant bonding.

What did they find?

• Strong associations were found between increased maternal psychological distress and mother-infant bonding challenges.
• Maternal depression saw the strongest association with bonding challenges, while all other measures of psychological distress also had moderate to strong associations.
• The direction of the association between maternal psychological distress and mother-infant bonding was consistent in different populations and settings, the income of the country, or the number of children the mother had. The strength of association varied based on the bonding measure tools used by the studies.

What does this mean for practice?

• People working with mothers experiencing psychological distress, particularly depression, should be aware of the heightened risk of mother-infant bonding challenges, but not assume this is the case for all. Tools, strategies, and other supports could be provided to help mothers create healthy and positive bonds with their children.
• Early interventions to support people to reduce their psychological distress, before they become parents, could help support positive bonding with their infants later in life.
• Different mother-infant bonding measures used in different studies produced varied results, meaning there are likely inconsistencies around how bonding is broadly understood.