Highlights in child mental health research: February 2024

This month’s highlights include:

• Effectiveness of online and remote child and adolescent mental health interventions

This systematic review investigated the effectiveness of remote and online interventions on mental health outcomes for children, adolescents and young people. Included studies were conducted after the onset of the COVID-19 pandemic. The study found that online/remote interventions had positive effects on mental health outcomes for children, adolescents and young people, however, only one study directly compared online vs face-to-face delivery.

• Waiting list interventions for children and young people using child and adolescent mental health services

Waiting lists for child and adolescent mental health services are growing worldwide. This systematic review explored the evidence base for interventions for children and young people on waiting lists for mental health services, the effectiveness of these interventions on child mental health outcomes and parent outcomes, and factors that support implementation. Most waiting list interventions were aimed at the parent and included psychoeducation; other components included parental support, recommending books and literature and coaching. The study found that there is limited research exploring waiting list interventions, however findings from small-scale studies are promising for improved child behaviour and mental health symptoms, as well as parent’s ratings of acceptability, satisfaction and feasibility of the interventions.

• Promoting children’s physical and mental health via gamification
  

This systematic review looked at whether ‘gamification’- the application of game mechanics to non-gaming contexts – has the potential to promote physical and mental health in children and adolescents. The study found emerging evidence of improved physical and mental health and acceptability of gamification for children and adolescents. However, the risks of additional screen time and possible over-emphasis on competition over co-operation need to be considered.

• Mental health and wellbeing interventions for care-experienced children

This systematic review of process evaluations investigated what supports the implementation of mental health and wellbeing interventions for care-experienced children. Key barriers to implementation included practitioners experiencing heavy workloads, carer’s experiences of feeling under-valued and young people feeling disempowered when their perspectives aren’t considered. Enablers to implementation included young people finding meaningful relationships within interventions, and service systems that support interprofessional relationships.

Why is this important?

• There has been a swift adoption of remote and online interventions in response to COVID-19 related service restrictions and increased mental health difficulties in children, adolescents and young people.
• This study investigates the effectiveness of remote and online interventions on mental health outcomes for children, adolescents and young people, since the onset of the COVID-19 pandemic.

What did they do?

• The authors completed a systematic review of the literature and undertook a meta-analysis to calculate the average effect sizes of the interventions on the mental health of children.
• International studies were included in the review, two were from Australia. Sixteen of these studies were randomised control trials (RCTs) and eight studies focussed on children and adolescents.

What did they find?

• The format of online and remote interventions in the studies varied. Examples included using chat functions in apps, teleconferencing and self-administered video-based strategies/online booklets.
• Several studies reported significant reductions in anxiety and depression and improved social functioning, as a result of the online and remote interventions.
• The meta-analysis reported an overall medium effect (i.e. the difference between the treatment and control groups) for anxiety and social functioning and a strong effect for depression.
• Other outcome measures such as wellbeing, quality of life and self-efficacy showed mixed results with no significant improvements in outcomes for online/remote interventions (there were also fewer of these studies, making it difficult to draw conclusions).

What does this mean for practice?

• Although the systematic review found that online/remote interventions had positive effects on mental health outcomes for children, adolescents and young people, only one study directly compared online vs face-to-face delivery. This limits what can be concluded regarding whether online interventions are comparable or better than face-to-face delivery.
• Online and remote interventions showed promising mental health results, despite their rapid adoption during the COVID-19 pandemic. This suggests that online methods may be a viable option in supporting the mental health of children, adolescents and young people especially when accessibility is a barrier.

Why is this important?

• Waiting lists for child and adolescent mental health services are growing worldwide. Therefore, there is a need to understand how best to support children and adolescents while they wait for mental health services.
• This review explores the evidence base for interventions for children and young people on waiting lists for mental health services, the effectiveness of these interventions on child mental health outcomes and parent outcomes, and implementation factors such as service efficiency, acceptability, and barriers and facilitators to engagement.

What did they do?

• The authors conducted a systematic review of interventions to support children and young people (up to 18 years of age) and/or their family while on a waiting list for child and adolescent mental health services.
• A total of 18 studies were included for analysis; four of the studies were conducted in Australia. The authors report that most studies were of low quality and often exploratory in nature.

What did they find?

• Waiting list interventions were identified for children and adolescents with mental health conditions such as autism spectrum disorders, eating disorders, transgender health, anxiety and depression, self-harm and suicide and behavioural issues.
• The type of interventions varied and many were multicomponent. 94% involved psychoeducation and other components included parental support, bibliotherapy (recommending books and literature) and coaching. Most interventions were aimed at the parent.
• When child-related outcomes were explored (9 studies), many interventions showed positive impacts on child behaviour and mental health symptoms. Seven studies investigated parent-related outcomes such as parent stress, anxiety or depression and the results were mixed and inconclusive.
• The review found that parents highly rated the acceptability, satisfaction and feasibility of wait-list interventions. Families highlighted the need for more frequent and intensive intervention and parent support group/advice lines. Children and young people highlighted the need for more convenient times to attend. Barriers to recruitment into wait-list interventions included concerns that engagement may delay chances of future mental health support for the child/adolescent.

What does this mean for practice?

• Waiting list interventions have the potential to support children, young people and their families while waiting for mental health assessment and/or treatment.
• There is limited research exploring waiting list interventions, however the findings from small-scale studies are promising. The outcomes assessed in most cases are parent and clinician viewpoints, so more research is required on children’s perspectives.
• If waiting list interventions are to be implemented, there needs to be clear communication about their role and purpose. For example, it needs to be clearly communicated that they will not affect the chance of entry into, or replace the need for, future mental health therapeutic support.

Why is this important?

• There has been has a rapid growth of digital technology use and electronic gaming by children and adolescents.
• This study looks at whether ‘gamification’- the application of game mechanics to non-gaming contexts – has the potential to promote physical and mental health in children and adolescents.

What did they do?

• A systematic review of literature from the 2018-2023 English-language studies was conducted on using gamification tools to promote physical and mental health for children and adolescents.
• A total of 44 studies were included in the review and included studies from a mix of qualitative, quantitative primary and secondary studies as well as randomised control trials and systematic reviews.
• The findings are summarised in a narrative approach, providing key themes from the studies, including the ways in which gamification has been used in health promotion, potential benefits and limitations of gamification, and examples of where gamification has been shown to be effective in improving mental or physical health outcomes.

What did they find?

• Examples of gamified interventions and potential benefits include:
  • ‘Excergames’ (e.g. Nintendo Wii Fit, Just Dance) that reward physical activity can make exercise more appealing
  • multiplayer games which can encourage social skills
  • interactive learning games and cooking games for educating children about nutrition, which can promote healthy eating habits.
• Evidence suggests that gamified applications could make health practices more exciting and engaging for children and adolescents, and there is emerging evidence for improved physical health outcomes and acceptability for children and adolescents. However, there is limited evidence for the benefits of physical health applications on mental health.
• Coping, emotional regulation, social skills and mindfulness games can support mental health, and growth mindset games can boost resilience and motivation.

What does this mean for practice?

• Research shows emerging benefits of ‘gamification’ to promote physical and mental health in children and adolescents; however, it is important to balance this with awareness of the risks of additional screen time and possible over-emphasis on competition over co-operation.
• Multidisciplinary teams of health professionals, educators, game designers and psychologists may be required to develop games to ensure efficacy, safety and benefit to young people.

Why is this important?

• Children and young people who have experienced out-of-home care tend to have higher levels of mental health difficulties.
• There are existing systematic reviews for interventions to support the mental health of children who have experienced out-of-home care, but most of these only report on outcomes. This review provides a synthesis both of intervention outcomes and what supports the implementation of interventions, i.e. what works and why.

What did they do?

• A systematic review of process evaluations was conducted between 1990-to 2024, and included a broad search of academic databases, websites of social and healthcare organisations and existing systematic reviews.
• There were 50 stand-alone process evaluations included in the analysis. These evaluations provided qualitative insights about how interventions might interact with complex systems. Most included studies were from the UK and USA, with one from Australia.

What did they find?

• There were a diverse range of interventions such as those targeting skills and knowledge of care experienced young people, changing relationships between carers and care-experienced young people, mentoring programs, therapeutic approaches (e.g. trauma-based cognitive behavioural approaches), and alcohol and substance use interventions. Some interventions were multi-component and complex; for example, providing a holistic package of support and wrap-around services.
• Three key themes were identified from the qualitative findings:
  • Those working in social care reported heavy workloads and unsupportive workplace cultures as challenges to implementing interventions (e.g. due to competing care priorities) and attendance at training sessions.
  • Care-experienced young people can disengage from interventions when they feel disenfranchised or disempowered. This can include young people feeling unable to express opinions about participation and/or feeling they are to blame if interventions break down.
  • Children and young people value building positive, meaningful relationships within interventions, particularly where those relationships are with individuals who understand or have experienced care.
• Other themes that were identified from the qualitative findings:
  • Intervention burden may limit both professionals’ and young people’s engagement with interventions. Intervention burden includes the time, cognitive and emotional burden of implementing or participating in an intervention.
  • Tensions between health and social care professionals can limit the effectiveness of interventions that are reliant on multi-agency communication and collaboration. A system that supports interprofessional relationships is needed for successful implementation.
  • Carers often feel their expertise and history of parenting practices are not valued in interventions.

What does this mean for practice?

• When implementing programs to support the mental health of children and young people who have/are experiencing out-of-home care, it is important to consider factors that enable successful implementation such as acceptability, coordination and integration of multiple types of professionals working together, workload and workplace cultures.
• There is a need for interventions to be well resourced and ensure the needs and voices of young people are prioritised in the design and implementation process.