Highlights in child mental health research: January 2020

Highlights:

• This systematic review explored the factors that impact on children and adolescents’ seeking and accessing help from professionals for their mental health difficulties.
• The review included 53 studies (both quantitative and qualitative). Studies were required to have a mean sample age of a maximum of 18 years.  The age of participants ranged from 7 to 21 years old.
• 20% of the studies included were conducted in Australia.
• The review identified four themes related to barriers and facilitators to children and adolescents’ seeking and accessing professional help for their mental health difficulties. These themes were:

1. Individual factors (reported in 96% of studies) – Examples included the level of knowledge about mental health and associated services, attitudes towards seeking help, perceptions about whether difficulties were severe enough to warrant help, and perceptions about how effective professionals might be.
2. Social factors (92% of studies) – Examples included stigma, perceived embarrassment, perceived implications of seeking help for their social connections (e.g., removal from parents, loss of peer status), and views about mental health and seeking help amongst their support network (e.g. family, friends) and the wider community.
3. Client-professional relationship factors (68% of studies) – Examples included perceptions about confidentiality and trust levels towards professionals who are unknown to them.
4. System and structural factors (58% of studies) – Examples included logistical issues (e.g., insufficient time, transport issues, financial costs) and availability issues (e.g., waiting times) associated with accessing professional help.

• These “findings highlight many potential ways to improve access to treatment” for children and adolescents who are experiencing mental health problems. Examples provided by the researchers include:
  • Providing targeted and evidence-based Interventions and public health initiatives that aim to reduce mental health sigma and improve children and adolescent’s knowledge (i.e. literacy) about mental health and help-seeking. The researchers propose that this should include awareness raising about what they can expect from professionals and services (e.g., requirements like confidentiality).
  • Ensuring that professional support for children and adolescents with mental health problems is widely available and sufficient. The researchers propose that offering services in the school setting might help to reduce potential barriers (e.g., through reducing the effort needed to access help, minimising the potential impact of transportation and insufficient time, and offering help in a setting that is potentially less stigmatising).

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Highlights:

• A main challenge faced by the mental health sector is linking children and families to timely services when child mental health problems arise.
• Numerous barriers exist that can prevent families from accessing child and adolescent mental health care. One potential barrier is the level of engagement of a family with child and adolescent mental health services (CAMHS).
• This scoping review of 40 studies identified the main factors that can influence the engagement of families with child and adolescent mental health services. It also investigated intervention models that seek to promote engagement of families with these services.
• From their review of 26 studies, the researchers found that key factors associated with the engagement of families with CAMHS included:
  • The attitudes of the child/adolescent and family towards mental health problems, mental health treatment, and help-seeking.
  • Logistical challenges associated with service access (e.g., insufficient time to attend due to employment commitments; problems with accessing childcare; transport difficulties).
  • The availability and flexibility of mental health services (e.g., long waiting times between referral and initial appointment; no after-hours options; limited flexibility in appointment times/locations).
  • The level of integration and coordination between different systems (e.g., health care, social care).
  • Healthcare system issues (e.g., treatment costs; shortages of mental health practitioners).
• From their review of 14 studies, the researchers identified models of intervention that aim to promote the engagement of families with mental health services. These interventions included:
  • “Family outreach…[i.e.] a collection of interpersonal approaches designed to build rapport, educate, share information and facilitate connections to needed services” (p. 5).
  • “Telephone and digital health strategies [i.e.] those which relied on technology to facilitate provider-client communication, provide psychoeducation, coordinate referrals and follow up, and deliver clinical services” (p. 5). Technology was sometimes used to help overcome barriers to engagement.
  • “Integrated care approaches [i.e.] policies and practices that were designed to support the intentional and systematic coordination of care and sharing of information within and between health and social care organisations” (p. 5).
• While the researchers indicated that the evidence appeared “strongest for family outreach and integrated care approaches,” they noted that telephone and digital health strategies may still hold promise as they are currently under-researched (p. 2).
• Practitioners and service providers in the healthcare and social care sectors are well-positioned to use the factors reported in this study to help identify barriers to family engagement in their own local settings (including in relation to specific families for practitioners).
• Practitioners and service providers could explore whether some of the engagement approaches above (e.g. family outreach) might be appropriate in their local context when seeking to develop, implement and evaluate intervention strategies that support family engagement.

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Highlights

• This study investigated protective factors associated with having no adverse childhood experiences (ACEs) despite having been identified as being at high risk of ACEs. Examples of ACEs include physical abuse, emotional abuse, and parental or partner substance misuse
• The researchers used data from the Growing Up in New Zealand (GUiNZ) longitudinal birth cohort study.
• Of the entire study cohort, there were 790 children that were identified as being at greatest risk of ACEs. 164 of these 790 children did not have observed ACEs by age 4.5 years despite this increased risk.
• Protective factors that were significantly associated with high-risk children demonstrating no observed ACE’s (grouped according to domains) were:
  • Relationship between mother and partner – For example, decreasing reports of the mother and partner shouting at the other when upset. 40% of all protective factors identified were within this domain.
  • Finances of the family – For example, reports of the mother or partner receiving unemployment benefits. 22% of all protective factors were in this domain.
  • Parental wellness and health – For example, stronger self-reported health.
  • Neighbourhood or community – For example, mothers reporting a social network in the form of a baby/parent group.
  • Relationship between parent and child – For example, the mother’s partner reporting taking an active interest in the baby.
• As the researchers highlight, these protective factors offer useful domains for practitioners, service providers and policy-makers to reflect upon when considering how to best support high-risk families. For example, these factors could assist the design of  preventative programs and services for families at high-risk of adverse childhood experiences.
• This study supports the need for family supports, programs and interventions that focus on the mother-partner relationship (e.g., relationship education programs, which have also shown early evidence for also improving children’s mental health).
• Walsh and colleagues propose that further research is needed to determine how to best integrate relationship education into existing services and supports. They suggest a role for child welfare professionals in this education.
• The researchers also highlight the need for relationship education programs to be culturally-sensitive given that a large number of high-risk families tend to be from culturally and linguistically diverse backgrounds.

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Highlights:

• Most studies exploring the impact of adverse childhood experiences (ACEs) on mental health have used an overall score to determine a cumulative level of risk. That is, the majority of studies have not distinguished between individual questionnaire items – nor the separate effects of household dysfunction versus

• This study used a sample of 454 adolescents (aged 9 to 13 years at baseline) to compare the effects of household dysfunction versus childhood maltreatment on subsequent mental health outcomes. Follow up data was used when the adolescents were aged around 18 years old (i.e. at 7.2 years after baseline).

• Examples of items on the household dysfunction scale of the ACEs questionnaire include parental divorce, substance use by a member of the household, incarceration of a member of the household, and witnessing intimate partner violence.
• Examples of items on the maltreatment scale include physical abuse, sexual abuse, emotional abuse, and physical neglect.
• Consistent with past research, it was found that “the maltreatment scale of the ACEs questionnaire drives the effects of ACEs on mental health outcomes” (p. 6).
• Once maltreatment experiences were controlled for in the analysis, household dysfunction did not have significant effects on any mental health outcomes. In contrast, when household dysfunction was controlled for, maltreatment still had significant effects on all mental health outcomes (i.e. depression, trauma, anxiety, externalising behaviour).
• The researchers conclude that their findings support maltreatment events [e.g. abuse, neglect] as having a more salient effect on subsequent mental health.
• Importantly, these results do not mean that that household dysfunction does not have an impact on mental health. Rather they suggest that maltreatment is a stronger predictor of subsequent mental health problems.
• Importantly, “witnessing intimate partner violence was the primary item on the household dysfunction scale to show main effects on mental health outcomes” (p. 6).
• These findings are important because the ACEs questionnaire is frequently used to obtain a “cumulative score,” but this disregards the possibility that different ACEs items may have different impacts on mental health.
• The researchers suggest their findings caution practitioners “against only using the total ACEs score in clinical decision-making” (p. 1). Rather than using a cut-off score for clinical decisions and referrals for mental health support, it is suggested that practitioners only use this approach when it is supported with additional exploration into the kinds of ACEs that have been endorsed.
• Further research is needed to explore the specific effects that different kinds of ACEs have on mental health outcomes.

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Highlights:

• Can a behavioural sleep intervention for attention-deficit/hyperactivity disorder (ADHD) lead to improvements in child wellbeing? – This was the question that Australian researchers sought to answer in this randomised controlled trial.
• Participants were 244 Victorian children (aged 5 to 13 years). All children demonstrated moderate/severe sleep problems and were required to meet criteria (i.e. American Academy of Sleep Medicine Criteria) for a sleep disorder based on parent report.
• Participants were randomly allocated to either a control group (care as usual, n = 89) or an intervention group (n = 94). Children were followed up at 12 months.
• The behavioural sleep intervention consisted of two face-to-face sessions with a trained practitioner that covered “sleep hygiene and standardised behavioural strategies” (see p. 3 for intervention details).
• Children who participated in the sleep intervention were less likely to still have moderate to severe sleep problems 12 months later (compared to those that received usual clinical care). They also showed fewer sleep difficulties overall.
• Children who participated in the sleep intervention showed better results (compared to care as usual) on parent reports of:
  • ADHD symptoms
  • quality of life
  • daily functioning
  • behaviour
• Overall, the researchers concluded that “a brief behavioural sleep intervention [for ADHD] was associated with sustained benefits 12 months later, albeit small, across numerous [child wellbeing] outcomes” (p. 7).
• These findings support practitioners providing assessment, support and review of sleep problems in children with ADHD (e.g., assessing the sleep problem; providing parent education about normal sleep, sleep cycles and sleep hygiene; providing management strategies for sleep problems). Doing so may have the potential for positive effects on children’s wellbeing and daily functioning.

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Highlights:

• This review paper provides a helpful summary of the current state of evidence on Autism Spectrum Disorder (ASD). This may assist practitioners with the early identification, diagnosis and intervention with children who present with the disorder.
• The article provides updates regarding:
  • prevalence rates
  • risk factors (e.g. genetic, maternal health, neurological)
  • protective factors
  • trajectories in brain development and behavioural development
  • early identification, diagnosis and intervention
• The review highlights the significant need for additional research into protective factors and resilience processes (i.e. why do some individuals with ASD go on to demonstrate better outcomes than others?). This will be critical for developing early identification and intervention strategies – and attempting to alter developmental trajectories and outcomes.
• Unfortunately to this point, most research has focused on risk factors rather than protective factors.

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