Highlights in child mental health research: July 2023

This month’s highlights include:

• Australian child protection contact pre-birth and during infancy

This study analysed data (from 2012-13 to 2018-19) on child protection notifications, substantiations, and out-of-home care (OOHC) placement for children in the prenatal period and for infants (aged <1 year). The study found significant variation between states and territories in relation to how data is collected and trends over time in child protection contact. Nationally, child protection notifications increased by an average of 3-4% each year between 2012-13 and 2018-19. Rates of infants being admitted into OOHC also increased nationally on average by 2% each year. Aboriginal and Torres Strait Islander infants experienced contact with child protection services at significantly higher rates than non-Indigenous infants.

• Parent experiences of seeking support for a child with an eating disorder

This study explored the experiences of Australian parents of children with an eating disorder (ED). Most parents were the first to identify signs of ED in their child. On average, parents and children saw 3-4 therapists before they found a therapist they considered helpful. Parents perceived significant impacts on their wellbeing as result of caring for a child with an ED and navigating help-seeking, but only around half of parents had accessed support for themselves. The financial costs of seeking support for ED created socioeconomic strain for families and was a barrier to timely and consistent treatment.

• Family therapy for depression and suicidal ideation in adolescents

This systematic review investigated the effectiveness of family therapy for the treatment of depressive disorder and of suicidal ideation in adolescents. Across the 10 studies analysed, the paper concluded that family therapy was no more or less effective than other therapies for treating depression in adolescents, but family therapy was potentially more useful for suicidal ideation in adolescents when compared with other approaches. The authors suggest that further research is necessary to make firm conclusions about the benefits of family therapy in comparison to other therapies for adolescent mental health.

• A review of adverse childhood experiences (ACEs) and long-term outcomes

This systematic review analysed 22 studies to better understand the mediating and moderating mechanisms that may underpin the relationship between adverse childhood experiences (ACEs) and negative physical health and mental health outcomes. Consistent with existing research, the paper found that ACEs were associated with long-term mental and physical health challenges. However, the underlying mechanisms that unpin the relationship between ACEs and poor outcomes remain unclear due to the variability in study designs, and the differences in ACEs, outcomes, and mediator/moderators used in the reviewed studies.

Why is this important?   

• In Australia, infants have the highest rates of involvement with child protection of any age group. There is a concerning trend of increasing child protection involvement prior to birth (pregnancy) and amongst infants.

What did they do?

• This study analysed Australian Institute of Health and Welfare (AIHW) data on child protection contact in the prenatal period and for infants (children aged under 12 months) between 2012 and 2019.
• Data included child protection notifications (reports alleging possible maltreatment or risk of harm to a child), substantiations (confirmation following an investigation that a child is at risk of harm) and out-of-home care (OOHC)

What did they find?

• There was significant variation across Australian state and territories in terms of the child protection data that is collected, and the trends in child protection and OOHC contact for children pre-birth and during infancy. As a result, jurisdictional variation influenced national averages.
• At a national level, the rate of children with prenatal and infant child protection notifications increased by an average of 3-4% each year (between 2012-13 and 2018-29). Approximately one third of all notifications were substantiated (i.e., investigation indicated that children were at risk of harm).
• The rate of prenatal and infant child protection notifications for Aboriginal and Torres Strait Islander children were more than four times the national average (in 2018-19).
• Nationally, the rate of infants entering OOHC increased on average by 2% each year between 2012 and 2019. Most jurisdictions experienced increased rates of infants entering OOHC over time. Victoria experienced the largest increase of infants entering care with an average increase of 6% per year. NSW was the only state to experience a decrease in OOHC admissions over time.
• Nationally, the rate of Aboriginal and Torres Strait Islander infants entering OOHC was almost six times the national rate (in 2018-19). Trends over time in the numbers of Aboriginal and Torres Strait Islander infants entering OOHC varied by jurisdiction.
• In 2018-2019, approximately one quarter of the infants admitted to OOHC were removed in the first week following birth and almost half (45%) were removed within the first month.

What does this mean for practice?

• Prenatal and infant child protection involvement differ between jurisdictions and some states lack data collection or monitoring for pre-natal child protection involvement.
• Nationally, the rates of child protection involvement before birth, and in infancy, appear to be increasing.
• The removal of Aboriginal and Torres Strait Islander infants into OOHC is increasing in most states, despite over-representation of Aboriginal and Torres Strait Islander children in OOHC being a key Closing the Gap
• There is a need for prevention of child protection involvement in the prenatal and infancy period, particularly for Aboriginal and Torres Strait Islander families. Family-led participation and decision-making and culturally embedded care should be supported in service delivery.

Why is this important?

• Parent involvement is an important element in recovery from eating disorders (EDs).
• Previous research has explored the parent experience of caring for a child with an ED, but there has been less research on parent experiences of seeking treatment.

What did they do?

• This study used an online survey to explore the experiences of Australian parents (n=480) with a child who had an ED. The survey explored issues relating to ED detection, experiences accessing ED treatment, and impacts of help-seeking experiences on parent wellbeing.

What did they find?

• Most parents had a child with anorexia nervosa (81.9%), while other disorders were less common (bulimia nervosa: 3.5%, avoidant and restrictive food intake disorder: 5.2%, other specific feeding and eating disorders: 7.3%, binge eating disorder: <1%). Almost all parents (96.8%) indicated their child had a comorbid mental health condition, including depression (56.9%), anxiety (81.9%), obsessive-compulsive disorder (31.3%), self-harm (29.3%), and suicidal ideation (23.8%).
• Most parents (81.3%) were the first person to identify signs of an ED in their child. Parents saw a GP on average 4 months after their initial after symptom detection, and a therapist on average 6 months after their initial symptom detection.
• Parents saw an average of 3-4 different therapists before they found a therapist they considered helpful for supporting their child.
• Most parents reported significant impacts on their own mental health and wellbeing related to their child’s ED and help-seeking experiences. Parents who had a child with a current ED had significantly higher scores of depression, anxiety and stress (on the DASS-21) compared to parents of children whose ED was considered recovered. Just under half (48.8%) of parents had accessed support for their own mental health.
• Almost all parents (92.7%) had experienced deterioration in their relationship with their spouse.
• Families also experienced significant socioeconomic strain. Most parents experienced out-of-pocket treatment costs (91.8%), with median expenses between $10,000-$20,000. On average, households needed to take off 70 days (or 14 working weeks) from work to support their child’s recovery. 13.9% of parents had lost their job or had to stop work completely to support their child.
• More than a third of parents arranged for appointments to be less frequent than they would like due to the financial pressures of treatment. Families who could financially afford consistent and regular treatment sessions were three times more likely to report that their child had recovered from their ED.

What does this mean for practice?

• Parents play an important role in symptom detection for ED and can be a valuable resource to help children with EDs. However, there is a need to improve practitioner awareness of EDs to ensure children are identified earlier.
• There is also a need to reduce other barriers to help-seeking including financial barriers to effective treatment and support. Parents and children often experience barriers to effective treatment and support, which can strain family wellbeing. Financial costs of treatment for EDs are high and can present a significant barrier to treatment access and can reduce rates of recovery.
• There is a need for greater support for parents and carers of children with EDs, including support for their physical and mental health, and relationship support. It may be important for services to reach out to parents of children with EDs to support them considering they experience significant psychosocial challenges, and around half will not access support for their own mental health. The authors propose that carer support programs, parent-led support groups, and skills-based workshops may hold promise.

Why is this important?

• Family functioning is a key determinant of adolescent mental health. Healthy family functioning can be a protective factor, whilst conversely, poor family functioning can be a risk factor for depression and suicidal ideation.
• Family therapy is a psychotherapeutic approach that aims to support the healthy interaction between family members and/or the healthy functioning of families. This study aimed to explore the utility of family therapy for depression and suicidal ideation in adolescents compared to other treatment approaches.

What did they do?

• The authors reviewed studies of randomized controlled trials (RCTs) published prior to April 2020 that explored family therapy for the treatment of depressive disorder or suicidal ideation in adolescents (9-18 years) compared to other treatments or treatment as usual.
• Two separate meta-analyses were conducted: one for depression outcomes and one for suicidal ideation outcomes. Secondary outcomes included social functioning and relationships, quality of life, and family conflict.

What did they find?

• In the 10 studies that met the inclusion criteria, mental health outcome measures included the Children Depression Inventory (CDI), Beck Depression Inventory (BDI-II), The Short Moods and Feelings Questionnaire (SMFQ), Hamilton Depression Rating Scale (HAMD), and the Suicidal Ideation Questionnaire-Junior (SIQ-JR).
• Various family therapies were examined, including Attachment Based Family Therapy (ABFT), Family-Focused CBT (F-CBT), and Systems Integrative Family Therapy (SIFT). Comparison treatments included Cognitive Behavioural Therapy (CBT) and psychodynamic therapy.
• The meta-analysis for depression outcomes showed no significant differences in depression levels for adolescents who received family therapy compared to other treatments or treatment as usual.
• The meta-analysis for suicidal ideation outcomes showed family therapy was associated with a significant benefit in levels of suicidal ideation, compared to other treatments.

What does this mean for practice?

• This study indicates that family therapy is as effective as other therapies for depression in adolescents. However, family therapy is potentially more useful for suicidal ideation compared to other approaches.
• Due to variations between different types and methods of family therapy, drawing broad conclusions across all family-based treatments is challenging. Further research is necessary to make firm conclusions regarding the functionality of family therapy compared with other treatments.

Why is this important?   

• The relationship between adverse childhood experiences (ACEs) and poor child development and mental health outcomes has been well established. However, the underlying mechanisms (moderators/meditators) that underpin this relationship are not as well understood and studies have been limited by cross-sectional findings or methodological issues.
• This study aimed to understand the relationship between ACEs and negative mental health and physical health outcomes, as well as possible mediating and moderating mechanisms that influence this relationship.

What did they do?

• A systematic review of literature published prior to March 2020 was conducted for prospective longitudinal studies that explored the impact of ACEs/adversity on physical health and mental health outcomes in adulthood, and possible moderating/mediating factors. 22 studies published between 2006 and 2020 were included in the review.
• The review included studies that explored ACEs including child maltreatment (abuse, neglect, harsh punishment, limited caregiver warmth), adverse family-level experiences (e.g., household mental illness, alcohol or drug use, family and domestic violence, financial stress, etc.), and ‘other’ experiences.
• Included studies explored various mediators/moderators (including depression symptoms, smoking and alcohol intake, body mass index, education, socioeconomic variables), and various outcomes across physical health (inflammation, chronic illness, mortality, cancer), and mental health (mood disorder symptoms, drugs or alcohol dependence, suicidal ideation, borderline personality disorder, psychotic experiences).

What did they find?

• Consistent with previous research, ACEs were associated with long-term adverse outcomes across mental health and physical health. However, the moderating/mediating mechanisms underpinning the relationship between ACEs and adverse outcomes were not clear.
• This lack of clarity was due to significant variation in study design and outcomes across the included studies, and few studies examined the same cohorts, ACEs, mediators/moderators, or outcomes. Moreover, many of the mediators/moderators and outcomes were overlapping. For instance, mental health symptoms or disorders were often explored as the mediators/moderators for other mental health outcomes (e.g., depression and anxiety as mediators, and psychotic experiences as the outcome).
• There was some evidence that psychological distress in childhood may moderate/meditate the relationship between ACEs and poor mental health outcomes in adulthood (e.g., depression, drug and alcohol dependence, suicidal ideation). However, these findings are preliminary and require further exploration and validation.

What does this mean for practice?

• There is well established evidence that ACEs increase the risk for long-term mental health and physical health challenges. However, the underlying mechanisms that drive the relationship between ACEs and poor mental health outcomes continue to remain poorly understood.
• More research is needed to understand the possible moderating or mediating factors that underpin the relationship between ACEs and adverse outcomes.