Highlights in child mental health research: June 2023

This month’s highlights include:

• Implementing a trauma-specific intervention in a child mental health service

This study evaluated the effectiveness of trauma-focused cognitive behaviour therapy (TF-CBT) for a small sample of trauma-exposed young people, aged 9-17 years. TF-CBT was associated with significant improvements in participant PTSD symptom severity and general mental health. Many participants were receiving ongoing support for their mental health 2 years after TF-CBT, reflecting the need for ongoing, long-term supports.

• Service contact for self-harm and suicidal ideation among children and adolescents

This study analysed patterns of service contact for self-harm and suicide-related incidents among children (from birth to 18 years). Records from emergency departments, inpatient hospital admissions, mental health ambulances, child protection and police administration were utilised. Child protection services were the most common service to have contact with children and young people for self-harm and suicidal ideation. Children and young people were more likely to have a recorded contact for self-harm or suicidal ideation with all service types if they were Aboriginal and/or Torres Strait Islander, had a parent with mental disorder and/or had a parent with a criminal conviction.

• Impact of childhood trauma on cognitive functioning in adults with mood disorders

This study aimed to provide insights into the role of childhood trauma on cognitive outcomes for people with mood disorders. A history of childhood trauma was found to have significant association with some, but not all measures of cognitive functioning amongst adults with mood disorders. The associations with cognitive outcomes and childhood trauma differed between adults who were currently experiencing an episode of mood disorder, compared to those who were not.

• Canadian service providers reimagining mental health care for newcomer families

This study interviewed service providers who worked with newly arrived migrant and refugee families in Canada to understand their perspectives on the barriers and opportunities for improved mental health service access and effectiveness. Interviews highlighted several opportunities for improved mental health care for newcomer migrant and refugee families, including an emphasis on structural/ systematic change, prioritisation of prevention and early intervention strategies, promoting the cultural responsiveness and humility of services and professionals, and adopting multidisciplinary and family-centred models of care.

Why is this important?

• Trauma-informed care and trauma-specific therapies are needed to support the high rates of young people with exposure to childhood adversity who are attending mental health services.
• This study evaluated the effectiveness of trauma-focused cognitive behaviour therapy (TF-CBT) delivered in a Child and Adolescent Mental Health Service (CAMHS).

What did they do?

• Young people (n=24, aged 9-17 years) who had been exposed to a potentially traumatic event participated in TF-CBT in a CAMHS in Canberra.
• TF-CBT is a trauma-focused approach that can include elements of CBT including talk therapy, exposure therapy, and Dialectical Behavioural Therapy (DBT). TF-CBT aims to support skills in relaxation, regulation, coping and processing, and includes psychoeducation and conjoint parent-child sessions. In this study, most participants received the full suite of TF-CBT components as intended. The average number of therapy sessions received per participant was 17.6.
• A pre-post study design was used to compare symptoms of posttraumatic stress disorder (PTSD), general mental health and functioning. A secondary aim was to explore if participants were still receiving CAMHS services 3 months and 2 years after TF-CBT.

What did they find?

• Participants often had experienced multiple potentially traumatic events, including sexual abuse (experienced by 70.8% of participants), emotional abuse (54.2%) and physical abuse (50%). At baseline, suicidal thoughts were experienced by all participants and almost all (91.7%) had a history of self-harm, half (50%) had attempted suicide, and almost half (45.8%) had a record of a prior mental health-related hospital presentation.
• TF-CBT was associated with statistically significant improvements in PTSD symptoms severity, general mental health symptoms, and mental health functioning.
• About a third (33.3%) of participants were still attending public mental health services at 3 months post-TF-CBT and 41.7% were 2 years after.

What does this mean for practice?

• Trauma-informed and trauma-specific therapies are needed to support children attending CAMHSs who have high rates of adversity, trauma, self-harm and suicidal ideation.
• Clinicians should be mindful of the likelihood that trauma-exposed clients may have experienced multiple traumas, multiple mental health issues and experienced suicidal thoughts and/or self-harm.
• In this sample, TF-CBT was effective at minimising PTSD symptoms and improving the general mental health and general functioning of young people.
• Ongoing, long-term supports are likely to be necessary for trauma-exposed young people to maintain improvements to their mental health following TF-CBT.

Why is this important?

• Understanding the services that children and young people (CYP) access when they are experiencing self-harm and suicide-related incidents, can help inform service delivery and indicate where further support is needed to assist CYP.

What did they do?

• This study used linked multi-agency data from 91,597 CYP in New South Wales (NSW).
• The authors analysed patterns of service contact for self-harm / suicide-related incidents for CYP (from birth to 18 years). The researchers used records from health services (e.g., emergency departments, inpatient hospital admissions, mental health ambulances), and social services (e.g., child protection and police administration records).

What did they find?

• 7% (n=5,212) of the total sample had a reported incident for self-harm and/or suicidal ideation. Approximately half (51.9%) of children with a reported incident of self-harm and/or suicidal ideation also had a record of contact with a health service for a mental disorder.
• Child protection services had the most contact with CYP with reported self-harm and/or suicidal ideation. About two thirds (67.4%) of CYP with self-harm/suicidal ideation had contact with child protection services. The next most frequently contacted services were hospital emergency departments (35.7% of CYP with self-harm/suicidal ideation had a service contact), inpatient hospital administration (19.2%), mental health ambulatory (13.5%), and police services (4.0%).
• 2% of CYP who had contact with child protection services for self-harm and/or suicidal ideation had later contact with health services. It took an average of almost a year (349 days after contact with child protection) for CYP to be referred on and receive access to health services for self-harm and suicidal ideation. For CYP with contact with police services for self-harm and/or suicidal ideation, it took an average of over two years (753 days) for them to be referred on and receive access to health services.
• Children were more likely to have a recorded contact (with all service types) for self-harm and/or suicidal ideation if they were Aboriginal and/or Torres Strait Islander, had a parent with a mental disorder, and/or had a parent with a criminal conviction.

What does this mean for practice?

• Child protection services respond to a significant proportion of CYP experiencing self-harm and suicidal ideation.
• Self-harm and suicidal ideation in CYP are a concern, not only for health services, but also significantly for child protection services. Staff working in child protection services require training and resourcing to respond appropriately, including ensuring that CYP receive referral to mental health services.
• Around half of CYP with service contact for self-harm and/or suicidal ideation had a record of previous mental health service use. This suggests that many CYP with mental health concerns may not be being reached by services or receiving support until they are at crisis point.

Why is this important?

• Impaired cognitive functioning is a common feature of mood disorders. Poor cognitive outcomes, including cognitive functioning and impairment can affect functioning and quality of life. Childhood trauma is also a risk factor for poor cognitive functioning.
• This study aimed to provide insights into the long-term influence of childhood trauma on cognitive outcomes among adults with mood disorders.

What did they do?

• Authors conducted a systematic review of literature published prior to 2022. Studies included in this review (n=17) included adults with a mood disorder diagnosis (including major depressive disorder and bipolar disorder).
• Studies compared cognitive outcomes of patients who had, or had not, experienced childhood trauma. Studies were found to mostly be conducted with either individuals currently experiencing mood disorder episode (in-episode) or those in a stable mood.

What did they find?

• There were mixed findings on the influence of childhood trauma on cognitive functioning for participants with a mood disorder. Findings were influenced by the mood state of the participant when cognitive function was tested, symptom severity and different contexts and diagnosis across the studies included.
• For individuals with mood disorders who were in a stable mood, a history of childhood trauma was found to have a significant association with poorer global cognitive functioning (in 3 of 4 studies) and poorer executive functioning and attention (in 6 of 6 studies).
• For individuals who were experiencing a current episode of a mood disorder, a history childhood trauma was associated with significantly poorer psychomotor speed (in 5 of 7 studies), but mixed impacts were found for executive functioning and attention.
• The association between childhood trauma and non-verbal learning and memory was mixed.

What does this mean for practice?

• Understanding childhood trauma as a contributing factor to cognitive impairment can help professionals recognise individuals with mood disorders who may have persistent cognitive concerns.
• However, it is important to note that cognitive functioning of people currently experiencing a mood disorder episode is likely to differ to when they are not experiencing an active episode.
• Implementing trauma-informed care can help create a safe environment that is conducive to effective support for individuals with mood disorders and cognitive impairment.

Why is this important?

• Refugee and immigrant families can experience barriers to accessing effective mental health (MH) services. This study aimed to inform strategies for improving MH care access and effectiveness by identifying barriers and opportunities for improved care.

What did they do?

• Researchers conducted a series of individual and group interviews with leadership and frontline staff across health, education, settlement, and social services sectors that provide support to newcomer (migrant and refugee) families in Canada.
• They examined the service providers’ perspectives on the barriers and opportunities for improved MH supports for newcomer children and families.

What did they find?

• Service providers identified structural/ systemic barriers, provider-level barriers and, to a lesser extent, individual/ family level barriers for newcomer families accessing effective MH care.
• Structural and systemic level barriers to MH service access and effectiveness included inadequate funding and services, systems that are complex and difficult to navigate, language and cultural barriers, and a lack of preventative/early identification measures.
• Provider-level barriers to MH service access and effectiveness included a lack of provider diversity and representation, staff shortages and burnout, and insufficient MH knowledge and cultural competency among service providers (e.g., settlement workers did not always have training in MH).
• Individual and family level barriers to MH service access and effectiveness involved limited MH literacy among families, prioritisation of settlement needs over MH, stigma and fear associated with help-seeking. Participants felt these barriers could reduce family’s initiation of MH service use for their children until a point of crisis.
• Service provider suggestions for how MH care systems could be improved included meaningful engagement with newcomers in decision-making, adopting person- and family-centred care (e.g., ‘meeting people where they’re at’), promoting cultural responsiveness and humility, investing in MH promotion and prevention, enhancing practitioner and organisational knowledge, diversifying the workforce, and integrating care across various services.

What does this mean for practice?

• The authors provided insights on how MH service access could be improved. For example:
  • MH services can co-locate with other commonly used services (e.g., settlement services) and be coordinated by a multidisciplinary team to address the material and social stressors of newcomers alongside MH concerns.
  • Services could be embedded in community settings, employ culturally diverse professionals, and provide professional development in cultural competency to staff to reduce stigma and mistrust.
  • Adoption of community-based and collaborative models of care can also support effective service delivery.
  • MH prevention and early intervention strategies should be prioritised, to reach newcomer families before a crisis is reached.