Highlights in child mental health research: November 2023

This month’s highlights include:

• Assessing the impact of blue and green spaces on the mental health of children with disability

This scoping review identified relationships between exposure to blue and green spaces and mental health among children with disabilities. Results broadly showed that access to green spaces was associated with better mental health outcomes (relating to emotional, cognitive, or behavioural outcomes) for children with disabilities. Overall, the effect of green spaces on mental health was influenced by sociodemographic (e.g., gender, household income), personal/parental health (e.g., parental mental health history), and environmental/contextual (e.g., air pollution) factors, however there was not a consistent effect between studies.

• Early parenting interventions to prevent internalising problems in children and adolescents
  

This systematic literature review and network meta-analysis of randomised controlled trials (RCTs) examined the effect of parenting interventions (interventions with a central focus on parenting abilities or behaviours) on internalising problems in young children. Parenting interventions that focused on the parent-child relationship were effective in reducing internalising and externalising problems compared to treatment as usual. Evidence suggested that being placed on a waitlist increased internalising problems. However, there was little supporting evidence that early parenting interventions had lasting beneficial effects (after 3 or more years) on reducing internalising problems in children.

• Emotional behavioural outcomes of children with unilateral and mild hearing loss

This study examined the relationship between hearing loss and emotional, behavioural and health related quality-of-life (HRQoL) and parental distress outcomes. Data from 339 children (aged 5-12 years) with hearing loss (HL) enrolled in the Victorian Childhood Hearing Longitudinal Databank was analysed.  The study indicated that around 1 in 5 children with different types of hearing loss had emotional and behavioural difficulties; most commonly hyperactivity and poor social behaviours. The prevalence of HRQoL, and parental distress scores, were higher in children with unilateral/mild HL or moderate to profound HL  than children without hearing loss.

• Mothers’ experiences of emotional abuse and its associations with child development

This study sought to understand how children’s exposure to their mother’s experience of emotional intimate partner violence (IPV) when the child was 3-5 years old is linked to child developmental outcomes at age 5. Data was analysed from 194 Australian mothers who were recruited based on their experience of adversity during pregnancy. The authors found that 57% of mothers in the study had experienced emotional IPV at least once when the child was 3-5 years old. Children exposed to emotional IPV had poorer outcomes at 5 years than children who were not exposed. The differences were most evident in the internalising and externalising symptoms.

• Economic evaluations of digital health interventions for children and adolescents

This systematic review of economic evaluations of digital health interventions (DHI) for children and adolescents (1-18 years) aimed to understand the cost-effectiveness of DHIs. 82% of the included studies concluded that DHIs are cost-effective or cost saving in comparison to the non-digital standard of care. Cost-effectiveness was mostly dependent on implementation costs, supervision/training of health care professionals, intervention effect size, and the potential for the intervention to be scaled up.

Why is this important?

• Recent research demonstrates positive relationships between time spent in blue (e.g. lakes, rivers, shorelines) and green spaces (e.g. national and urban parks) and positive mental health outcomes for children. However, the impact of blue and green spaces on mental health for children with disabilities is relatively unexplored.
• This study aimed to identify relationships between exposure to blue and green spaces and mental health among children with disabilities.

What did they do?

• The authors conducted a literature scoping review using the PRISMA-ScR method to identify original peer-reviewed studies that considered how blue and green spaces affect the mental health of children with disabilities.
• 20 papers published between 2010 and 2022 were included, with a mix of quantitative and qualitative studies from the US, Europe, and Asia.

What did they find?

• Most studies focused on green space, with only one study exploring the impact of time spent in blue spaces on the mental health of children with disability. Studies typically focused on the availability or accessibility of green space, rather than their quality or how they were used.
• Results broadly showed that access to green spaces was associated with better mental health outcomes (e.g., relating to emotional, cognitive, or behavioural outcomes) for children with disabilities.
• Some studies accounted for possible confounding factors. Overall, the effect of green spaces on mental health was influenced by sociodemographic (e.g., gender, household income), personal/parental health (e.g., parental mental health history), and environmental/contextual (e.g., air pollution) factors, however there was not a consistent effect between studies.

What does this mean for practice?

• Positive mental health outcomes for children with disabilities can be supported by interventions that increase access to and time spent in blue and green spaces, particularly in urban areas.
• The reviewed literature focused on the behavioural, social, emotional, and cognitive aspects of mental health. The authors recommend further research to better understand the relationship between green spaces and other dimensions of mental health, including anxiety, depression, and neurodevelopmental disorders.
• The existing evidence is mainly focused on children with ADHD, ASD, and behavioural problems. The authors highlighted a need for research into impacts of blue and green spaces and mental health for children with other types of disabilities, including vision, hearing, physical and learning types of disability.
• There is less research on the impact of access to blue spaces, and further research is necessary to assess whether time spent in blue spaces has similar positive mental health outcomes for children with disabilities compared to green spaces.

Why is this important?

• Childhood internalising problems (e.g., anxiety, depression) are a common mental health issue worldwide, and a major risk factor for poor mental health outcomes later in life.
• Developing effective interventions early in childhood can help increase children’s and family’s quality of life, and positive parent-child relationships in early childhood can support preventative interventions for internalising problems.
• This paper compared the effectiveness of parenting interventions, and the impact of being put on a waitlist or provided treatment as usual, in reducing internalising problems with children under 4 years old.

What did they do?

• The authors conducted a systematic literature review and network meta-analysis of randomised controlled trials (RCTs) to examine the effect of parenting interventions (interventions with a central focus on parenting abilities or behaviours) on internalising problems in young children.
• The effectiveness of parenting interventions was compared with ‘comparator’ interventions (treatment as usual or waitlist).
• 62 studies, with a total of 28,265 participants in RCTs, were included. Most of these studies were conducted in the US or the Netherlands. Studies aimed to increase positive parenting behaviours and decrease child behavioural problems.

What did they find?

• Parenting interventions that focused on the parent-child relationship or included multiple components had some effect on reducing internalising and externalising problems compared to treatment as usual.
• Video-feedback, parenting courses, home visits, coparenting did not appear to be more effective than treatment as usual.
• Both parenting interventions and treatment as usual interventions were more effective than when children were placed on a waitlist.
• Evidence suggested that being placed on a waitlist increased internalising problems.
• However, there was little supporting evidence that early parenting interventions had lasting beneficial effects (after 3 or more years) on reducing internalising problems in children.
• The high risk of bias from within the included studies means that there is only moderate confidence in the findings of the review.

What does this mean for practice?

• Parenting interventions may provide opportunity for parents to ‘practise’ parenting skills in a supportive environment, which may lead to greater behavioural change for parents, and support positive parent-child relationships.
• Previous research reporting on differences between interventions may be influenced by the negative effects of waitlists rather than the positive effects of interventions. The authors recommend that future research should consider this when comparing treatment or intervention options.
• Providing timely support to families in the first years of a child’s life, including relational approaches to services and programs, should remain a priority for policy and program funding.

Why is this important?

• Emotional and behavioural difficulties are more common among children who are deaf and hard of hearing than in the general population. There is limited research into the impacts of different types of hearing loss on emotional and behavioural difficulties.
• Understanding emotional/behavioural difficulties can help prevent poorer outcomes and guide effective interventions for children with hearing loss.

What did they do?

• Authors analysed data from 339 children (aged 5-12 years) with hearing loss (HL) enrolled in the Victorian Childhood Hearing Longitudinal Databank. 169 children had unilateral/mild HL and 170 children had moderate to profound HL.
• They collected sociodemographic, audiological and medical information for children. Parents also completed standard parent-rated questionnaires (ASQ, SDQ, Peds-Ql, K6).
• The study looked at emotional/behavioural, health related quality-of-life (HRQOL) and parent psychological distress outcomes of children with unilateral/mild HL compared to children with moderate to profound HL and the normal hearing population.
• For children with unilateral/mild HL, the authors also explored factors that can be predictive of emotional/behavioural difficulties.

What did they find?

• The study indicated that around 1 in 5 children with different types of hearing loss had emotional and behavioural difficulties. These prevalences of difficulties were similar between those who had unilateral/mild HL (18.3%) and moderate to profound HL (20.6%), which is higher than in the general population.
• Common symptoms of emotional and behavioural difficulties were hyperactivity and poor social behaviour. Emotional symptoms were slightly more common for children with unilateral/mild HL (19.5% vs. 14.7%) and peer problems more common for children with moderate to profound HL (14.8% vs. 21.8%).
• HRQoL was more prevalent, and parental distress scores were higher, in both groups of children with hearing loss compared to the general population.
• Factors that were predictive of later emotional/behavioural difficulties included additional health needs and early developmental concerns among children with unilateral/mild HL.
• Authors suggested that the elevated emotional/behavioural difficulties may be linked to the challenges that children with hearing loss have with language acquisition, understanding and communicating their needs. Child development of emotional and behavioural regulation partly depends on cognitive and language processing and difficulties in these areas leave children vulnerable to poor emotional and behavioural regulation.

What does this mean for practice?

• Practitioners should be aware that almost 1 in 5 children with hearing loss are affected by emotional/behavioural difficulties and should look out for the relevant signs and symptoms.
• A greater focus should be given in practice to early identification, prevention and treatment of the emotional and behavioural difficulties of children with hearing loss.

Why is this important?

• Emotional intimate partner violence (IPV) is common worldwide, and associated with negative developmental outcomes in children, especially in the early years. 1 in 4 Australian children (28%) under age 10 have been exposed to IPV.
• There is limited research that explores links between emotional IPV and children’s development, particularly for families experiencing social adversity (e.g., unemployed, family violence).
• This study sought to understand how children’s exposure to their mother’s experience of emotional IPV when the child was 3-5 years old is linked to child developmental outcomes at age 5.
• Emotional IPV was defined as behaviours by an intimate partner or ex-partner that cause psychological harm.

What did they do?

• The authors conducted a secondary analysis of existing data. Data was collected from 194 Australian women recruited from antenatal clinics based on their experience of adversity during pregnancy.
• Mothers completed standard questionnaires on emotional abuse at child ages 3-5 years (CASR) and child development at 5 years (SDQ, SSis, Peds-Ql, CELF, SEAPART, NIH executive function subtests, sleep and health).

What did they find?

• Emotional IPV was very common and experienced by 57% of mothers in the study sample at least once when their child was 3–5 years old.
• One third of women disclosed ongoing emotional IPV at each assessment (when the child was 3, 4 and 5 years old).
• Women who were exposed to emotional IPV were more likely than those not exposed to experience co-occurring social adversities, e.g. being a sole parent (47% compared to 20%), being unemployed (69% compared to 60%), receiving a benefit or pension as the main income source (58% compared to 30%), feeling threatened in their home (24% compared to 4%), having had a drug problem (17% compared to 7%), or speaking language other than English as their first language (10% compared to 5%).
• Children exposed to emotional IPV had poorer outcomes at 5 years than children who were not exposed. The differences were most evident in the internalising and externalising symptoms.

What does this mean for practice?

• Identification of emotional IPV and effective care pathways for preventing and reducing experiences of emotional IPV are important for supporting both parents and children.
• A greater focus should be given to early identification and to interventions that prioritise families experiencing co-occurring social adversities. Assessments that consider a broad range of social circumstances may be more appropriate to identify at-risk families.
• The poor developmental outcomes from exposure to emotional IPV during preschool years may become evident by age 5, or later. Practitioners should continue monitoring at risk children and look out for the relevant signs and symptoms.

Why is this important?

• The use and clinical effectiveness of digital health interventions (DHIs) is relatively well studied for children and adolescents, but there is limited research into their cost-effectiveness.
• To inform effective resource allocation, and the future development of DHIs, it is important to understand the cost-effectiveness of the DHIs and what features make them cost effective.
• Digital health interventions were defined as digital technologies (online health applications, information and communications technology systems, e.g. electronic medical records, videoconferencing systems and mobile apps) used to meet health objectives.

What did they do?

• The authors conducted a systematic literature review using the PRISMA checklist to identify original peer-reviewed economic evaluations of digital health interventions for children and adolescents (1-18 years).
• The different types of economic evaluations included were cost-effectiveness analyses (costs per clinical effect), cost-benefit analyses (costs and effects expressed in monetary terms as net benefit), and cost-utility analyses (cost per quality-adjusted life year or disability-adjusted life year).
• 22 papers were included, with a mix of quantitative and qualitative studies with most from Europe and Africa, published between 2011 and 2021.

What did they find?

• 82% of the studies concluded that DHIs are cost-effective or cost saving in comparison to non-digital standard of care. However, 1 in 4 studies (23%) did not find statistically significant differences in health outcomes.
• The mean cost savings for DHIs ranged from US $164 to US $5423 per patient compared with the non-digital standard of care.
• Most studies evaluated health care specialties such as mental health and maternal, newborn, and child health. Common health outcomes reported were deaths averted or lives saved, quality-adjusted life year or disability-adjusted life year.
• The economic evaluations were mostly based on individual patient data (64%) or focused on decision analytical modelling (32%).
• The DHIs were mostly distributed through web portals (36%), SMS text messages (27%) or mobile phone apps (14%). Telephone consultations (9%), audiovisual consultations (9%), and web-based symptom monitoring were less common.
• The cost-effectiveness was mostly dependent on implementation costs, supervision/training of health care professionals, intervention effect size, and the potential to be scaled up.

What does this mean for practice?

• Digital health interventions are a cost-effective or cost saving method of care for children and adolescents.
• The cost effectiveness of digital health interventions is highly dependent on how well they are implemented and the supervision/training of health care professionals.