Five-Year Trends in US Children's Health and Well-being, 2016-2020

Physical Activity, Sleep, and Screen Time in Children and Adolescents Before and During the COVID-19 Pandemic: An Analysis of the 2019-2020 National Survey of Children's Health

PURPOSE

The purpose of this study was to examine whether engagement in health behaviors changed from pre-pandemic (2019) to during the pandemic (2020).

METHODS

The combined 2019-2020 National Survey of Children's Health (NSCH) was used to inform this study. The NSCH is an annual survey designed to provide national estimates of key indicators of childhood health and well-being. Physical activity (number of days/week with >60 min of activity), screen-time (hours/day of TV viewing and computer use), and sleep (hours/day) were assessed by parental report. Adjusted binomial and multinomial logistic regression models were used to determine the association between survey year and health behaviors.

RESULTS

Children and adolescents were 36% more likely to be physically inactive in 2020 compared to 2019. Additionally, children and adolescents were 14% more likely to meet sleep guidelines and 39% less likely to meet screen-time guidelines in 2020 compared to 2019, independent of age, sex, race/ethnicity, and poverty level. Children (6-13 year) and adolescents (14-17 years) were 10% and 15% less likely to get below the recommended amount of sleep in 2020 compared to 2019, respectively.

CONCLUSION

Prevalence of meeting sleep guidelines increased among children and adolescents in 2020 but decreased for physical activity and screen-time. Initiatives targeting activity and screen-time may be urgently needed. Whether rates of these health behaviors return to pre-pandemic levels over the next few years should be closely assessed.

Inpatient pediatric nursing staff experiences treating psychiatric patients: A mixed methods study

PROBLEM

A gap in the literature exists attempting to understand the impact that the influx of pediatric psychiatric patients has had on inpatient general medicine pediatric nursing staff.

METHODS

A mixed-method research study was conducted among full- and part-time pediatric nurses and nursing assistants working on general pediatric units. Quantitative data was collected via an anonymous survey using the Professional Quality of Life Scale version 5 and Support Appraisal for Work Stressors scale. Surveys were followed by semistructured interviews.

FINDINGS

Of the 158 staff eligible, 47 (29.7%) participated in the quantitative portion. [Correction added on 29 September 2023, after the first online publication: In the preceding sentence, the participation rate was revised from 23.5% to 29.7% in this version.] Significant differences were found between roles, with nurses experiencing lower levels of compassion satisfaction and higher levels of burnout. Role differences were seen in supervisor support and nonwork support, with nurses reporting less support from both. Supervisor support showed a significant correlational relationship with compassion satisfaction and burnout. Nonwork support showed similar correlations with compassion satisfaction and burnout. Themes that emerged from the interviews were Barriers to Care, Emotional Impact, and "Help Me Help You."

CONCLUSION

Nurses may be at greater risk for compassion fatigue due to perceived inadequate support from leadership, unclear role expectations, and lack of resources.

Child Health Needs and the Adolescent Medicine Workforce Supply: 2020-2040

Adolescent medicine (AM) subspecialists provide primary, subspecialty, and consultative care to adolescents and young adults (AYAs). Given insufficient numbers of AM subspecialists to care for all AYAs, the workforce supports AYAs health care capacity through education, research, advocacy, and the development of policies and programs sensitive to their unique needs. A modeling project funded by the American Board of Pediatrics Foundation was developed to forecast the pediatric subspecialty workforce in the United States from 2020 to 2040 on the basis of current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios, and reports results in headcount and headcount adjusted for percentage of time spent in clinical care, termed "clinical workforce equivalent." For the AM subspecialty, several scenarios were considered that modified the number of fellows and/or clinical time. The baseline model predicted low growth nationally (27% and 13% increase in total AM subspecialists and AM subspecialists per 100 000 children, respectively) and declines in AM workforce relative to population growth in census divisions with existing geographic workforce disparities. In the alternative scenarios, fellow number and clinical time changes did not significantly change predictions relative to the baseline model, but a 12.5% decrease in fellows predicted a 40% reduction in the workforce from baseline with a widening of geographic workforce disparities. On the basis of the expansive clinical and nonclinical roles of AM subspecialists and these forecasted workforce challenges, significant educational, practice, and policy changes will be necessary to bolster the supply of well-trained clinicians addressing the dynamic health care needs of AYAs.

Trends in Mental Wellbeing of US Children, 2019-2022: Erosion of Mental Health Continued in 2022

We provide fresh estimates of a change in the nationwide prevalence of mental health symptoms among US children during the COVID-19 pandemic using National Health Interview Survey data (2019-22) on children aged 2-17 years (n = 27,378; age subgroups 2-5, 6-11, and 12-17) to assess overall mental distress and 19 specific outcomes related to developmental, communicative, cognitive, affective, and behavioral domains. Raw and adjusted (for socio-demographics) linear regressions estimated the change in prevalence for each outcome between 2019 (baseline year) and three succeeding years (2020-2022). Summary scores for mental distress rose between 2019 and 2020 (1.01 to 1.18 points, range of 0-15), declined slightly in 2021 (1.09), and climbed sharply again in 2022 (1.25). The declines primarily affected adolescents (1.11 at baseline, 1.24 in 2020, 1.30 in 2021, and 1.49 in 2022). Specific outcomes belonging to all domains of mental health showed similar increases in prevalence. US children suffered significant erosion of mental health during the COVID-19 pandemic that continued into 2022. Expansion of mental health programs aimed at school-going children will likely be needed to respond effectively to the ongoing crisis.

School children's mental health during the COVID-19 pandemic

Introduction

The COVID-19 pandemic significantly impacted the daily routines of children, with social distancing and quarantine leading to reduced social interactions and potential increased conflicts within families. These factors can increase the risk for anxiety and depression while reducing overall quality of life.

Methods

Our study included 1843 school children aged 8 to 12 from 56 schools over a 2.5-year period before and during the pandemic. This multi-wave cross-sectional study utilized baseline data from an optimization trial of an indicated preventive intervention. The main outcomes were self-reported symptoms of anxiety and depression, and quality of life was the secondary outcome measure. Furthermore, responses to COVID-relevant questions were measured using a self-composed scale. Our objectives were to compare anxiety and depression symptom levels between cohorts of children who participated in the study before and during the pandemic, to examine if anxiety or depression predicted the COVID response, and whether anxiety and depression and subtypes of anxiety had an impact on quality of life during the pandemic. Linear regression and interaction models were used to examine relevant associations.

Results

Levels of anxiety and depression were higher in all waves compared to pre-pandemic levels. Quality of life was lower during the pandemic than before the pandemic, particularly among children with generalized anxiety symptoms. Quality of life was negatively associated with loneliness.

Discussion

Our study revealed that children reported higher anxious and depressive symptoms during the pandemic compared to pre-pandemic levels, as well as reduced quality of life. Lockdowns and restrictions may have contributed to this burden. Additionally, self-reported loneliness was a significant possible consequence of the restrictive measures imposed on children during the pandemic. Additional research is needed to investigate the long-term effects of the pandemic on children, particularly regarding the stability of elevated levels of anxiety and depression. Such studies could examine whether these conditions are indicative of a trajectory toward more severe internalizing disorders.Clinical trial registration: NCT04263558.

Mental illness in children and its determinants in Ethiopia: A systematic review and meta-analysis, 2023

INTRODUCTION

Young people are at risk of developing mental health disorders. Depression, anxiety, and behavioral problems are among the primary causes of illness and impairment among teenagers. Suicide is the fourth highest cause of mortality in those aged 15 to 29. This study aimed to assess the determinants of mental health among children in Ethiopia.

METHODS

Online databases were searched from inception until March 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 was used in this review. Subgroup analysis, I2 test, funnel plot, and Egger's test were performed. Pooled odds ratios (OR) were calculated.

RESULT

Fourteen studies were included in the meta-analysis. The pooled prevalence of mental illnesses among Ethiopian children was 24.68% (95% CI: 19.99%-32.38%). Having previous child abuse history (OR: 5.65; 95% CI: 4.32-7.39), poor socio-economic status (OR: 1.94; 95% CI: 1.24-3.04), urban residence (OR: 1.93; 95% CI:1.39-2.67), and being male (OR: 1.65; 95% CI: 1.15-2.38) were determinants of childhood mental illness in Ethiopia.

CONCLUSION

and Recommendations: Mental disorders are highly prevalent in children with a history of child abuse, and a strong legislative body must be established to prosecute child abusers. Interventions that focus on gender equality in education and the creation of a safe environment for poor urban children are suggested.

Mental Health in the Youth Athlete

Though research is inconclusive in being able to determine if young athletes are more or less likely to suffer from mental health disorders compared with their non-athlete peers, there are important psychological considerations that are unique to the athletic population. This includes depression in the context of overtraining and burnout, performance anxiety, perfectionism, psychological sequalae of concussion, and injury as an independent risk factor for depression, anxiety, post-traumatic stress, and high-risk behaviors. Optimization of mental health care in youth athletes requires continued efforts to improve mental health literacy, decrease stigma, encourage help-seeking behaviors, and advance the routine implementation of effective screening practices.

COVID-19 and Adolescent Outpatient Mental Health Service Utilization

OBJECTIVE

The COVID-19 pandemic created challenges in accessing mental health (MH) services when adolescent well-being declined. Still, little is known about how the COVID-19 pandemic affected outpatient MH service utilization for adolescents.

METHODS

Retrospective data were collected from electronic medical records of adolescents aged 12-17 years at Kaiser Permanente Mid-Atlantic States, an integrated health care system from January 2019 to December 2021. MH diagnoses included anxiety, mood disorder/depression, anxiety and mood disorder/depression, attention-deficit/hyperactivity disorder, or psychosis. We used interrupted time series analysis to compare MH visits and psychopharmaceutical prescribing before and after the COVID-19 onset. Analyses were stratified by demographics and visit modality.

RESULTS

The study population of 8121 adolescents with MH visits resulted in a total of 61,971 (28.1%) of the 220,271 outpatient visits associated with an MH diagnosis. During 15,771 (7.2%) adolescent outpatient visits psychotropic medications were prescribed. The increasing rate of MH visits prior to COVID-19 was unaffected by COVID-19 onset; however, in-person visits declined by 230.5 visits per week (P < .001) from 274.5 visits per week coupled with a rise in virtual modalities. Rates of MH visits during the COVID-19 pandemic differed by sex, mental health diagnosis, and racial and ethnic identity. Psychopharmaceutical prescribing during MH visits declined beyond expected values by a mean of 32.8 visits per week (P < .001) at the start of the COVID-19 pandemic.

CONCLUSIONS

A sustained switch to virtual visits highlights a new paradigm in care modalities for adolescents. Psychopharmaceutical prescribing declined requiring further qualitative assessments to improve the quality of access for adolescent MH.

Dealing with overwhelming life situations - young people's experiences of becoming depressed

Background

Depression is common and increasing in young people, who seem especially vulnerable, both in the probability of developing depression, and in the resulting negative consequences across the lifespan. Unfortunately, available treatments rarely lead to full remission and even in cases of remission relapse rates are high. Different explanatory models have been proposed, and research indicates a multifaceted etiology. The descriptive DSM-5 has low diagnostic validity in this age-group, especially for depressive disorders, and limited attention has been given to young people's own experiences of becoming depressed. Hence, there is a risk of missing clinical information that is important for the therapeutic alliance and treatment.

Objective

This study aimed to explore young people's experiences of becoming depressed.

Method

A qualitative study was performed. Six participants with clinical depression, currently in treatment at child and adolescent psychiatric outpatient clinics in northern Sweden were recruited. Interviews followed a semi-structured manual, and data was analyzed with inductive qualitative content analysis.

Results

Participants described different reasons for their depression, and from their stories four categories were identified: "Being subjected to violence", "Suffering separation and loss", "Feeling abandoned", and "Feeling burdened and vulnerable". These categories were interpreted in the theme: "Dealing with an overwhelming life situation".

Conclusions

The participants presented mainly stressful external and relational events preceding their depression. A combination of overwhelming stressors, lack of support and lack of time for recovery was described. This points to the importance of validating the narratives of young patients with depression and to offer trauma-informed treatment approaches in mental health care.

Social Media and Youth Mental Health

PURPOSE OF REVIEW

We review recent evidence regarding the relationship between the social media (SM) habits, experiences, and the mental health of youth. We examine effects of social media use (SMU) on specific diagnoses including depression and anxiety. The relationship between psychiatric illness, specific SM experiences, and the issue of SM mental health contagion is also explored.

RECENT FINDINGS

Youth engagement in SMU has increased dramatically in recent years, concurrent with increases in prevalence of depression and anxiety. The relationship between SMU and mental illness is complex and depends on characteristics of the user (e.g., social comparison and fear of missing out (FOMO) and their SM habits and experiences (e.g., cyberbullying, and sexting,). SM engagement has distinct impacts on anxiety, depression, and suicidality. Growing evidence documents how SM may be a medium for psychiatric contagion. Research findings are largely correlational and dependent on subjective report, limiting their interpretation. The mental health of youth is increasingly tied to their SMU, depending greatly on how youth engage with SM and resultant feedback. Future research must look to establish causality in relationships between SM and mental illness.

Exploring the Number of Web-Based Behavioral Health Coaching Sessions Associated With Symptom Improvement in Youth: Observational Retrospective Analysis

BACKGROUND

Rates of anxiety and depression have been increasing among children and adolescents for the past decade; however, many young people do not receive adequate mental health care. Digital mental health interventions (DMHIs) that include web-based behavioral health coaching are widely accessible and can confer significant improvements in youth anxiety and depressive symptoms. However, more research is necessary to determine the number of web-based coaching sessions that confer clinically significant improvements in anxiety and depressive symptoms in youth.

OBJECTIVE

This study uses data from a pediatric DMHI to explore the number of web-based coaching sessions required to confer symptom improvements among children and adolescents with moderate or moderately severe symptoms of anxiety and depression.

METHODS

We used retrospective data from a pediatric DMHI that offered web-based behavioral health coaching in tandem with self-guided access to asynchronous chat with practitioners, digital mental health resources, and web-based mental health symptom assessments. Children and adolescents who engaged in 3 or more sessions of exclusive behavioral health coaching for moderate to moderately severe symptoms of anxiety (n=66) and depression (n=59) were included in the analyses. Analyses explored whether participants showed reliable change (a decrease in symptom scores that exceeds a clinically established threshold) and stable reliable change (at least 2 successive assessments of reliable change). Kaplan-Meier survival analyses were performed to determine the median number of coaching sessions when the first reliable change and stable reliable change occurred for anxiety and depressive symptoms.

RESULTS

Reliable change in anxiety symptoms was observed after a median of 2 (95% CI 2-3) sessions, and stable reliable change in anxiety symptoms was observed after a median of 6 (95% CI 5-8) sessions. A reliable change in depressive symptoms was observed after a median of 2 (95% CI 1-3) sessions, and a stable reliable change in depressive symptoms was observed after a median of 6 (95% CI 5-7) sessions. Children improved 1-2 sessions earlier than adolescents.

CONCLUSIONS

Findings from this study will inform caregivers and youth seeking mental health care by characterizing the typical time frame in which current participants show improvements in symptoms. Moreover, by suggesting that meaningful symptom improvement can occur within a relatively short time frame, these results bolster the growing body of research that indicates web-based behavioral health coaching is an effective form of mental health care for young people.

Propelling the Global Advancement of School Mental Health

Rates of mental health problems and disorders in children and youth have been increasing for at least three decades, and these have escalated due to the pandemic and multiple other societal stressors. It is increasingly recognized that students and families frequently struggle to receive needed care through traditional locations such as specialty mental health centers. Upstream mental health promotion and prevention strategies are gaining support as a public health approach to supporting overall population well-being, better utilizing a limited specialty workforce, and reducing illness. Based on these recognitions, there has been a progressive and escalating movement toward the delivery of mental health support to children and youth "where they are," with a prominent and more ecologically valid environment being schools. This paper will provide a brief review of the escalating mental health needs of children and youth, advantages of school mental health (SMH) programs in better meeting these needs, example model SMH programs from the United States and Canada, and national and international SMH centers/networks. We conclude with strategies for further propelling the global advancement of the SMH field through interconnected practice, policy, and research.

The effectiveness of collaborative care delivered via telehealth in a pediatric primary care population

Introduction

The prevalence of mental health conditions among children and adolescents in the United States has become a pressing concern, exacerbated by the COVID-19 pandemic. Collaborative care is an evidence-based model for identifying and treating depression and anxiety in healthcare settings, with additional promise for remote healthcare delivery. This study aims to evaluate the impact of a telehealth collaborative care model for adolescents with depression and anxiety in pediatric and primary care settings.

Methods

Secondary analysis was conducted using de-identified national data from Concert Health, a behavioral health medical group offering remote collaborative care across 17 states. Baseline, 90-day, and 120-day assessments of the PHQ-9 and GAD-7 were collected, along with baseline covariates. Stepwise regression analysis was performed to determine the contribution of select covariates to improvement rates.

Results

Among the analyzed data, 263 participants had complete PHQ-9 data, and 230 had complete GAD-7 data. In both the PHQ-9 and GAD-7 groups, over 50% of patients experienced treatment success based on success at discharge, as well as 90- and 120-day improvement rates. Predictors of success at discharge for the GAD-7 group included age at enrollment (OR 1.2258, 95% CI 1.01-1.496), clinical touchpoints (OR 1.1469, 95% CI 1.086-1.218), and lower baseline GAD-7 score (OR 0.9319, 95% CI 0.874-0.992). For the PHQ-9 group, Medicaid was significantly associated with not achieving a 50% reduction in PHQ-9 score at 120 days (OR 0.5874, 95% CI 0.349-0.979).

Discussion

Collaborative care has demonstrated its effectiveness in treating adolescent populations, providing an opportunity to expand access to evidence-based behavioral health treatment for young individuals. Notably, collaborative care is already integrated into the Medicaid fee schedule for 22 states and accepted by all commercial payers. Given that individuals often turn to their trusted primary care providers for behavioral health care, offering collaborative care to adolescents can play a crucial role in addressing the ongoing mental health crisis.

Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021

Importance

Before and during the COVID-19 public health emergency (PHE), commercially and publicly insured children may have faced different challenges in obtaining consistent and adequate health insurance.

Objective

To compare overall rates, COVID-19 PHE-related changes, and child and family characteristics associated with inconsistent and inadequate coverage for publicly and commercially insured children.

Design, Settings, and Participants

This was a cross-sectional study using nationally representative data from the 2016 to 2021 National Survey of Children's Health of children from age 0 to 17 years living in noninstitutional settings.

Exposure

Parent- or caregiver-reported current child health insurance type defined as public or commercial.

Main Outcomes and Measures

Inconsistent insurance, defined as having an insurance gap in the past year; and inadequate insurance, defined by failure to meet 3 criteria: (1) benefits usually/always sufficient to meet child's needs; (2) coverage usually/always allows child to access needed health care practitioners; and (3) no or usually/always reasonable annual out-of-pocket payments for child's health care. Survey-weighted logistic regression was used to compare outcomes by insurance type, by year (2020-2021 vs 2016-2019), and by child characteristics within insurance type.

Results

Of this nationally representative sample of 203 691 insured children, 34.5% were publicly insured (mean [SD] age, 8.4 [4.1] years; 47.4% female) and 65.5% were commercially insured (mean [SD] age, 8.7 [5.6]; 49.1% female). Most publicly insured children were either non-Hispanic Black (20.9%) or Hispanic (36.4%); living with 2 married parents (38.4%) or a single parent (33.1%); and had a household income less than 200% of the federal poverty level (79%). Most commercially insured children were non-Hispanic White (62.8%), living with 2 married parents (79.0%); and had a household income of 400% of the federal poverty level or higher (49.1%). Compared with commercially insured children, publicly insured children had higher rates of inconsistent coverage (4.2% vs 1.4%; difference, 2.7 percentage points [pp]; 95% CI, 2.3 to 3.2) and lower rates of inadequate coverage (12.2% vs 33.0%; difference, -20.8 pp; 95% CI, -21.6 to -20.0). Compared with the period from 2016 to 2019, inconsistent insurance decreased by 42% for publicly insured children and inadequate insurance decreased by 6% for commercially insured children during the COVID-19 PHE (2020-2021). The child and family characteristics associated with inadequate and inconsistent insurance varied by insurance type.

Conclusions and Relevance

The findings of this cross-sectional study indicate that insurance gaps are a particular problem for publicly insured children, whereas insurance inadequacy and particularly, out-of-pocket costs are a challenge for commercially insured children. Both challenges improved during the COVID-19 PHE. Improving children's health coverage after the PHE will require policy solutions that target the unique needs of commercially and publicly insured children.

Factors associated with unmet pediatric health care needs during the coronavirus pandemic

PURPOSE

To examine risk factors for unmet pediatric health care needs during the coronavirus pandemic in a national sample of US children under 17 years of age.

DESIGN AND METHODS

In this cross-sectional study, we used data from the 2021 National Survey of Children's Health (n = 50,892). Unmet pediatric health care needs were assessed as follows: "during the past 12 months, was there any time when this child needed health care but it was not received?". Logistic regression with multiple imputations was used to evaluate bivariate and multivariable associations between predisposing, enabling, and need factors of health care services use and unmet pediatric health care needs.

RESULTS

Approximately 3.6% of children had unmet health care needs, with significant differences by sample characteristics. Unmet health care needs were notably prevalent among select groups, including children with difficulty covering basic needs (10.6%) and those with ≥2 health conditions (8.9%). In multivariable analyses, factors associated with unmet pediatric health care needs included predisposing factors such as older age, ≥2 children with special health care needs in the household, primary language other than English or Spanish, and poor caregiver health; enabling factors such as difficulty covering basic needs, no insurance, and no personal doctor or nurse; and need factors such as poor perceived or evaluated child health. Reasons for unmet needs included financial, nonfinancial, and accessibility barriers.

CONCLUSIONS

Several factors were associated with unmet health care needs.

PRACTICE IMPLICATIONS

We identified children who would benefit from targeted interventions aimed at promoting health care services use.

Editorial: Mindfulness in Schools: Promises, Challenges, and Future Directions

Amid rising national rates of childhood depression and anxiety,1,2 the development and accessibility of therapeutic psychosocial interventions for children have taken on paramount importance. Given the limited bandwidth of the existing clinical mental health services nationally, there is also an imperative to integrate therapeutic interventions within nonclinical, community-based settings (eg, schools) that can address emergent symptoms before crises manifest. Mindfulness-based interventions are a promising therapeutic modality for such preventive community-based strategies. While the literature on the therapeutic potential of mindfulness in adults is well established,3 the evidence for mindfulness in children is more precarious, with one meta-analysis demonstrating unconvincing results.4 Especially in school-based mindfulness training (SBMT) for children, there is a dearth of literature showing intervention effectiveness,5 and researchers have cited many implementation challenges,6 which spotlights SBMT as a burgeoning, promising, and multifaceted intervention deserving of more inquiry.

Majority of new patient referrals to a large pediatric rheumatology center result in non-rheumatic diagnosis

OBJECTIVE

Pediatric rheumatology faces a looming supply-demand crisis. While strategies have been proposed to address the supply shortfall, investigation into the increased demand for pediatric rheumatic care has been limited. Herein, we analyze new patient visits to a large tertiary care pediatric rheumatology center to identify emerging trends in referrals and areas for potential intervention to meet this increased demand.

METHODS

All patients referred to and seen by the University of Alabama at Birmingham Pediatric Rheumatology Division between January 2019 and December 2021 for a new patient evaluation were identified. Patient data was retrospectively abstracted, de-identified, and analyzed to develop trends in referrals and frequency of rheumatic disease, non-rheumatic disease, and specific diagnoses.

RESULTS

During the study period, 2638 patients were referred to and seen in by the pediatric rheumatology division. Six hundred and ten patients (23.1%) were diagnosed with rheumatic disease. The most common rheumatic disease was juvenile idiopathic arthritis (JIA) at 45.6%, followed by primary Raynaud phenomenon (7.4%), recurrent fever syndromes (6.9%), vasculitides (6.7%), and inflammatory eye disease (6.2%). Of the 2028 patients (76.9%) diagnosed with a non-rheumatic condition, benign musculoskeletal pain was the most common (61.8%), followed by a combination of somatic conditions (11.6%), and non-inflammatory rash (7.7%).

CONCLUSION

In this analysis of new patient referrals to a large pediatric rheumatology center, the majority of patients were diagnosed with a non-rheumatic condition. As a worsening supply-demand gap threatens the field of pediatric rheumatology, increased emphasis should be placed on reducing non-rheumatic disease referrals.

Association of Food Insecurity Status with Resolution of Mental Health Conditions in Children and Adolescents

OBJECTIVE

Adverse consequences related to unresolved mental health issues underscore the importance of identifying factors that impede resolution of mental health conditions. Although studies have identified food insecurity as a risk factor for the diagnosis of mental health conditions, its impact on unresolved mental health issues is not understood. The objective of this study is to investigate the association of food insecurity status with resolution of depression, anxiety, and behavioral/conduct problems in children and adolescents.

METHODS

Using National Survey of Children's Health 2016 to 2019, logistic regression analyses examined the relationship of food insecurity status with the diagnosis and resolution of depression, anxiety, and behavioral/conduct problems in children (aged 5-11 years) and adolescents (aged 12-17 years).

RESULTS

Mild, moderate, and severe food insecurity were significantly associated with higher odds of being diagnosed with depression, anxiety, and behavioral/conduct problems. Severe food insecurity was significantly associated with higher odds of unresolved behavioral/conduct problems in children (adjusted odds ratio [aOR], 10.09; 95% confidence interval [CI], 2.99-34.04), after adjustment for demographic covariates. In adolescents, severe food insecurity was significantly related to greater odds of unresolved depression (aOR, 6.64; 95% CI, 2.13-20.70), anxiety (aOR, 3.27; 95% CI, 1.31-8.14), and behavioral/conduct problems (aOR, 5.57; 95% CI, 2.09-14.85). These associations of severe food insecurity with unresolved mental health conditions were significant even after adjustment for the receipt of mental health care. Mild and moderate food insecurity were not significantly associated with unresolved mental health conditions.

CONCLUSION

The findings suggest that severe food insecurity is associated with increased odds of unresolved mental health conditions in children and adolescents. This study highlights the importance of tailoring interventions to provide appropriate mental health services for children and adolescents from severely food insecure households.

Social media behaviors and symptoms of anxiety and depression. A four-wave cohort study from age 10-16 years

Background

Concerns have been raised that social media use causes mental health problems in adolescents, but findings are mixed, and effects are typically small. The present inquiry is the first to measure diagnostically-defined symptoms of depression and anxiety, examining whether changes in social media behavior predict changes in levels of symptoms from age 10 to 16, and vice versa. We differentiate between activity related to one's own vs. others' social media content or pages (i.e., self-oriented: posting updates, photos vs other-oriented: liking, commenting).

Methods

A birth-cohort of Norwegian children was interviewed about their social media at ages 10, 12, 14 and 16 years (n = 810). Symptoms of depression, social anxiety and generalized anxiety were captured by psychiatric interviews and data was analyzed using Random Intercept Cross-lagged Panel Modeling.

Results

Within-person changes in self- and other oriented social media behavior were unrelated to within-person changes in symptoms of depression or anxiety two years later, and vice versa. This null finding was evident across all timepoints and for both sexes.

Conclusions

The frequency of posting, liking, and commenting is unrelated to future symptoms of depression and anxiety. This is true also when gold standard measures of depression and anxiety are applied.

Estimated Prevalence of Depressive Disorders in Children From 2004 to 2019: A Systematic Review and Meta-Analysis

Importance

Depression during childhood (ie, age <13 years) poses a major health burden. Recent changes in environmental and lifestyle factors may increase children's risk of mental health problems. This has been reported for anxiety disorders, but it is unclear whether this occurs for depressive disorders.

Objective

To provide prevalence estimates for the depressive disorders (ie, major depressive disorder [MDD], dysthymia, disruptive mood dysregulation disorder [DMDD], and overall) in children, and whether they have changed over time.

Data Sources

The MEDLINE, PsycINFO, Embase, Scopus, and Web of Science databases were searched using terms related to depressive disorders, children, and prevalence. This was supplemented by a systematic gray literature search.

Study Selection

Studies were required to provide population prevalence estimates of depressive disorder diagnoses (according to an established taxonomy and standardized interviews) for children younger than 13 years, information about participants' year of birth, and be published in English.

Data Extraction and Synthesis

Data extraction was compliant with the Meta-Analysis of Observational Studies in Epidemiology guidelines. A total of 12 985 nonduplicate records were retrieved, and 154 full texts were reviewed. Data were analyzed from 2004 (the upper limit of a previous review) to May 27, 2023. Multiple proportional random-effects meta-analytic and mixed-effects meta-regression models were fit.

Main Outcomes and Measures

Pooled prevalence rates of depressive disorders, prevalence rate differences between males vs females and high-income countries (HICs) vs low-and middle-income countries (LMICs), and moderating effects of time or birth cohort.

Results

A total of 41 studies were found to meet the inclusion criteria. Pooled prevalence estimates were obtained for 1.07% (95% CI, 0.62%-1.63%) for depressive disorders overall, 0.71% (95% CI, 0.48%-0.99%) for MDD, 0.30% (95% CI, 0.08%-0.62%) for dysthymia, and 1.60% (95% CI, 0.28%-3.90%) for DMDD. The meta-regressions found no significant evidence of an association with birth cohort, and prevalence rates did not differ significantly between males and females or between HICs and LMICs. There was a low risk of bias overall, except for DMDD, which was hindered by a lack of studies.

Conclusions and Relevance

In this systematic review and meta-analysis, depression in children was uncommon and did not increase substantially between 2004 and 2019. Future epidemiologic studies using standardized interviews will be necessary to determine whether this trend will continue into and beyond the COVID-19 pandemic.

Electronic health records identify timely trends in childhood mental health conditions

BACKGROUND

Electronic health records (EHRs) data provide an opportunity to collect patient information rapidly, efficiently and at scale. National collaborative research networks, such as PEDSnet, aggregate EHRs data across institutions, enabling rapid identification of pediatric disease cohorts and generating new knowledge for medical conditions. To date, aggregation of EHR data has had limited applications in advancing our understanding of mental health (MH) conditions, in part due to the limited research in clinical informatics, necessary for the translation of EHR data to child mental health research.

METHODS

In this cohort study, a comprehensive EHR-based typology was developed by an interdisciplinary team, with expertise in informatics and child and adolescent psychiatry, to query aggregated, standardized EHR data for the full spectrum of MH conditions (disorders/symptoms and exposure to adverse childhood experiences (ACEs), across 13 years (2010-2023), from 9 PEDSnet centers. Patients with and without MH disorders/symptoms (without ACEs), were compared by age, gender, race/ethnicity, insurance, and chronic physical conditions. Patients with ACEs alone were compared with those that also had MH disorders/symptoms. Prevalence estimates for patients with 1+ disorder/symptoms and for specific disorders/symptoms and exposure to ACEs were calculated, as well as risk for developing MH disorder/symptoms.

RESULTS

The EHR study data set included 7,852,081 patients < 21 years of age, of which 52.1% were male. Of this group, 1,552,726 (19.8%), without exposure to ACEs, had a lifetime MH disorders/symptoms, 56.5% being male. Annual prevalence estimates of MH disorders/symptoms (without exposure to ACEs) rose from 10.6% to 2010 to 15.1% in 2023, a 44% relative increase, peaking to 15.4% in 2019, prior to the Covid-19 pandemic. MH categories with the largest increases between 2010 and 2023 were exposure to ACEs (1.7, 95% CI 1.6-1.8), anxiety disorders (2.8, 95% CI 2.8-2.9), eating/feeding disorders (2.1, 95% CI 2.1-2.2), gender dysphoria/sexual dysfunction (43.6, 95% CI 35.8-53.0), and intentional self-harm/suicidality (3.3, 95% CI 3.2-3.5). White youths had the highest rates in most categories, except for disruptive behavior disorders, elimination disorders, psychotic disorders, and standalone symptoms which Black youths had higher rates. Median age of detection was 8.1 years (IQR 3.5-13.5) with all standalone symptoms recorded earlier than the corresponding MH disorder categories.

CONCLUSIONS

These results support EHRs' capability in capturing the full spectrum of MH disorders/symptoms and exposure to ACEs, identifying the proportion of patients and groups at risk, and detecting trends throughout a 13-year period that included the Covid-19 pandemic. Standardized EHR data, which capture MH conditions is critical for health systems to examine past and current trends for future surveillance. Our publicly available EHR-mental health typology codes can be used in other studies to further advance research in this area.

Effects of the COVID-19 Pandemic on Pediatric and Adolescent ASCVD Risk Factors

PURPOSE OF REVIEW

In this review, we provide insight into and raise awareness of the impact of the COVID-19 pandemic on the prevalence of acquired atherosclerotic cardiovascular disease (ASCVD) risk factors in adolescents. We highlight data that could be used to guide the response to a future pandemic with the goal of reducing premature cardiovascular disease (CVD)-related morbidity and premature mortality.

RECENT FINDINGS

During the global COVID-19 pandemic, many individuals, including youth, voluntarily or were mandated to alter the usual lifestyle in order to limit exposure and reduce the spread of the virus. Some of these changes resulted in unintended consequences, particularly acquisition of risk factors such as excessive weight gain, insulin resistance/diabetes, and dyslipidemia, commonly associated with ASCVD. A study from China examined changes in the prevalence of obesity and found a 2.4% rise attributable to the pandemic. Adequate daily physical activity plays an important role in ASCVD risk reduction. A systematic review and meta-analysis showed a 20% (90% CI, -34 to -4%) reduction in physical activity from before vs. during the COVID-19 pandemic. Another study of patients with type 2 diabetes found the mean HbA1c was significantly elevated during the COVID-19 pandemic (7.53 ± 1.02% in 2020) compared with the previous 2 years. In addition, there has been an alarming rise of childhood mental health concerns and suicide during the pandemic. Early identification and optimum management of CVD risk factors play an important role helping prevent future cardiovascular disease. Following the rapid spread of the virus, the World Health Organization (WHO) officially declared COVID-19 a global pandemic on March 11th, 2020. In an attempt to avoid infection and reduce the spread of the virus, many alterations in lifestyle were adopted on an international scale. While necessary, these modifications resulted in many adverse unintended health consequences in children and adolescents. This paper reviews the impact of the pandemic and the associated lifestyle changes on the prevalence of acquired atherosclerotic cardiovascular disease (ASCVD) risk factors in youth. In addition to providing insight, we hope to raise awareness of the pandemic's impact, and highlight specific data that could be used to guide the response to a future pandemic.

Clinicians' Perspectives on Equitable Health Care Delivery in Group Well-Child Care

OBJECTIVE

To explore clinicians' perspectives about the impact of group well-child care (GWCC) on equitable health care delivery.

METHODS

In this qualitative study, we conducted semistructured interviews with clinicians engaged in GWCC recruited via purposive and snowball sampling. We first conducted a deductive content analysis using constructs from Donabedian's framework for health care quality (structure, process, and outcomes) followed by inductive thematic analysis within these constructs.

RESULTS

We completed 20 interviews with clinicians who deliver or research GWCC in 11 institutions across the United States. Four major themes around equitable health care delivery in GWCC emerged from clinicians' perspectives: 1) shifts in power dynamics (process); 2) enabling relational care, social support, and a sense of community (process, outcome); 3) centering multidisciplinary care delivery around patient and family needs (structure, process, and outcomes); and 4) unaddressed social and structural barriers limit patient and family participation.

CONCLUSIONS

Clinicians perceived that GWCC enhances equity in health care delivery by shifting hierarchies in clinical visits and promoting relational, patient, and family-centered care. However, potential opportunities exist to further address provider implicit bias in group care delivery and structural inequities at the level of the health care institution. Clinicians underscored the need to address barriers to participation so that GWCC can more fully enhance equitable health care delivery.

Examining Whether Genetic Variants Moderate the Skeletal Effects of Selective Serotonin Reuptake Inhibitors in Older Adolescents and Young Adults

Objective: To examine whether serotonin (5-HT) related genetic variants moderate the effects of selective serotonin reuptake inhibitors (SSRIs) on skeletal outcomes. Methods: Trabecular bone mineral density (BMD) at the radius, lumbar spine (LS) BMD, total body less head (TBLH) bone mineral content (BMC) and markers of bone metabolism (osteocalcin, C-terminal telopeptide of type I collagen [CTX-1], and bone specific alkaline phosphatase to CTX-1 ratio) were examined in an observational study, enrolling 15- to 20-year-old participants, unmedicated or within a month of SSRI initiation. Variants in HTR1A (rs6295), HTR1B (rs6296), HTR1D (rs6300), HTR2A (rs6311 and rs6314), HTR2B (rs6736017), and the serotonin transporter intron 2 variable number tandem repeat (STin2 VNTR) were genotyped. Linear mixed-effects regression analysis examined associations between SSRI use, genetic variants, and skeletal outcomes. Results: After adjusting for relevant covariates, rs6295 CC and GC genotypes in 262 participants (60% female, mean ± SD age = 18.9 ± 1.6 years) were significantly associated with higher LS BMD compared to the GG genotype. Rs6311 GG SSRI users had greater LS BMD compared to nonusers (β = 0.18, p = <0.0001). Female SSRI users with the combination of rs6295 CC+GC and rs6311 GG genotypes had greater LS BMD than female SSRI nonusers (β = 0.29, p < 0.0001). SSRI users with the rs6295 GG genotype had higher trabecular BMD compared to nonusers (β = 3.60, p = 0.05). No significant interactions were found for TBLH BMC or bone turnover markers. After correcting for multiple comparisons, none of the results retained significance. Conclusions: In older adolescents and young adults, HTR1A (rs6295) and HTR2A (rs6311) variants may moderate the effect of SSRIs on BMD. Sex differences may exist and require further examination. Further research with larger sample sizes is needed to confirm our preliminary findings. Clinical Trial Registration: clinicaltrials.gov NCT02147184.

State of the Evidence for Use of Psychotropic Medications in School-Age Youth

Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

Long COVID as a functional somatic symptom disorder caused by abnormally precise prior expectations during Bayesian perceptual processing: A new hypothesis and implications for pandemic response

This review proposes a model of Long-COVID where the constellation of symptoms are in fact genuinely experienced persistent physical symptoms that are usually functional in nature and therefore potentially reversible, that is, Long-COVID is a somatic symptom disorder. First, we describe what is currently known about Long-COVID in children and adults. Second, we examine reported "Long-Pandemic" effects that create a risk for similar somatic symptoms to develop in non-COVID-19 patients. Third, we describe what was known about somatization and somatic symptom disorder before the COVID-19 pandemic, and suggest that by analogy, Long-COVID may best be conceptualized as one of these disorders, with similar symptoms and predisposing, precipitating, and perpetuating factors. Fourth, we review the phenomenon of mass sociogenic (functional) illness, and the concept of nocebo effects, and suggest that by analogy, Long-COVID is compatible with these descriptions. Fifth, we describe the current theoretical model of the mechanism underlying functional disorders, the Bayesian predictive coding model for perception. This model accounts for moderators that can make symptom inferences functionally inaccurate and therefore can explain how to understand common predisposing, precipitating, and perpetuating factors. Finally, we discuss the implications of this framework for improved public health messaging during a pandemic, with recommendations for the management of Long-COVID symptoms in healthcare systems. We argue that the current public health approach has induced fear of Long-COVID in the population, including from constant messaging about disabling symptoms of Long-COVID and theorizing irreversible tissue damage as the cause of Long-COVID. This has created a self-fulfilling prophecy by inducing the very predisposing, precipitating, and perpetuating factors for the syndrome. Finally, we introduce the term "Pandemic-Response Syndrome" to describe what previously was labeled Long-COVID. This alternative perspective aims to stimulate research and serve as a lesson learned to avoid a repeat performance in the future.

Life satisfaction in the context of the COVID-19 pandemic among middle school adolescents in France: findings from a repeated cross-sectional survey (EnCLASS, 2012-2021)

Background and aims

Since the COVID-19 pandemic, several studies have reported a decrease in adolescents' well-being. We aim to describe life satisfaction over the last decade and examine the factors associated with its variations between 2020 and 2021 among French students in their last year of middle school (around 14-15 years old).

Methods

Data were drawn from a repeated biennial cross-sectional national survey conducted in French schools over the last decade (EnCLASS study), using a self-administered questionnaire. After describing life satisfaction trends between 2012 and 2021 using the Cantril ladder, we examined individual changes in life satisfaction between 2020 and 2021 and their associations with housing and studying conditions during the COVID-19 lockdown, using multinomial logistic regression analysis (decrease, increase, no change as reference).

Results

Among the 17,686 survey respondents, an overall slight decrease in the prevalence of adolescents reporting high life satisfaction (i.e., Cantril score ≥6) was observed since 2012 with the lowest proportion reported in 2021 (77.4%). Between 2020 and 2021, 16.3% of French adolescents experienced an improvement in life satisfaction, while 17.7% experienced the opposite. Decrease in life satisfaction between 2020 and 2021 was more likely experienced by adolescents living in reconstructed families [aOR 2.09 (95%CI, 1.58-2.77)], those who did not have their own room [aOR 1.58 (1.16-2.15)], nor access to the Internet to interact with their friends during the lockdown [aOR 1.47 (1.09-1.98)]. Interestingly, more girls than boys were represented in both those reporting increase and decrease in life satisfaction [aOR 1.82 (1.40-2.37) and 1.43 (1.14-1.79), respectively].

Conclusions

This study shows that the way adolescents experienced the first 2020 lockdown in France was not uniform, and that one must consider sex as well as housing and studying conditions when interpreting adolescents' life satisfaction decrease during the COVID-19 pandemic.

Be ExPeRT (Behavioral Health Expansion in Pediatric Residency Training): A Case-Based Seminar

Introduction

Pediatric residents report behavioral or mental health (B/MH) assessment and treatment as a training gap and often feel ill-equipped to address these issues in clinical practice. We developed a novel interactive training program to improve resident confidence in managing common pediatric B/MH conditions.

Methods

The Be ExPeRT curriculum comprised a half-day interactive seminar on attention deficit hyperactivity disorder, anxiety, depression, and suicidality followed by monthly case-based discussions. Content included didactic material, role-play, and case discussion. The training was optional and open to pediatric or combined medicine-pediatrics trainees.

Results

Twenty-three residents (70% female) participated in four separate seminars over 2 years. Of the participants attending the seminars, 17 (74%) completed the presurvey, and 16 (70%) completed the postsurvey. Statistically significant improvement was noted in comfort treating major depressive disorder (41% pre, 94% post, p = .002), suicide risk (29% pre, 94% post, p < .001), and anxiety (24% pre, 94% post, p < .001) following program participation. Twelve (75%) of the 16 participants completing the survey rated the training in the top 5%-10% with respect to other resident learning experiences.

Discussion

We developed this curriculum to enhance trainee knowledge and comfort in addressing common pediatric B/MH conditions in primary care. Significant improvement was noted in self-reported comfort in treating major depressive disorder, suicide risk, and anxiety, and the program was well received. The curriculum can be adapted for use in any training program for primary care providers to provide B/MH education that may be lacking or supplement existing programming.

Racial and Ethnic Differences in Encounters Related to Suicidal Behavior Among Children and Adolescents With Medicaid Coverage During the COVID-19 Pandemic

This cohort study evaluates rates of encounters for suicidal behavior by race and ethnicity among children with Medicaid coverage during vs before the COVID-10 pandemic.

Understanding adolescent stress during the COVID-19 pandemic

Longitudinal studies across the globe documented significant increases in psychological stress and mental health problems among adolescents during the COVID-19 pandemic. Health concerns, school disruptions, and social disconnection were major sources of stress. High levels of perceived stress predicted worse mental health outcomes, with girls, older adolescents, and socio-economically marginalized youth experiencing more pronounced mental health deteriorations. However, social support from family and peers was a protective factor against increased stress and accompanying mental health problems. We urge policymakers and other key decision-makers to improve the availability and financing of mental health services and support programs for adolescents to address the wave of mental health challenges following the pandemic.

Predicting Adolescent Mental Health Outcomes Across Cultures: A Machine Learning Approach

Adolescent mental health problems are rising rapidly around the world. To combat this rise, clinicians and policymakers need to know which risk factors matter most in predicting poor adolescent mental health. Theory-driven research has identified numerous risk factors that predict adolescent mental health problems but has difficulty distilling and replicating these findings. Data-driven machine learning methods can distill risk factors and replicate findings but have difficulty interpreting findings because these methods are atheoretical. This study demonstrates how data- and theory-driven methods can be integrated to identify the most important preadolescent risk factors in predicting adolescent mental health. Machine learning models examined which of 79 variables assessed at age 10 were the most important predictors of adolescent mental health at ages 13 and 17. These models were examined in a sample of 1176 families with adolescents from nine nations. Machine learning models accurately classified 78% of adolescents who were above-median in age 13 internalizing behavior, 77.3% who were above-median in age 13 externalizing behavior, 73.2% who were above-median in age 17 externalizing behavior, and 60.6% who were above-median in age 17 internalizing behavior. Age 10 measures of youth externalizing and internalizing behavior were the most important predictors of age 13 and 17 externalizing/internalizing behavior, followed by family context variables, parenting behaviors, individual child characteristics, and finally neighborhood and cultural variables. The combination of theoretical and machine-learning models strengthens both approaches and accurately predicts which adolescents demonstrate above average mental health difficulties in approximately 7 of 10 adolescents 3-7 years after the data used in machine learning models were collected.

Structural and Intermediary Social Determinants of Health and the Emotional and Behavioral Health of US Children

Children grow up in homes where varying environmental and socioeconomic contexts have a bearing on their emotional and behavioral health (EBH). This study used data from a representative sample of the child supplement of the US National Health Information Survey (NHIS) and applied the social determinants of health (SDoH) framework to explore factors associated with child EBH. We conducted a path analysis of the child's EBH measured by the strengths and difficulties questionnaire (SDQ) from their macro and socioeconomic contexts, e.g., policy, household, and other health system risk factors. For children in the sample, aged 4 to 17 years old (n = 9205), most path relationships to child SDQ scores were statistically significant. The total effects from a child's visit to a mental health specialist (0.28) and child's age (0.22) had the highest coefficients to child SDQ scores. A modified model showed a better fit with X2 (4) = 22.124, RMSEA = 0.021, and 90% CI [0.013-0.03], CFI = 0.98. Findings indicate that child factors such as being older, the use of mental healthcare services, and family socioeconomic status were significantly associated with EBH, calling attention to the need for more responsive policy and behavioral health interventions that address household/familial and child-level factors, critical determinants of child wellbeing.

Research and Evaluation in a Child-Focused Place-Based Initiative: West Philly Promise Neighborhood

Place-based initiatives attempt to reduce persistent health inequities through multisectoral, cross-system collaborations incorporating multiple interventions targeted at varying levels from individuals to systems. Evaluations of these initiatives may be thought of as part of the community change process itself with a focus on real-time learning and accountability. We described the design, implementation, challenges, and initial results of an evaluation of the West Philly Promise Neighborhood, which is a comprehensive, child-focused place-based initiative in Philadelphia, Pennsylvania. Priorities for the evaluation were to build processes for and a culture of ongoing data collection, monitoring, and communication, with a focus on transparency, accountability, and data democratization; establish systems to collect data at multiple levels, with a focus on multiple uses of the data and future sustainability; and adhere to grant requirements on data collection and reporting. Data collection activities included the compilation of neighborhood-level indicators; the implementation of a program-tracking system; administrative data linkage; and neighborhood, school, and organizational surveys. Baseline results pointed to existing strengths in the neighborhood, such as the overwhelming majority of caregivers reporting that they read to their young children (86.9%), while other indicators showed areas of need for additional supports and were programmatic focuses for the initiative (e.g., about one-quarter of young children were not engaged in an early childhood education setting). Results were communicated in multiple formats. Challenges included aligning timelines, the measurement of relationship-building and other process-focused outcomes, data and technology limitations, and administrative and legal barriers. Evaluation approaches and funding models that acknowledge the importance of capacity-building processes and allow the development and measurement of population-level outcomes in a realistic timeframe are critical for measuring the success of place-based approaches.

Child and Adolescent Anxiety and Depression Prior to and During the COVID-19 Pandemic in the United States

Childhood anxiety and depression have been increasing for years, and evidence suggests the COVID-19 pandemic has exacerbated this trend. However, research has examined anxiety and depression primarily as exclusive conditions, overlooking comorbidity. This study examined relationships between the COVID-19 pandemic and anxiety and depression to clarify risk factors for singular and comorbid anxiety and depression in children. Using 2018-2019 and 2020-2021 samples from the National Survey of Children's Health, a nationally representative survey of children aged 0-17 in the United States, associations between the COVID-19 pandemic and child anxiety and depression were examined via survey-weights' adjusted bivariate and multiple regression analyses, controlling for demographic characteristics. The COVID-19 pandemic was associated with higher odds of having comorbid anxiety and depression but not singular anxiety or depression. Female sex, older age, having special healthcare needs, more frequent inability to cover basic needs on family income, and poorer caregiver mental health were associated with having been diagnosed with singular and comorbid anxiety and depression. Children that witnessed or were victims of violence in the neighborhood were also more likely to have comorbid anxiety and depression. Implications for prevention, intervention, and policy are discussed.

Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety

Increases in adolescent anxiety over the past several years suggest a need for trauma-informed, culturally responsive interventions that help teens cope with environmental stressors like those associated with the COVID-19 pandemic. Although abundant evidence supports the efficacy of cognitive behavioral therapy (CBT) in treating adolescent anxiety, not all teens respond positively to CBT. CBT does not typically include strategies that address important family factors that may be impacting the teen's functioning, such as the attachment relationship. Attachment-based family therapy (ABFT) addresses the attachment relationship and other factors that contribute to the adolescent's anxiety and related distress. By enhancing positive parenting behaviors, such as acceptance and validation of the adolescent's distress and promotion of their autonomy, ABFT sessions may repair the attachment relationship and increase the family's ability and willingness to engage in CBT tasks aimed at reducing anxiety. This theoretical paper describes the ABFT model and proposes that implementing ABFT sessions prior to CBT could result in better clinical outcomes for adolescents with anxiety disorders by improving the context within which the anxiety symptoms and treatment are experienced. Given that ABFT is sensitive and responsive to family and other contextual factors, adolescents from marginalized communities and those from less individualistic cultures may find the model to be more acceptable and appropriate for addressing factors related to their anxiety. Thus, a combined ABFT+CBT model might result in better outcomes for adolescents who have not historically responded well to CBT alone.

Using Digital Measurement-Based Care for the Treatment of Anxiety and Depression in Children and Adolescents: Observational Retrospective Analysis of Bend Health Data

BACKGROUND

A growing body of evidence supports the efficacy of measurement-based care (MBC) for children and adolescents experiencing mental health concerns, particularly anxiety and depression. In recent years, MBC has increasingly transitioned to web-based spaces in the form of digital mental health interventions (DMHIs), which render high-quality mental health care more accessible nationwide. Although extant research is promising, the emergence of MBC DMHIs means that much is unknown regarding their effectiveness as a treatment for anxiety and depression, particularly among children and adolescents.

OBJECTIVE

This study uses preliminary data from children and adolescents participating in an MBC DMHI administered by Bend Health Inc, a mental health care provider that uses a collaborative care model to assess changes in anxiety and depressive symptoms during participation in the MBC DMHI.

METHODS

Caregivers of children and adolescents participating in Bend Health Inc for anxiety or depressive symptoms reported measures of their children's symptoms every 30 days throughout the duration of participation in Bend Health Inc. Data from 114 children (age 6-12 years) and adolescents (age 13-17 years) were used for the analyses (anxiety symptom group: n=98, depressive symptom group: n=61).

RESULTS

Among children and adolescents participating in care with Bend Health Inc, 73% (72/98) exhibited improvements in anxiety symptoms and 73% (44/61) exhibited improvement in depressive symptoms, as indicated by either a decrease in symptom severity or screening out of completing the complete assessment. Among those with complete assessment data, group-level anxiety symptom T-scores exhibited a moderate decrease of 4.69 points (P=.002) from the first to the last assessment. However, members' depressive symptom T-scores remained largely stable throughout their involvement.

CONCLUSIONS

As increasing numbers of young people and families seek DMHIs over traditional mental health treatments due to their accessibility and affordability, this study offers promising early evidence that youth anxiety symptoms decrease during involvement in an MBC DMHI such as Bend Health Inc. However, further analyses with enhanced longitudinal symptom measures are necessary to determine whether depressive symptoms show similar improvements among those involved in Bend Health Inc.

Sudden Unexpected Infant Deaths: 2015-2020

OBJECTIVE

Although the US infant mortality rate reached a record low in 2020, the sudden infant death syndrome (SIDS) rate increased from 2019. To understand if the increase was related to changing death certification practices or the coronavirus disease 2019 (COVID-19) pandemic, we examined sudden unexpected infant death (SUID) rates as a group, by cause, and by race and ethnicity.

METHODS

We estimated SUID rates during 2015 to 2020 using US period-linked birth and death data. SUID included SIDS, unknown cause, and accidental suffocation and strangulation in bed. We examined changes in rates from 2019 to 2020 and assessed linear trends during prepandemic (2015-2019) using weighted least squares regression. We also assessed race and ethnicity trends and quantified COVID-19-related SUID.

RESULTS

Although the SIDS rate increased significantly from 2019 to 2020 (P < .001), the overall SUID rate did not (P = .24). The increased SIDS rate followed a declining linear trend in SIDS during 2015 to 2019 (P < .001). Other SUID causes did not change significantly. Our race and ethnicity analysis showed SUID rates increased significantly for non-Hispanic Black infants from 2019 to 2020, widening the disparities between these two groups during 2017 to 2019. In 2020, <10 of the 3328 SUID had a COVID-19 code.

CONCLUSIONS

Diagnositic shifting likely explained the increased SIDS rate in 2020. Why the SUID rate increased for non-Hispanic Black infants is unknown, but warrants continued monitoring. Interventions are needed to address persistent racial and ethnic disparities in SUID.

The Coronavirus Disease 2019 Pandemic and Mental Health-Related School-Nurse Visits in United States Schools

OBJECTIVE

No studies have examined school-nurse visits related to mental health (MH) during the coronavirus disease 2019 (COVID-19) pandemic. We examined changes in the rate of MH-related school-nurse visits before and during the COVID-19 pandemic.

METHODS

We analyzed school-nurse visit data (n = 3,445,240) for subjects Grade K-12 in US public schools using electronic health record software (SchoolCare, Ramsey, NJ). Data between January 1 and December 31 in 2019 (pre-COVID-19 pandemic) versus January 1 to December 31 in 2020 (during COVID-19 pandemic) were compared. For each year, total visits to a school-nurse were calculated for general MH, anxiety, and self-harm. The exposure was number of school-nurse visits in each time period (2019 vs 2020). The main outcome was change in the rate of general MH, anxiety, and self-harm visits in 2019 versus 2020.

RESULTS

There were 2,302,239 total school-nurse visits in 2019 versus 1,143,001 in 2020. During the COVID-19 pandemic, the rate of visits for general MH increased by 30% (4.7-6.1 per 10,000 visits, 95% confidence interval [CI] {18%, 43%}; P < .001), and visits for anxiety increased by 25% (24.8-31 per 10,000 visits, 95% CI [20%,30%]; P < .001). There was no significant difference in self-harm visits across all ages during the COVID-19 pandemic.

CONCLUSIONS

Our study found a significant increase in the rate of school-nurse visits for MH and anxiety during the COVID-19 pandemic, suggesting the pediatric population is at-risk for increased negative MH-effects associated with the pandemic and highlights a critical role of school-nurses in identifying youth with potential MH-needs.

Changes in Lifestyle and Body Weight in Children and Adolescents during the COVID-19 Pandemic: A Representative Survey of Parents in Germany

INTRODUCTION

The public restrictions taken during the COVID-19 pandemic have substantially affected lifestyle and health behavior of children and adolescents. In Germany, little is known how these changes influenced daily life in families with children and adolescents.

METHODS

A cross-sectional survey was performed in April/May 2022 across Germany, similar to a survey performed in 2020. Parents (N = 1,004, 20-65 years) with at least one child aged 3-17 years filled in an online questionnaire released by the Forsa Institute for Social Research and Statistical Analysis. Fifteen questions related to eating habits, dietary patterns, physical activity, media consumption, fitness, mental health, and body weight were included, and standard socioeconomic parameters were assessed.

RESULTS

Parents' answers indicated that there was a parental self-reported weight gain in every sixth child since the beginning of the COVID-19 pandemic. This was most obvious in children from families with lower household income and preexisting overweight. Parents also reported that lifestyle patterns had worsened: 70% reported an increase of media consumption during leisure time, 44% a decrease in daily physical activity, and 16% the worsening of dietary habits (e.g., 27% stated to eat more cake and sweets). Children aged 10-12 years were most severely affected.

CONCLUSION

Negative health effects related to the COVID-19 pandemic are predominantly observed in children 10-12 years of age and in children from families with low household income, suggesting a worsening social disparity. Political action is urgently needed to tackle the adverse consequences of the COVID-19 pandemic on childhood lifestyle and health.

Neuroimaging profiling identifies distinct brain maturational subtypes of youth with mood and anxiety disorders

Mood and anxiety disorders typically begin in adolescence and have overlapping clinical features but marked inter-individual variation in clinical presentation. The use of multimodal neuroimaging data may offer novel insights into the underlying brain mechanisms. We applied Heterogeneity Through Discriminative Analysis (HYDRA) to measures of regional brain morphometry, neurite density, and intracortical myelination to identify subtypes of youth, aged 9-10 years, with mood and anxiety disorders (N = 1931) compared to typically developing youth (N = 2823). We identified three subtypes that were robust to permutation testing and sample composition. Subtype 1 evidenced a pattern of imbalanced cortical-subcortical maturation compared to the typically developing group, with subcortical regions lagging behind prefrontal cortical thinning and myelination and greater cortical surface expansion globally. Subtype 2 displayed a pattern of delayed cortical maturation indicated by higher cortical thickness and lower cortical surface area expansion and myelination compared to the typically developing group. Subtype 3 showed evidence of atypical brain maturation involving globally lower cortical thickness and surface coupled with higher myelination and neural density. Subtype 1 had superior cognitive function in contrast to the other two subtypes that underperformed compared to the typically developing group. Higher levels of parental psychopathology, family conflict, and social adversity were common to all subtypes, with subtype 3 having the highest burden of adverse exposures. These analyses comprehensively characterize pre-adolescent mood and anxiety disorders, the biopsychosocial context in which they arise, and lay the foundation for the examination of the longitudinal evolution of the subtypes identified as the study sample transitions through adolescence.

Prevalence of Autism Spectrum Disorder in the United States is Stable in the COVID-19 Era

Although the United States (US) have been monitoring the autism spectrum disorder (ASD) prevalence, whether the prevalence has continued to increase, decrease, fluctuate or reached a stable level remained unclear during the COVID-19 pandemic. We have requested the 2016-2021 National Survey of Children's Health (NSCH) data in the United States to estimate weighted ASD prevalence and assess linearity/nonlinearity in the time trend. We did not observe linear or nonlinear trends of the ASD prevalence during the 2016-2021 periods. The current ASD prevalence experienced a 0.3% drop from 2019 to 2020 but a 0.3% uptick in 2021, suggesting a stable trend during the COVID-19 pandemic. Our findings shed lights on the need for the modified strategy of monitor ASD prevalence during the COVID-19 era.

A cross-sectional analysis of long-term exposure to ambient air pollution and cognitive development in children aged 3-4 years living in 12 low- and middle-income countries

Exposure to ambient air pollution may affect cognitive functioning and development in children. Unfortunately, there is little evidence available for low- and middle-income countries (LMICs), where air pollution levels are highest. We analysed the association between exposure to ambient fine particulate matter (≤2.5 μm [PM_2.5]) and cognitive development indicators in a cross-sectional analysis of children (aged 3-4 years) in 12 LMICs. We linked Demographic and Health Survey data, conducted between 2011 and 2018, with global estimates of PM_2.5 mass concentrations to examine annual average exposure to PM_2.5 and cognitive development (literacy-numeracy and learning domains) in children. Cognitive development was assessed using the United Nations Children's Fund's early child development indicators administered to each child's mother. We used multivariable logistic regression models, adjusted for individual- and area-level covariates, and multi-pollutant models (including nitrogen dioxide and surface-level ozone). We assessed if sex and urban/rural status modified the association of PM_2.5 with the outcome. We included 57,647 children, of whom, 9613 (13.3%) had indicators of cognitive delay. In the adjusted model, a 5 μg/m³ increase in annual all composition PM_2.5 was associated with greater odds of cognitive delay (OR = 1.17; 95% CI: 1.13, 1.22). A 5 μg/m³ increase in anthropogenic PM_2.5 was also associated with greater odds of cognitive delay (OR = 1.05; 95% CI: 1.00, 1.10). These results were robust to several sensitivity analyses, including multi-pollutant models. Interaction terms showed that urban-dwelling children had greater odds of cognitive delay than rural-dwelling children, while there was no significant difference by sex. Our findings suggest that annual average exposure to PM_2.5 in young children was associated with adverse effects on cognitive development, which may have long-term consequences for educational attainment and health.

Social media as an incubator of personality and behavioral psychopathology: Symptom and disorder authenticity or psychosomatic social contagion?

There has been an increasing recognition among both medical and psychological professionals, as well as the public media, of a concerning trend for child and adolescent users of audiovisual-based, algorithmic social media platforms (e.g., TikTok) to present with or claim functional psychiatric impairment that is inconsistent with or distinct from classic psychiatric nosology. In this short communication, we provide a detailed historical overview of this transdiagnostic phenomenon and suggest a conceptual model to organize thinking and research examining it. We then discuss the implications of our suggested model for accurate assessment, diagnosis, and medical-psychiatric treatment. We believe there is an urgent need for focused empirical research investigation into this concerning phenomenon that is related to the broader research and discourse examining social media influences on mental health.

The Utility of the Behavior Assessment System for Children-2 Behavioral and Emotional Screening System and Strengths and Difficulties Questionnaire in Predicting Mental Disorders in the Project to Learn About Youth-Mental Health

We examined the predictive utility of the Behavior Assessment System for Children-2 Behavioral and Emotional Screening System (BASC-2-BESS) and Strengths and Difficulties Questionnaire (SDQ) in identifying students with a mental disorder. Data were collected in a two-stage study over 34 months with kindergarten-12th grade (K-12) students (aged 5-19 years) in four U.S. school districts. In Stage 1, teachers completed the BASC-2-BESS and the SDQ. In Stage 2, parents of 1,054 children completed a structured diagnostic interview to determine presence of a mental disorder. Results suggest that teacher versions of the BASC-2-BESS and SDQ have modest utility in identifying children meeting criteria for a mental disorder based on parent report. Area Under the Curve (AUC) statistics representing prediction of any externalizing disorder (.73 for both measures) were higher than the AUCs predicting any internalizing disorder (.58 for both measures). Findings can inform the use of teacher report in mental health screening, specifically the selection of measures when implementing screening procedures.

Growth During Infancy After Extremely Preterm Birth: Associations with Later Neurodevelopmental and Health Outcomes

OBJECTIVE

To evaluate associations between changes in weight, length, and weight/length ratio during infancy and outcomes later in life among individuals born extremely preterm.

STUDY DESIGN

Among participants in the Extremely Low Gestational Age Newborn (ELGAN) study, we measured weight and length at discharge from the neonatal intensive care unit (NICU) and at age 2 years and evaluated neurocognitive, psychiatric, and health outcomes at age 10 years and 15 years. Using multivariable logistic regression, we estimated associations between gains in weight, length, and weight/length ratio z-scores between discharge and 2 years and outcomes at 10 and 15 years. High gain was defined as the top quintile of change; low gain, as the bottom quintile of change.

RESULTS

High gains in weight and weight/length were associated with greater odds of obesity at 10 years, but not at 15 years. These associations were found only for females. High gain in length z-score was associated with lower odds of obesity at 15 years. The only association found between high gains in growth measures and more favorable neurocognitive or psychiatric outcomes was between high gain in weight/length and lower odds of cognitive impairment at age 10 years.

CONCLUSIONS

During the 2 years after NICU discharge, females born extremely preterm with high gains in weight/length or weight have greater odds of obesity at 10 years, but not at 15 years. Infants with high growth gains in the 2 years after NICU discharge have neurocognitive and psychiatric outcomes in middle childhood and adolescence similar to those of infants with lower gains in weight and weight/length.