Psychometric properties of the 7-item Generalized Anxiety Disorder Scale (GAD-7) in a large representative sample of Finnish adolescents

Prevention and Treatment of Social Anxiety Disorder in Adolescents: Protocol for a Randomized Controlled Trial of the Online Guided Self-Help Intervention SOPHIE

BACKGROUND

Social anxiety symptoms are highly prevalent among adolescents and are associated with poor quality of life and low psychosocial functioning. If untreated, social anxiety often persists into adulthood and increases the risk for comorbid disorders. Therefore, early interventions for social anxiety to prevent negative long-term consequences are critical. However, adolescents rarely seek help and often avoid face-to-face psychotherapeutic interventions due to the perceived lack of autonomy and anonymity. Thus, online interventions represent a promising opportunity to reach adolescents who have social anxiety but do not seek help yet.

OBJECTIVE

This study aims to evaluate the efficacy, moderators, and mediators of an online intervention developed to reduce social anxiety in adolescents.

METHODS

A total of 222 adolescents aged 11-17 years with subclinical social anxiety (N=166) or with a diagnosis of social anxiety disorder (N=56) are randomly assigned to the online intervention or a care-as-usual control group. The 8-week guided online intervention is based on the Cognitive Model of Social Phobia and evidence-based online interventions for social anxiety adapted to the specific needs of adolescents. The care-as-usual group will be given access to the online intervention after the follow-up assessment. Participants are assessed at baseline, at 4 and 8 weeks post intervention, and at 3-month follow-up assessment on the primary outcome, that is, social anxiety, on secondary outcomes (eg, level of functioning, fear and avoidance, general anxiety, depression, quality of life, self-esteem, and negative effects of the intervention), on potential moderators (eg, therapy motivation, therapy expectancy, and satisfaction with the intervention), and potential mediators (eg, therapeutic alliance and adherence to the intervention). Data will be analyzed based on an intention-to-treat approach and both groups (intervention and care-as-usual) will be compared at each assessment time point. Furthermore, potential mechanisms of change and generalization of intervention effects on daily life are assessed using an ecological momentary assessment procedure that includes items on maintaining mechanisms of social anxiety, social context, and affect. Participants are prompted 3 times a day during the first 8 weeks of the study and again for 2 weeks following the follow-up assessment.

RESULTS

Recruitment is ongoing; initial results are expected in 2024.

CONCLUSIONS

Results are discussed considering the potential of online interventions as a low-threshold prevention and treatment option for adolescents with social anxiety and in light of current advances in dynamic modeling of change processes and mechanisms in early intervention and psychotherapy in adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04782102; https://clinicaltrials.gov/ct2/show/NCT04782102.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44346.

Internet addiction and mental health disorders in high school students in a Peruvian region: a cross-sectional study

OBJECTIVES

To determine the association between internet addiction disorder (IAD) and anxiety and depressive symptomatology in high school students in two private schools in Chiclayo, Peru, during the COVID-19 pandemic.

MATERIALS AND METHODS

Analytical cross-sectional investigation of 505 adolescents from two private schools. The dependent variables were anxiety and depressive symptomatology, measured with the Beck Adapted Depression Questionnaire (BDI-IIA) and the Beck Anxiety Inventory (BAI), respectively. The main independent variable was IAD, measured with the Internet Addiction Test instrument(IATI). Prevalence ratios (PR) and 95% confidence intervals (95%CI) were estimated.

RESULTS

The average age was 14.16 years and 54.9% were women. 22.2% and 3.2% presented mild and moderate IAD; respectively. 9.3% presented severe anxiety and 34.3% severe depressive symptomatology. In the simple regression, adolescents with mild, moderate and severe IAD presented 19% (PR = 1.19; 95%CI: 1.05-1.35), 25% (PR = 1.25; 95%CI: 1.02-1.53) and 53% (PR = 1.47; 95% CI: 1.47-1.60) higher prevalence of depressive symptomatology; however, this association was not maintained in the multiple model. Anxiety increased 196% in adolescents with severe IAD (PR = 2.96; 95%CI: 1.86-4.71).

CONCLUSION

 We found that 2, 1, and 3 out of 10 students presented IAD, depressive symptomatology, and anxiety, respectively. We did not find an association between IAD and depressive symptomatology, but we did find an association with anxiety. Among the factors associated with the development of depressive symptomatology were the male sex, the presence of eating disorders, subclinical insomnia, using devices for more than 2 h, and using the Internet for academic activities. About anxiety, the associated factors are the female sex, the presence of eating disorders, subclinical insomnia, and the use of the Internet as social interaction. We recommend implementing counseling programs in view of the imminent introduction of the Internet as a pillar in education.

In Sync: Inclusive school communities supporting students with anxiety

This study aimed to investigate the experiences of educators (working in inclusive schools) supporting students with anxiety and anxiety-related disorders.

Method

A qualitative refractive phenomenological case study was used to collect data from 44 participants (educators in various roles) in six Australian primary and secondary schools, which previous research identified as using inclusive practices to support a diverse range of students.

Results

Educators shared that they supported what they saw as learning needs using intrinsic, intuitive, and inclusive (3I's) ways of working. Interestingly, all educators reported that students felt supported despite a lack of explicit strategies focused on reducing anxiety. The 3I's were a way of working educators used to support all students, even though they experienced difficulties in recognising anxiety as behaviours were often internalised. This was particularly the case where disability and anxiety disorders co-occurred. Furthermore, educators did not identify evidence to support any one type of intervention being effective in mitigating anxiety.

Conclusions

The data suggests that there is a culture of inclusion reducing student anxiety, even though teachers and support staff may not have recognise the student's anxiety. Parents were mostly the first identifier of anxiety in their child. This research highlights the need for educators to engage in professional development around recognising anxiety and, secondly, in the implementation of specific strategies to support students with anxiety or anxiety-related disorders.

Hospital-based higher calorie refeeding and mealtime distress in adolescents and young adults with anorexia nervosa or atypical anorexia nervosa

OBJECTIVE

The StRONG study demonstrated that higher calorie refeeding (HCR) restored medical stability faster in patients hospitalized with anorexia nervosa (AN) and atypical AN (AAN), with no increased safety events compared with standard-of-care lower calorie refeeding (LCR). However, some clinicians have expressed concern about potential unintended consequences of HCR (e.g., greater mealtime distress). The purpose of this study was to examine patient treatment preference and compare mealtime distress, food refusal, and affective states between treatments.

METHOD

Participants (N = 111) in this multisite randomized clinical trial were ages 12-24 years, with AN or AAN, admitted to hospital with medical instability who received assigned study treatment (HCR or LCR). Treatment preference was assessed prior to randomization in the full sample. In a subset of participants (n = 45), linear mixed effect models were used to analyze momentary ratings of mealtime distress (pre, during, and post-meals) and daily affective state during the hospitalization.

RESULTS

About half (55%) of participants reported a preference for LCR. Treatment assignment was not associated with food refusal, mealtime distress, or affective states in the subsample. Food refusal increased significantly over the course of refeeding (p = .018). Individuals with greater depression experienced more negative affect (p = .033), with worsening negative affect over time for individuals with higher eating disorder psychopathology (p = .023).

DISCUSSION

Despite understandable concerns about potential unintended consequences of HCR, we found no evidence that treatment acceptability for HCR differed from LCR for adolescents and young adults with AN and AAN.

PUBLIC SIGNIFICANCE

The efficacy and safety of higher calorie refeeding in hospitalized patients with anorexia nervosa has been demonstrated. However, it is not known whether higher calorie refeeding (HCR) increases meal-time distress. This study demonstrated that HCR was not associated with increased mealtime distress, food refusal, or affective states, as compared with lower calorie refeeding. These data support HCR treatment acceptability for adolescents/young adults with anorexia nervosa and atypical anorexia nervosa.

Healthcare utilization and costs of singaporean youth with symptoms of depression and anxiety: results from a 2022 web panel

BACKGROUND

There is evidence that the prevalence of depression and anxiety among youth is increasing and that these factors contribute to high healthcare costs and poor school performance. The goal of this study is to provide up-to-date estimates of the prevalence and economic burden of depression and anxiety among youth in Singapore.

METHODS

Using an existing web panel, 991 parents filled out the PHQ-4 screener on behalf of 1,515 youth. 104 of these parents whose children (ages 4 to 21) had symptoms consistent with depression or anxiety filled out a full survey with questions on mental health symptoms, school absences, school performance, and healthcare utilization. The survey was fielded between April and June 2022. Publicly available prices were used to estimate the cost associated with the observed rates of health service use.

FINDINGS

Based on parental responses, 11.7% (95% CI:10.2 - 13.5%) of youth had symptoms consistent with depression and 12.8% (95% CI:11.2 - 14.6%) had symptoms consistent with anxiety. In total, 16.2% (95% CI:14.5 - 18.3%) were reported to have symptoms consistent with at least one of these conditions. These youths missed an average of 190 (95% CI: 126-254) hours of school per year due to their mental health conditions and parents reported that school and daily activities performance was significantly degraded. Per capita annual healthcare costs averaged S$10,250 (95% CI: 7,150-13,350), with 64% of youth receiving emergency or inpatient services. In aggregate, annual costs associated with these conditions were estimated to be S$1.2 billion (95% CI:S$1.1bn - S$1.4bn).

INTERPRETATION

Even with significant potential for underreporting, these results reveal concerning rates of Singaporean youth with symptoms consistent with depression or anxiety, many of whom remain untreated. Results also reveal the short-term economic burden caused by these symptoms and hint at longer-term consequences resulting from poor school performance. This study should represent a call to action for Singapore to address poor mental health among youth.

Psychometric properties and measurement invariance of the 7-item General Anxiety Disorder scale (GAD-7) in an Italian coronary heart disease population

BACKGROUND

Generalized Anxiety Disorder is predominant in coronary heart disease (CHD) patients. 7-item Generalized Anxiety Disorder (GAD-7) scale psychometric properties have never been tested in CHD populations. This study aims to verify the GAD-7 psychometric properties and measurement invariance in an Italian CHD sample.

METHOD

A baseline data secondary analysis from HEARTS-IN-DYADS study. Several healthcare facilities enrolled an adult inpatient sample. Anxiety and depression data were collected using GAD-7 and Patient Health Questionnaire 9 (PHQ-9). Factorial validity was assessed with confirmatory factor analysis; construct validity was tested by correlating GAD-7 scores with PHQ-9 scores and other sociodemographic characteristics; internal consistency reliability was assessed using Cronbach's alpha and the composite reliability index, while confirmatory multigroup factor analysis was employed to investigate measurement invariance across gender and age (65 vs. 65).

RESULTS

We enrolled 398 patients (mean age 64.7 years; 78.9 % male; 66.8 % married). Factor structure was confirmed as unidimensional. Construct validity was confirmed with significant associations between GAD-7 and PHQ-9 scores, female gender, having a caregiver, and being employed. Cronbach's alpha and composite reliability index were 0.89 and 0.90, respectively. Measurement invariance across gender and age was confirmed at the scalar level.

LIMITATIONS

A convenience sample in one European country, a small female sample, validity testing against a single criterion.

CONCLUSION

Study results demonstrate adequate validity and reliability of the GAD-7 in an Italian CHD sample. It showed satisfactory invariance properties; GAD-7 is suitable for measuring anxiety in CHD while making significant comparisons of scores among stratified gender and age groups.

Integrating Behavioral Health and Primary Care in an Inner-City High School: Expanded Care in a School-Based Clinic in Mississippi, 2018-2020

Adolescence, a critical and rapid stage of human development, requires innovative approaches in the provision of health care. With considerable mental health issues occurring among adolescents, an urgent need exists to address their mental and behavioral health. School-based health centers can provide an important safety net, particularly for young people who lack access to comprehensive and behavioral health care. We describe the design and implementation of behavioral health assessment, screening, and treatment services in a primary care school-based health center. We reviewed primary care and behavioral health measures as well as the challenges and lessons learned of this process. Five hundred and thirteen adolescents and young adults aged 14-19 years from an inner-city high school in South Mississippi were screened for behavioral health issues from January 2018 through March 2020, and all 133 adolescents deemed at risk for behavioral health issues received comprehensive health care. Lessons learned included the importance of recruiting behavioral health providers to ensure sufficient staff, establishing academic-practice arrangements to ensure funding, increasing student enrollment by improving the return rate of consent for care, and enhancing data collection through process automation. This case study may help inform the design and implementation of integrated primary and behavioral health care in school-based health centers.

The impact of 12 modifiable lifestyle behaviours on depressive and anxiety symptoms in middle adolescence: prospective analyses of the Canadian longitudinal COMPASS study

BACKGROUND

Unhealthy lifestyle behaviours are becoming increasingly common and might contribute to the growing burden of mental disorders in adolescence. We examined the associations between a comprehensive set of lifestyle behaviours and depression and anxiety in middle adolescents.

METHODS

School-based survey responses were collected from 24,274 Canadian high school students at baseline and 1-year follow-up (average age 14.8 and 15.8 years, respectively). Using linear mixed-effects models, we examined prospective associations of adherence to recommendations for vegetables and fruit, grains, milk and alternatives, meat and alternatives, sugar-sweetened beverages [SSB], physical activity, screen time, sleep, and no use of tobacco, e-cigarettes, cannabis, and binge drinking at baseline with the depressive and anxiety symptoms (measured by CESD-R-10 and GAD-7 scales, respectively) at follow-up.

RESULTS

Adherence to recommendations was low overall, particularly for vegetables and fruit (3.9%), grains (4.5%), and screen time (4.9%). Students adhering to individual recommendations, particularly for meat and alternatives, SSB, screen time, sleep, and no cannabis use, at baseline had lower CESD-R-10 and GAD-7 scores at follow-up. Adhering to every additional recommendation was associated with lower CESD-R-10 (β=-0.15, 95% CI -0.18, -0.11) and GAD-7 scores (β=-0.10, 95% CI -0.14, -0.07) at follow-up. Assuming cumulative impact, this might translate into 7.2- and 4.8-point lower CESD-R-10 and GAD-7 scores, respectively, among students adhering to 12 vs. 0 recommendations over four years of high school.

CONCLUSIONS

The results highlight the preventive potential of population-based approaches promoting healthy lifestyle behaviours, particularly those with the lowest prevalence, as a strategy to improve mental health in adolescence.

Validation of Generalized Anxiety Disorder 6 (GAD-6)-A Modified Structure of Screening for Anxiety in the Adolescent French Population

Anxiety disorders remain underdiagnosed and undertreated, especially in child and adolescent populations. This study aimed to examine the construct validity of the Generalized Anxiety Disorder Scale 7 (GAD-7) in a sample of French adolescents by combining the Classical Test Theory (CTT) and the Item Response Theory (IRT) and to assess the invariance of items. A total of 284 adolescents enrolled in school in the Lorraine region were randomly selected to participate in a cross-sectional study. A psychometric evaluation was performed using a combination of CTT and IRT analyses. The study of psychometric properties of GAD-7 revealed poor adequation to the sample population, and engendered the deletion of one item (#7) and the merger of two response modalities (#2 and #3). These modifications generated the new GAD-6 scale, which had a good internal consistency reliability (Cronbach α = 0.85; PSI = 0.83), acceptable goodness-of-fit indices (χ2 = 28.89, df = 9, P = 0.001; RMSEA (90% CI) = 0.088 [0.054; 0.125]; SRMR = 0.063; CFI = 0.857), and an acceptable convergent validity (r = -0.62). Only one item (#5) had a consistent Differential Item Functioning (DIF) by gender. This study evaluated the structure of the GAD-7 scale, which was essentially intended at discriminating adolescent patients with high levels of anxiety, and adapted it to a population of adolescents from the general population. The GAD-6 scale presents better psychometric properties in this general population than the original GAD-7 version.

Characteristics of trichotillomania and excoriation disorder across the lifespan

Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are body-focused repetitive behaviors, which often first present in adolescence and cause distress and impairment into adulthood. Few studies have examined the clinical characteristics of the co-occurrence of these conditions across the lifespan. We examined cross-sectional survey responses collected from April 2018-February 2020 to evaluate the relationship between trichotillomania, excoriation disorder, and their co-occurrence. Responses from individuals with trichotillomania (n = 50), excoriation disorder (n = 52), and both conditions (n = 50) ages 4-67 years old were compared for co-occurring conditions and current symptoms. Self-report measures of hair-pulling and skin-picking severity and subtypes were assessed. Gender, race, and co-occurring conditions were generally similarly distributed across the three groups with high rates of self-reported anxiety (63-82%), depression (34-50%), obsessive-compulsive disorder (16-29%), and attention-deficit/hyperactivity disorder (12-32%). Among individuals with both trichotillomania and excoriation disorder, significant positive correlations were observed between hair-pulling and skin-picking severity scores as well as hair-pulling and skin-picking subtypes. Hair-pulling and skin-picking severity peaked at the transition from adolescence to adulthood and hair-pulling/skin-picking styles appeared to shift across the lifespan. Our results support several similarities between trichotillomania and excoriation disorder, providing new insight into the clinical characteristics of these conditions.

Multicenter Study of Utility and Acceptability of Depression and Anxiety Screening in Adolescents and Young Adults With Childhood-Onset Systemic Lupus

OBJECTIVE

To determine the utility and acceptability for depression and anxiety screening of adolescents and young adults (AYA) with childhood-onset systemic lupus erythematosus (cSLE) in the pediatric rheumatology setting.

METHODS

AYA with cSLE, ages 12-21 years, from 8 collaborating sites, were consecutively screened for depression and anxiety with the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder 7-item scale (GAD-7). Demographic and disease characteristics were collected, as well as patient-reported outcome measures using the Patient Reported Outcomes Measurement Information System (PROMIS) pediatric profile-25. Acceptability of screening was assessed with postscreening surveys completed by AYA and parents. Chi-square and Wilcoxon rank sum tests examined the relationship between patient characteristics and history of previous screening. Spearman correlations examined relationships between screening scores, PROMIS domains, and other disease factors.

RESULTS

Among 106 AYA screened, 64 (60%) had been previously screened, 25 (24%) by general pediatricians. Thirty-two (30%) AYA screened positive, including 24% for depression, 17% for anxiety, and 14% for suicidal ideation. Depression and anxiety symptom severity were highly correlated with increased PROMIS domain scores for fatigue and pain interference and moderately correlated with increased pain severity, decreased mobility, and decreased peer relationships. Eighty-six percent of AYA and 95% of parents expressed comfort with screening in the pediatric rheumatology setting.

CONCLUSION

Depression, anxiety, and suicidal ideation are common among AYA with cSLE, and symptoms are correlated with important patient-reported outcomes. Mental health screening in the pediatric rheumatology setting was highly acceptable among AYA with cSLE and their parents.

Association Between Head Impact Exposure, Psychological Needs, and Indicators of Mental Health Among U.S. High School Tackle Football Players

PURPOSE

Age of first exposure to tackle football and head impact kinematics have been used to examine the effect of head impacts on mental health outcomes. These measures coupled with retrospective and cross-sectional designs have contributed to conflicting results. The purpose of this study was to identify the effect of one season of head impact exposure, age of first exposure to football, and psychological need satisfaction on acute mental health outcomes in adolescent football players.

METHODS

This prospective single-season cohort study used sensor-installed mouthguards to collect head impact exposure along with surveys to assess age of first exposure to football, psychological satisfaction, depressive symptoms, anxiety symptoms, and thriving from football players at four high schools (n = 91). Linear regression was used to test the association of head impact exposure, age of first exposure, and psychological satisfaction with acute mental health outcomes.

RESULTS

A total of 9,428 impacts were recorded with a mean of 102 ± 113 impacts/player. Cumulative head impact exposure and age of first exposure were not associated with acute mental health outcomes at postseason or change scores from preseason to postseason. Greater psychological satisfaction was associated with fewer depressive symptoms (β = -0.035, SE = 0.008, p = < .001), fewer anxiety symptoms (β = -0.021, SE = 0.008, p = .010), and greater thriving scores (β = 0.278, SE = 0.040, p = < .001) at postseason.

DISCUSSION

This study does not support the premise that greater single-season head impact exposure or earlier age of first exposure to tackle football is associated with worse acute mental health indicators over the course of a single season in adolescent football players.

Exploring Determinants of COVID-19 Vaccine Acceptance, Uptake, and Hesitancy in the Pediatric Population: A Study of Parents and Caregivers in Saudi Arabia during the Initial Vaccination Phase

OBJECTIVES

This study aims to assess COVID-19 vaccine acceptance, uptake, and hesitancy among parents and caregivers of children in Saudi Arabia during the initial rollout of pediatric COVID-19 vaccination.

METHODS

An electronic survey was used to collect data from participants who visited a COVID-19 vaccine center. The survey included demographic data, COVID-19 vaccine status among participants and their children, and reasons for vaccine acceptance or rejection. The Vaccine Hesitancy Scale (VHS) tool was also employed to assess vaccine hesitancy and attitudes toward the COVID-19 vaccine and routine childhood vaccination. Multivariate binary regression analysis was used to identify predictors of actual COVID-19 vaccine uptake among children.

RESULTS

Of the 873 respondents included in the analysis, 61.5% were parents and 38.5% were other caregivers. Of the participants, 96.9% had received the COVID-19 vaccine. Six hundred and ninety-four participants accepted the vaccine for their children, with the main reasons being an endorsement by the Saudi Ministry of Health (60%) and the importance of going back to school (55%). One hundred and seventy-nine participants would not vaccinate their children, with the most common reasons being fear of adverse effects (49%) and inadequate data about vaccine safety (48%). Factors such as age, COVID-19 vaccination status, self-rated family commitment level, attitudes toward routine children's vaccines, and participants' generalized anxiety disorder (GAD7) score did not significantly correlate with children's COVID-19 vaccination status. Parents were less likely to vaccinate their children compared to other caregivers, and participants with a higher socioeconomic status were more likely to vaccinate their children.

CONCLUSION

Vaccine acceptance and uptake were high during the initial pediatric COVID-19 vaccination rollout in Saudi Arabia. Still, the ongoing endorsement of the Ministry of Health and healthcare authorities should continue to advocate for better vaccine uptake in children.

The Power Dynamics of Friendship: Between- and Within- Person Associations among Friend Dominance, Self-Esteem, and Adolescent Internalizing Symptoms

Although forming close, egalitarian peer relationships is a central developmental task of adolescence, little is known about the psychological consequences of power imbalances in adolescents' friendships. The current study investigated whether there are psychological costs of feeling subordinate to friends by examining longitudinal associations between adolescents' perceived friend dominance and internalizing symptoms. Across one year, five waves of survey data were collected from 388 adolescents (M_age = 14.05, SD_age = 0.41; 61% female; 46% White, 19% Black, 17% Asian, 6% Arab, Middle Eastern, North African, 6% Biracial/Multiethnic, 3% Latinx/Hispanic, 1% American Indian/Native American, 1% identifying with another race/ethnicity, <1% not reporting). Multilevel modeling disentangled between- and within-person effects of perceived friend dominance on depressive and anxiety (internalizing) symptoms and tested self-esteem as a mediator. The results indicated that both individual differences and intraindividual fluctuations in perceived friend dominance were associated with internalizing symptoms. At the between-person level, adolescents who perceived their friends as more dominant reported more severe depressive and anxiety symptoms than adolescents who perceived their friends as less dominant. At the within-person level, increases in perceived friend dominance were accompanied by increases in depressive and anxiety symptoms, and these associations were partially explained by changes in self-esteem. The findings advance understanding of power dynamics in adolescents' close friendships and highlight the psychological toll of feeling dominated by friends.

Generalized anxiety among Finnish youth from 2013 to 2021-Trend and the impact of COVID-19

BACKGROUND

Alarming levels of emotional symptoms among youth were reported during the COVID-19 pandemic. Studies assessing these figures against the pre-pandemic developments are rare. We examined the trend of generalized anxiety (GA) in adolescents in the 2010s and the effect of the COVID-19 pandemic against this trend.

METHODS

Data from the Finnish School Health Promotion study with 750,000 participants aged 13-20 between 2013 and 2021 was analyzed using GAD-7 to measure self-reported GA (cut-off ≥10). Inquiries were made about remote learning arrangements. Effects of time and COVID-19 were analyzed with logistic regression.

RESULTS

Among females, an increasing trend in GA between 2013 and 2019 was found (OR per year 1.05), and the prevalence increased from 15.5 % to 19.7 %. Among males, the trend was decreasing (OR = 0.98), with prevalence from 6.0 % to 5.5 %. Increase in GA from 2019 to 2021 was stronger in females (19.7 % to 30.2 %) than males (5.5 % to 7.8 %), while the effect of COVID-19 on GA was equally strong (OR = 1.59 vs. OR = 1.60) against the pre-pandemic trends. Remote learning was associated with elevated levels of GA, especially among those with unmet needs for learning support.

LIMITATIONS

The design of repeated cross-sectional surveys doesn't allow analyses of within individual changes.

CONCLUSIONS

Given the pre-pandemic trends of GA, the COVID-19 effect on it appeared equal in both sexes. The increasing pre-pandemic trend among adolescent females and the strong effect of COVID-19 on GA among both sexes warrants constant monitoring of mental health of the youth in the aftermath of the COVID-19 pandemic.

Assessing the Feasibility, Acceptability, and Preliminary Effectiveness of a School-Aged Program that Supports Physical Activity and Wellness

The prevalence of anxiety symptoms in children and adolescents aged 4 to 18 years has nearly doubled after the first year of the pandemic. However, only one in five adolescents diagnosed with anxiety is treated. We R H.O.P. E. is a school-based mental health program that includes evidence-based principles designed to engage children and adolescents in anxiety treatment, including wellness and emotional regulation, and the emotional CPR method. We R H.O.P. E. augments traditional services provided by school administrators, school social workers, school teachers, and school nurses. The purpose of this study was to examine the feasibility, acceptability, and preliminary effectiveness of We R H.O.P. E.

Impact of the Russian Invasion on Mental Health of Adolescents in Ukraine

OBJECTIVE

Very limited evidence is available on the psychological impact of war on adolescents in Ukraine. This study compared war experiences and posttraumatic stress disorder (PTSD), anxiety and depression in adolescents living in war-torn and peaceful regions of Ukraine, more than 2 years after Russia first invaded in 2014.

METHOD

The cross-sectional study included 2,766 students aged 11 to 17 years living in the war-torn Donetsk region and in Kirovograd in central Ukraine. Self-reported PTSD, depression, and anxiety were assessed by Harvard Trauma Questionnaire, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Data were collected from September 2016 to January 2017. Binary and multinomial logistic regression models were used to examine the association between PTSD, anxiety, and depression and regions.

RESULTS

War trauma and daily stress were higher in adolescents in the Donetsk region; 881 (60.2%) adolescents had witnessed armed attacks, 204 (13.9%) were victims of violence, and 409 (27.9%) were forced to leave their homes. They also had significantly increased risks for PTSD (odds ratio [OR] 4.11, 95% CI 2.37-7.13), severe anxiety (OR 3.10, 95% CI 1.83-5.27), and moderately severe/severe depression (OR 2.65, 95% CI 1.79-3.92).

CONCLUSION

Traumatic events and daily stress were strongly associated with psychological distress in adolescents living in a war-torn region in Ukraine. These findings can help in understanding, measuring, and addressing the long-term impact that the current escalating war in Ukraine will have on adolescents' mental health and social functioning.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

Stronger together: Coping behaviours and mental health changes of Canadian adolescents in early phases of the COVID-19 pandemic

BACKGROUND

The impact of the COVID-19 pandemic and consequent public health restrictions on the mental health of adolescents is of global concern. The purpose of this study was to examine how Canadian adolescents coped during the early pandemic and whether different coping methods were associated with changes in mental health from before the pandemic to the early lockdown response.

METHODS

Using two-year linked survey data (2018-2020) from a prospective cohort of secondary school students (n = 3,577), linear regression models were used to examine whether changes in mental health (anxiety [Generalized Anxiety Disorder-7 scale], depression [Center for Epidemiologic Studies Depression 10-item scale Revised], emotion regulation [Difficulties in Emotion Regulation Scale], psychosocial well-being [Flourishing scale]) were related to each coping behaviour.

RESULTS

The most common reported coping behaviours included staying connected with friends online (78.8%), playing video games, watching TV/movies, and/or surfing the internet/social media (76.2%), studying or working on schoolwork (71.0%), and getting exercise (65.2%). The use of positive coping mechanisms during the early pandemic period (e.g., keeping a regular schedule, time with family, time with friends online) was associated with less adverse mental health changes from before to during the early lockdown; whereas, negative coping mechanisms (e.g., spending time alone, eating junk food) were consistently associated with more adverse mental health changes.

CONCLUSION

This study demonstrates the importance of social support and connections with both friends and family, as well as keeping and maintaining a routine, over the pandemic. Interventions supporting positive relationships and engagement in these coping behaviours may be protective for adolescent mental health during disruptive events.

Examining the Latent Dimensions of Social Anxiety Disorder

While the body of literature has investigated the latent dimensions of Social Anxiety Disorder (SAD), only few have directly anchored in the DSM-5 SAD symptoms. Similarly, a continuing issue on measuring mental health disorders pertains to whether a symptom's frequency, intensity, or both, are appropriate and sufficient indicators of severity. To address this gap, the present study developed and validated a DSM-5-based measurement tool, the Social Anxiety Symptom Severity Inventory (SASSI), which assesses both the intensity (intensity of disturbance) and frequency (frequency of occurrence) of SAD symptoms. In study 1 (n = 6458, college students), the results revealed a two-factor structure using exploratory structural equation modeling. In study 2 (n = 425, left-behind emerging adults), confirmatory factor analysis, measurement invariance testing, and latent class analysis were used. Findings demonstrated the importance of using both frequency and intensity of symptoms in assessing SAD severity. Moreover, a five-class solution best fitted the sample. Studies 1 and 2 demonstrated the good psychometric properties of SASSI and filled an important gap among available measures in assessing SAD severity through symptom frequency and intensity.

Family Characteristics, Transgender Identity and Emotional Symptoms in Adolescence: A Population Survey Study

Sociodemographic and psychosocial family factors have profound implications for adolescent development, identity formation and mental health during the adolescent years. We explored the associations of sociodemographic and psychosocial family factors with transgender identity in adolescence and the role of these factors in the associations between gender identity and emotional disorders. Data from a large adolescent population survey from Finland were analysed using logistic regression models. Reporting transgender identity was associated with mother's low level of education, accumulating family life events, lack of family cohesion, perceived lack of family economic resources and female sex. A lack of family cohesion further differentiated between adolescents reporting identifying with the opposite sex and those reporting non-binary/other gender identification. The associations between transgender identity, depression and anxiety were attenuated but did not level out when family factors were controlled for. Transgender identity in adolescence is associated with socioeconomic and psychosocial family factors that are known correlates of negative outcomes in mental health and psychosocial well-being. However, transgender identification is also associated with emotional disorders independent of these family factors.

Feasibility of the virtual reality-based assessments in patients with panic disorder

Introduction

Recurrences and diagnostic instability of panic disorder (PD) are common and have a negative effect on its long-term course. Developing a novel assessment tool for anxiety that can be used in a multimodal approach may improve these problems in panic disorder patients. This study assessed the feasibility of virtual reality-based assessment in panic disorder (VRA-PD).

Methods

Twenty-five patients with PD (ANX group) and 28 healthy adults (CON group) participated in the study. VRA-PD consisted of four modules based on the key components of cognitive behavior therapy for an anxiety disorder: "Baseline evaluation module" (M0), "Daily environment exposure module" (M1), "Relaxation module" (M2), and "Interoceptive exposure module" (M3). Multiple evaluations, including self-rating anxiety scores (AS) and physiological responses [heart rate variability (HRV) index], were performed in three steps at M1, M2, and M3, and once at M0. Comparisons between patients with PD and healthy controls, factor analysis of variables in VRA-PD, changes in responses within modules, and correlation analysis between variables in VRA-PD and anxiety symptoms assessed by psychological scales were performed.

Results

All participants completed the VRA-PD without discontinuation. The ANX group reported significantly higher AS for all steps and a smaller HRV index in M1 (steps 1 and 2) and M2 (step 1). Repeated-measures analysis of covariance (ANCOVA) revealed significant interaction effects for AS in M1 (F = 4.09, p = 0.02) and M2 (F = 4.20, p = 0.02), and HRV index in M2 (F = 16.22, p < 0.001) and M3 (F = 21.22, p = 0.02). The HRV index only indicated a good model fit for the three-factor model, reflecting the construct of the VRA-PD. Both AS and HRV indexes were significantly correlated with anxiety and depression symptoms.

Discussion

The current study provides preliminary evidence that the VRA-PD could be a valid anxiety behavior assessment tool.

Generalized anxiety disorder in Berlin school children after the third COVID-19 wave in Germany: a cohort study between June and September 2021

BACKGROUND

During the COVID-19 pandemic, children and adolescents worldwide have disproportionally been affected in their psychological health and wellbeing. We conducted a cohort study among German school children, aiming at assessing levels of general anxiety disorder (GAD) and identifying associated factors in the second pandemic year.

METHODS

A cohort of 660 students from 24 Berlin schools was recruited to fill in questionnaires including the GAD-7 tool on anxiety symptoms at three time points between June and September 2021. To adjust for non-random attrition, we applied inverse probability weighting. We describe reported GAD levels stratified by time point, sex, and school type and report odds ratios from univariate logistic regression.

RESULTS

In total, 551 participants (83%) filled in at least one questionnaire at any time point. At the first time point in June 2021, 25% of the children and adolescents reported anxiety symptoms with a GAD-7 score ≥ 5, decreasing to 16% in August 2021 directly after the summer holidays and rising again to 26% in September 2021. The majority of reported anxiety levels belonged to the least severe category. Being female, attending secondary school, coming from a household with lower education or with lower income level, and being vaccinated against COVID-19 were significantly linked with reporting anxiety symptoms. Preceding COVID-19 infection and anxiety were negatively associated.

CONCLUSION

Overall, anxiety in school children was lower in mid-2021 than in the first pandemic year, but still double compared to pre-pandemic data. Reporting of anxiety symptoms during the second pandemic year was especially high in females and in secondary school students. Policy makers should pay additional attention to the mental health status of school children, even as the pandemic situation might stabilize.

The relationship between peer victimisation, self-esteem, and internalizing symptoms in adolescents: A systematic review and meta-analysis

BACKGROUND

Peer victimisation is common and predicts increased internalizing symptoms. Low self-esteem, which is associated with both greater peer victimisation and higher internalizing problems, may help explain why victimised adolescents experience greater internalizing symptoms. Objectives of the present research were to establish the relationships between peer victimisation, internalizing problems, and self-esteem, and to test whether self-esteem mediates the effect of victimisation on internalizing symptoms.

METHODS

We conducted a systematic literature search in Psychinfo, ERIC, Web of science, and Pubmed, following PRISMA guidelines. Inclusion criteria were: age 10-18 years; empirical studies that measured a) internalizing symptoms, b) self-esteem, and c) peer victimisation or bullying; design was either longitudinal or cross-sectional with a comparison group. Quality assessment were conducted using the Newcastle-Ottawa Quality Assessment Scale. We conducted random effects models and a meta-mediation analysis, with self-esteem acting as a mediator between peer victimization and internalizing symptoms.

RESULTS

Sixteen papers with a total of N = 35,032 (53% female) participants met the criteria for inclusion in the meta-analysis. The meta-analysis demonstrated an association between peer victimisation and both high internalizing problems (r = .31, CI 95 = .26 to.36) and low self-esteem (r = -.25, CI 95 = -.29; to -.22), and between low self-esteem and high internalizing problems ((r = -.38, CI 95 = -.42 to -.33), as well as an indirect effect of peer victimization on internalizing symptoms via self-esteem (ß = .10, CI lower = .07, CI upper = .13).

CONCLUSIONS

Peer victimization, high internalizing symptoms and low self-esteem are all mutually related. Peer victimization partially mediates internalizing symptoms via self-esteem. Anti-bullying programmes may consider incorporating self-esteem building exercises in bully-victims. Limitations include high heterogeneity of results.

Psychometric Properties and Validation of the General Anxiety Disorder 7-Item Scale Among Adolescents With Persistent Post-Concussive Symptoms

The General Anxiety Disorder 7-Item (GAD-7) scale is commonly used in primary care as a self-report measure of general anxiety symptoms with adult populations. There is little psychometric research on this measure with adolescent populations, particularly those with persistent post-concussive symptoms (PPCS). This study examined the psychometrics properties of the GAD-7 among youth with PPCS. We used baseline data from a randomized controlled trial of collaborative care for treatment of PPCS among 200 sports-injured adolescents 11-18 years of age (M_age = 14.7 years, standard deviation = 1.7). Eligible adolescents had three or more PPCS that lasted for ≥1 month and spoke English. Adolescents reported on their anxious (GAD-7 and Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]; RCADS) and depressive (Patient Health Questionnaire-9; PHQ-9) symptoms. Parents used the RCADS to report on their adolescents' anxious symptoms. The GAD-7 had good internal validity (Cronbach's alpha = 0.87), and significant (p < 0.001) correlations were detected between the GAD-7 and youth and parent report of anxiety on RCADS (r = 0.73 and r = 0.29) and PHQ-9 (r = 0.77) scores. Confirmatory factor analysis suggested a one-factor solution. These results suggest that the GAD-7 is a valid measure of anxiety with good psychometric properties for youth experiencing PPCS. ClinicalTrials.gov identifier: NCT03034720.

Gaming addiction and screen time in a context of increase of internalizing symptoms: Moderation evaluation

Children and adolescents were largely affected by the psychosocial impact of the 2019-2022 pandemic. During this time, there was an increase in internalizing symptoms, screen and internet use, and internet addiction. However, the interaction of these variables are not fully understood in a stressful time. Here, we have a repeated cross-sectional study aiming to model internalizing symptoms' prediction depending on screen time and game addiction during the COVID-19 pandemic. Parent-reported online data were collected at three timepoints, 6 months apart from each other, from a total of 1211 participants. We found an increase in screen time, game addiction, and internalizing symptoms. Regardless of the time spent in front of screens, higher levels of game addiction were associated with higher levels of internalizing symptoms in children and adolescents. Even if participants demonstrated low screen time, if they were virtually dependent they tended to exhibit higher levels of internalizing symptoms. The same result was found in all three samples. There is a need to investigate the nature of the relationship between internet addiction and internalizing symptoms and the long lasting effects of long hours on the screen.

Detecting Depression and Anxiety Among Adolescents in South Africa: Validity of the isiXhosa Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7

PURPOSE

Screening tools such as the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) could potentially be used in resource-limited settings to identify adolescents who need mental health support. We examined the criterion validity of the isiXhosa versions of the PHQ-9 and GAD-7 in detecting depression and anxiety among adolescents (10-19 years) in South Africa.

METHODS

Adolescents were recruited from the general population and from nongovernmental organizations working with adolescents in need of mental health support. The PHQ-9 and GAD-7 were culturally adapted and translated into isiXhosa and administered to 302 adolescents (56.9% female). The Kiddie Schedule for Affective Disorders and Schizophrenia was administered by trained clinicians as the gold standard diagnostic measure for depression and anxiety.

RESULTS

For the PHQ-9, the area under the curve was 0.88 for the full sample of adolescents (10-19 years old). A score of ≥10 had 91% sensitivity and 76% specificity for detecting adolescents with depression. For the GAD-7, the area under the curve was 0.78, and cutoff scores with an optimal sensitivity-specificity balance were low (≥6). A score of ≥6 had 67% sensitivity and 75% specificity for detecting adolescents with anxiety.

DISCUSSION

The culturally adapted isiXhosa version of the PHQ-9 can be used as a valid measure for depression in adolescents. Further research on the GAD-7 for use with adolescents is recommended.

Applying ensemble machine learning models to predict individual response to a digitally delivered worry postponement intervention

OBJECTIVE

Generalized anxiety disorder (GAD) is a prevalent mental health disorder that often goes untreated. A core aspect of GAD is worry, which is associated with negative health outcomes, accentuating a need for simple treatments for worry. The present study leveraged pretreatment individual differences to predict personalized treatment response to a digital intervention.

METHODS

Linear mixed-effect models were used to model changes in daytime and nighttime worry duration and frequency for 163 participants who completed a six-day worry postponement intervention. Ensemble-based machine learning regression and classification models were implemented to predict changes in worry across the intervention. Model feature importance was derived using SHapley Additive exPlanation (SHAP).

RESULTS

Moderate predictive performance was obtained for predicting changes in daytime worry duration (test r2 = 0.221, AUC = 0.77) and nighttime worry frequency (test r2 = 0.164, AUC = 0.72), while poor predictive performance was obtained for nighttime worry duration and daytime worry frequency. Baseline levels of worry and subjective health complaints were most important in driving model predictions.

LIMITATIONS

A complete-case analysis was leveraged to analyze the present data, which was collected from participants that were Dutch and majority female.

CONCLUSIONS

This study suggests that treatment response to a digital intervention for GAD can be accurately predicted using baseline characteristics. Particularly, this worry postponement intervention may be most beneficial for individuals with high baseline worry but fewer subjective health complaints. The present findings highlight the complexities of and need for further research into daily worry dynamics and the personalizable utility of digital interventions.

Psychometric Properties of the German Version of the Rivermead Post-Concussion Symptoms Questionnaire in Adolescents after Traumatic Brain Injury and Their Proxies

The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) assesses post-concussion symptoms (PCS) after traumatic brain injury (TBI). The current study examines the applicability of self-report and proxy versions of the German RPQ in adolescents (13-17 years) after TBI. We investigated reliability and validity on the total and scale score level. Construct validity was investigated by correlations with the Post-Concussion Symptoms Inventory (PCSI-SR13), Generalized Anxiety Disorder Scale 7 (GAD-7), and Patient Health Questionnaire 9 (PHQ-9) and by hypothesis testing regarding individuals' characteristics. Intraclass correlation coefficients (ICC) assessed adolescent-proxy agreement. In total, 148 adolescents after TBI and 147 proxies completed the RPQ. Cronbach's α (0.81-0.91) and McDonald's ω (0.84-0.95) indicated good internal consistency. The three-factor structure outperformed the unidimensional model. The RPQ was strongly correlated with the PCSI-SR13 (self-report: r = 0.80; proxy: r = 0.75) and moderately-strongly with GAD-7 and PHQ-9 (self-report: r = 0.36, r = 0.35; proxy: r = 0.53, r = 0.62). Adolescent-proxy agreement was fair (ICC [2,1] = 0.44, CI_95% [0.41, 0.47]). Overall, both self-report and proxy assessment forms of the German RPQ are suitable for application in adolescents after TBI. As proxy ratings tend to underestimate PCS, self-reports are preferable for evaluations. Only if a patient is unable to answer, a proxy should be used as a surrogate.

Depression and anxiety among multiethnic middle school students: Age, gender, and sociocultural environment

BACKGROUND

Depression and anxiety-related disorders are common among adolescents. Research attention to early adolescence and low-income ethnically diverse populations is limited.

AIM

To conduct screening for depression and anxiety at an early age with attention to gender and socioenvironmental context within a low-income setting.

METHOD

Mixed methods included the PHQ-9A and GAD-10 screening instruments and ethnographic interviews.

RESULTS

75 ethnically diverse middle school students were included. Mean years age was 11.2 (0.74). Females had higher PHQ-9A sum scores than males (p = .002, Mann-Whitney test) and higher GAD-10 sum scores than males (p = .016, Mann-Whitney test). After controlling for multiple comparisons, girls had higher mean responses on three PHQ-9A items (p < .006, two-sided t-test) and only one GAD-10 item (p < .005, two-sided t-test). Ethnographic interviews revealed contexts associated with girls' experiences of depression and anxiety, including gender-based violence in both school and home environments. Salient for girls and boys alike were worries about consequences of COVID-19 for family with respect to illness, death, job loss, economic hardship. Fears over student perceptions of intensified discrimination and racism in school and community were prominent. These problems were experienced by students as barriers to educational engagement.

CONCLUSION

Specific attention to early adolescence is needed to identify emergence of subsyndromal conditions which may benefit from therapeutic attention to reduce symptom severity, identify sociocultural, structural, and gender-specific stressors, and to enhance educational engagement.

Consequences of COVID-19 on adolescents in Arizona: A longitudinal study protocol

Introduction

The long-term impact of COVID-19 is unknown. We developed a 5-year prospective cohort study designed to generate actionable community-informed research about the consequences of COVID-19 on adolescents ages 12-17 years in Arizona.

Methods

The study has two primary outcomes: 1) acute and long-term outcomes of COVID-19 illness and 2) symptoms of depression and anxiety. Data is collected using an online survey with plans to integrate qualitative data collection methods. The survey is administered at baseline, 4, and 8 months in year one, and annually in years two through five. This study is informed by Intersectionality Theory, which considers the diverse identities adolescents have that are self and socially defined and the influence they have collectively and simultaneously. To this end, a sample of variables collected is race/ethnicity, language usage, generational status, co-occurring health conditions, and gender. Additional measures capture experiences in social contexts such as home (parent employment, food, and housing security), school (remote learning, type of school), and society (racism).

Results

Findings are not presented because the manuscript is a protocol designed to describe the procedure instead of report results.

Discussion

The unique contributions of the study is its focus on COVID-19 the illness and COVID-19 the socially experienced pandemic and the impact of both on adolescents.

Stress and Mental Health: A Focus on COVID-19 and Racial Trauma Stress

In the United States, COVID-19 unfolded alongside profound racial trauma. Drawing on a population representative sample of 20-60 year-olds who were married or cohabiting, the National Couples' Health and Time Study (N =3,642), we examine two specific sources of stress: COVID-19 and racial trauma. We leverage the fully powered samples of respondents with racial/ethnic and sexual minority identities and find that COVID-19 and racial trauma stress were higher among individuals who were not White or heterosexual most likely due to racism, xenophobia, and cis-heterosexism at the individual and structural levels. Both COVID-19 and racial trauma stress were associated with poorer mental health outcomes even after accounting for a rich set of potential mechanistic indicators, including discrimination and social climate. We argue that the inclusion of assessments of stress are critical for understanding health and well-being among individuals impacted by systemic and interpersonal discrimination.

Protocol for a randomised controlled trial evaluating the effectiveness of a CBT-based smartphone application for improving mental health outcomes in adolescents: the MobiliseMe study

BACKGROUND

Depression is a leading cause of disability in adolescents, however few receive evidence-based treatment. Despite having the potential to overcome barriers to treatment uptake and adherence, there are very few CBT-based smartphone apps for adolescents. To address this gap, we developed ClearlyMe®, a self-guided CBT smartphone app for adolescent depression and anxiety. ClearlyMe® consists of 37 brief lessons containing core CBT elements, accessed either individually or as part of a 'collection'. Here, we describe the protocol for a randomised controlled trial aiming to evaluate the effect of ClearlyMe® on depressive symptoms and secondary outcomes, including engagement, anxiety and wellbeing, when delivered with and without guided support compared to an attention matched control.

METHODS

We aim to recruit 489 adolescents aged 12-17 years with mild to moderately-severe depressive symptoms. Participants will be screened for inclusion, complete the baseline assessment and are then randomly allocated to receive ClearlyMe® (self-directed use), ClearlyMe® with guided SMS support (guided use) or digital psychoeducation (attention-matched control). Depressive symptoms and secondary outcomes will be assessed at 6-weeks (primary endpoint) and 4-months post-baseline (secondary endpoint). Engagement, conceptualised as uptake, adherence and completion, will also be assessed 6-weeks post-baseline. Mixed-effects linear modelling will be used to conduct intention-to-treat analyses to determine whether reductions in depressive symptoms and secondary outcomes are greater for conditions receiving ClearlyMe® relative to control at 6-weeks and 4-months post-baseline and greater for intervention adherers relative to non-adherers. To minimise risk, participants will be encouraged to use the Get Help section of the app and can also opt to receive a call from the team clinical psychologist at baseline, and at the 6-week and 4-month post-baseline assessments when reporting suicidal ideation.

DISCUSSION

This is the first clinical trial examining a CBT smartphone app specifically designed for adolescent depression. It will provide empirical evidence on the effects of ClearlyMe® on depressive symptoms when used with and without guided support.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12622000131752).

UNIVERSAL TRIAL NUMBER

U1111-1271-8519.

Chatbot-Delivered Cognitive Behavioral Therapy in Adolescents With Depression and Anxiety During the COVID-19 Pandemic: Feasibility and Acceptability Study

BACKGROUND

Symptoms of depression and anxiety, suicidal ideation, and self-harm have escalated among adolescents to crisis levels during the COVID-19 pandemic. As a result, primary care providers (PCPs) are often called on to provide first-line care for these youth. Digital health interventions can extend mental health specialty care, but few are evidence based. We evaluated the feasibility of delivering an evidence-based mobile health (mHealth) app with an embedded conversational agent to deliver cognitive behavioral therapy (CBT) to symptomatic adolescents presenting in primary care settings during the pandemic.

OBJECTIVE

In this 12-week pilot study, we evaluated the feasibility of delivering the app-based intervention to adolescents aged 13 to 17 years with moderate depressive symptoms who were treated in a practice-based research network (PBRN) of academically affiliated primary care clinics. We also obtained preliminary estimates of app acceptability, effectiveness, and usability.

METHODS

This small, pilot randomized controlled trial (RCT) evaluated depressive symptom severity in adolescents randomized to the app or to a wait list control condition. The primary end point was depression severity at 4-weeks, measured by the 9-item Patient Health Questionnaire (PHQ-9). Data on acceptability, feasibility, and usability were collected from adolescents and their parent or legal guardian. Qualitative interviews were conducted with 13 PCPs from 11 PBRN clinics to identify facilitators and barriers to incorporating mental health apps in treatment planning for adolescents with depression and anxiety.

RESULTS

The pilot randomized 18 participants to the app (n=10, 56%) or to a wait list control condition (n=8, 44%); 17 participants were included in the analysis, and 1 became ineligible upon chart review due to lack of eligibility based on documented diagnosis. The overall sample was predominantly female (15/17, 88%), White (15/17, 88%), and privately insured (15/17, 88%). Mean PHQ-9 scores at 4 weeks decreased by 3.3 points in the active treatment group (representing a shift in mean depression score from moderate to mild symptom severity categories) and 2 points in the wait list control group (no shift in symptom severity category). Teen- and parent-reported usability, feasibility, and acceptability of the app was high. PCPs reported preference for introducing mHealth interventions like the one in this study early in the course of care for individuals presenting with mild or moderate symptoms.

CONCLUSIONS

In this small study, we demonstrated the feasibility, acceptability, usability, and safety of using a CBT-based chatbot for adolescents presenting with moderate depressive symptoms in a network of PBRN-based primary care clinics. This pilot study could not establish effectiveness, but our results suggest that further study in a larger pediatric population is warranted. Future study inclusive of rural, socioeconomically disadvantaged, and underrepresented communities is needed to establish generalizability of effectiveness and identify implementation-related adaptations needed to promote broader uptake in pediatric primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04603053; https://clinicaltrials.gov/ct2/show/NCT04603053.

The Impact of School Education on Depressive Symptoms in Chinese Adolescents: a Prospective Longitudinal Study

There is a growing but limited literature on psychological distress among Chinese students, especially the impact of the COVID-19 pandemic, using a longitudinal comparison between in school and at home. This study aimed to assess the psychological status of adolescents in school and related risk and protective factors. We surveyed 13,637 adolescents before the COVID-19 outbreak (T1) and 10,216 after two months of home confinement (T2). The 9-item Patient Health Questionnaire (PHQ-9) was used to assess depressive symptoms or the severity of depression among the adolescents. In addition, the Childhood Trauma Questionnaire and the Connor-Davidson Resilience Scales were also used to screen for experiences of abuse and neglect and to measure resilience in adolescents. At baseline, 22.34% reported depressive symptoms. At T2, this rate decreased to 14.86%. When adolescents were in school, age (P < .0001), gender (P < .0001), and experience of abuse (P < .0001) were risk factors, while parent-child relationship (P < .0001), and resilience (P < .0001) were protective factors for depressive symptoms. After leaving school, age and physical abuse were no longer risk factors for depression. The negative impact of school education on the mental health of adolescents in China exceeds even the impact of the pandemic and home isolation. The focus should be on those adolescents with abuse experience and poor parent-child relationships to prevent the onset of psychological and psychiatric disorders.

Student and School Characteristics Associated With COVID-19-Related Learning Decline Among Middle and High School Students in K-12 Schools

BACKGROUND

COVID-19-disrupted schools, including shifts to virtual learning which may have impacted academic progress. This study assessed characteristics associated with changes in academic grades (before and during the pandemic) for different learning modalities for US students ages 13-19.

METHODS

Students (N = 2152) completed a web survey on school-related experiences during the 2020-2021 school year. County social vulnerability and SARS-CoV-2 transmission data were merged with survey data. Multivariable logistic regression analysis for grade change was conducted with student and school characteristics for each learning modality, controlling for community characteristics.

RESULTS

Greater proportions of remote/virtual (34.4%) and hybrid (30.1%) learning students reported grade decline compared to in-person students (19.9%). Among in-person students, odds of reporting same/improved grades were 65% lower among non-Hispanic black students and 66% lower among non-Hispanic students from other races, compared to non-Hispanic white students. Among hybrid students, odds of reporting same/improved grades for students reporting anxiety were 47% lower than students without anxiety, and odds of reporting same/improved grades among students reporting substance use were 40% lower than students not reporting substance use. Among remote/virtual students, odds of reporting same/improved grades among students with depression were 62% lower than odds of students not reporting depression symptoms. Remote/virtual students who received school-provided educational services also had 1.55 times the odds of reporting same/improved grades, compared to remote/virtual students not receiving these services.

CONCLUSIONS

Academic grades were negatively impacted during COVID-19 and learning mode may have contributed. Understanding these impacts is critical to student health and academic achievement.

Bullying Interrupted: Victimized Students in Remote Schooling During the COVID-19 Pandemic

We investigated how the transition to remote schooling during the COVID-19 pandemic affected the rates of bullying victimization among students in primary and lower secondary education and analyzed how a specific group of students, namely previously victimized students experienced remote schooling. The 2-month school lockdown offered a unique setting to explore the association between increasing Internet use and cyberbullying and reflect on the overlap between traditional bullying and cyberbullying in a new context. The main sample (n = 34 771) consisted of 10-16-year-old Finnish students who responded to an online survey during the remote schooling period in spring 2020. The sample was supplemented with data from two previous surveys conducted in the same schools in 2019 (n = 43,216) and in 2017 (n = 24,727). The prevalence of bullying victimization decreased substantially in all grade levels during the school lockdown. Physical isolation and surge in students' Internet use did not seem to lead to an increase in cyberbullying. Before-lockdown victimized students evaluated the time in remote schooling more positively than expected: they reported relatively high school liking and more teacher support than other students. The pre-existing gap in school adjustment between victimized and non-victimized students did not increase, but surprisingly, decreased. Our results highlight the notion that the main arena to fight bullying is within in-person interactions in schools.

Increased Risk of Generalized Anxiety Disorder According to Frequent Sedentary Times Based on the 16th Korea Youth Risk Behavior Web-Based Survey

This study aimed to identify the association between sedentary behavior and anxiety disorders in 53,510 Korean adolescents. It analyzed data from the 16th (2020) Korea Youth Risk Behavior Web-based Survey (KYRBS). The dependent variable was the generalized anxiety disorder-7 (GAD-7). The GAD-7 scores were divided into normal, mild, moderate, and severe levels. The independent variables were sedentary time for learning, other sedentary times, total sedentary time, and regular physical activity. The confounding variables were sex, grade, stress, depression, substance abuse, suicidal thoughts, violent victimization, drinking, smoking, sleep satisfaction, and smartphone addiction. A chi-squared test, one-way analysis of variance, and logistic regression analysis were used for analysis. After adjusting for all confounding variables, the risk of severe level in GAD-7 increased by 1.045 times each time the sedentary time for learning based on increased by one hour. In other sedentary time and total sedentary time, the risk of severe level in GAD-7 increased by 1.025 times and 1.045 times per hour, respectively. However, in regular physical activity, after adjusting for the confounding variables, there was no significant association with the GAD-7 levels. Therefore, to prevent generalized anxiety disorders in Korean adolescents, it is necessary to reduce the overall sedentary times including sedentary time for learning.

Coping strategy enhancement for the treatment of distressing voices in young people: A service evaluation within routine clinical practice

BACKGROUND

Hearing voices is a common experience in young people, irrespective of diagnosis. This experience can be associated with distress, self-harm and an increased risk of attempting suicide. However, there are currently no evidence-based interventions which specifically target distressing voice hearing experiences in young people.

METHOD

This was a service evaluation exploring the engagement, outcomes and experiences of young people who were offered a brief 4-session intervention for distressing voices within a Child and Adolescent Mental Health Service (CAMHS) in the UK's National Health Service. The intervention was based on the principles of Coping Strategy Enhancement (CSE).

RESULTS

A total of 24 young people were offered the CSE intervention over a 20-month period. The intervention was completed by 15 young people. Pre-post outcomes suggested clinically meaningful reductions in the negative impact of voices for the majority of the young people. Qualitative feedback was positive and highlighted the value of both a space to talk about voice hearing experiences and a focus upon coping strategies.

CONCLUSIONS

The findings from this service evaluation suggest that CSE can be a brief, acceptable and helpful way for young people within a CAMHS context to start a therapeutic conversation about their distressing voice hearing experiences.

The association of physical activity, sleep, and screen time with mental health in Canadian adolescents during the COVID-19 pandemic: A longitudinal isotemporal substitution analysis

BACKGROUND

The impact of COVID-19 on adolescent mental health is a global concern. Increased screen time and reduced physical activity due to the lockdown measures have been linked to detrimental mental health outcomes; however, the literature remains limited by cross-sectional and retrospective designs, and consideration of behaviours in isolation. Prospective evidence is necessary to examine whether moderate-to-vigorous physical activity (MVPA), sleep and screen time influenced changes in mental health.

METHOD

Analyses used data from a prospective cohort study of secondary school students in Canada with baseline data from the 2018-2019 school year and linked follow-up data from online surveys completed during the initial COVID-19 outbreak (May-July 2020). Multilevel linear regression models were used to evaluate the within- and between-person isotemporal substitution effects of sleep, MVPA and screen time behaviours on depression, anxiety, subjective well-being, and trait emotional dysregulation.

RESULTS

Linked longitudinal data from 2645 students attending 44 schools were available. Between-person effects indicated that individuals who engaged in more MVPA and sleep while minimizing screen time had lower depression scores, less severe emotional dysregulation, and better subjective well-being. While controlling for between-person effects, within-person year-on-year change suggests those who increased screen time while decreasing either MVPA or sleep experienced mental health decline on all outcomes.

CONCLUSION

MVPA and sleep were associated with youth mental health during the early COVID-19 lockdown. Increasing MVPA and sleep (or at least mitigating the increase of screen time) compared to the prior year was associated with better mental health during the early pandemic. A limitation to consider is that the screen time measure represents a combination of screen behaviours, and effects of replacing screen time may have varied if distinctions were made.

Outcomes From an Online Pilot Mindfulness Based Intervention with Adolescents: A Comparison by Categories of Risk

Comorbid psychiatric presentations, defined as those who present with more than one mental and/or behavioral health diagnosis at the same time, during adolescence are on the rise. Mindfulness-based interventions can alleviate psychological symptoms and improve emotion regulation in youth. Mindfulness is a multifaceted phenomenon, with five underlying facets (Observing, Describing, Acting with Awareness, Non-Judgment and Non-Reactivity of Inner Experience). Little evidence has documented which facets produce pronounced psychiatric symptom reduction for adolescents. This pilot study examined the efficacy of an online mindfulness-based intervention delivered to adolescents undergoing mental health treatment during COVID-19 to reduce psychiatric outcomes. Fifty-six adolescents (m = 14.5 years, 66.1% female) categorized as moderate-risk (treatment histories of outpatient therapy only) or high-risk (treatment histories with intensive service participation) participated in the 8-session mindfulness-based intervention. Significant reductions in psychiatric symptoms and increases in adaptive coping strategies were observed at post-test, particularly for those at moderate-risk. Multivariate stepwise regression found significant associations between mindfulness facet use and anxiety, depression, and somatic symptoms (R ² ranging from 42.5 to 52.8%). Results indicate preliminary efficacy for an online mindfulness-based intervention for adolescents, particularly those at moderate-risk, due to the introduction of new coping skills, given their history of less intense treatment. Further investigation is warranted to understand which mindfulness facet intervention components produce the most prominent outcomes.

A healthy lifestyle text message intervention for adolescents: protocol for the Health4Me randomized controlled trial

BACKGROUND

Adolescence presents a window of opportunity to establish good nutrition and physical activity behaviours to carry throughout the life course. Adolescents are at risk of developing cardiovascular and other chronic diseases due to poor the complex interplay of physical and mental health lifestyle risk factors. Text messaging is adolescents main form of everyday communication and text message programs offer a potential solution for support and improvement of lifestyle health behaviours. The primary aim of this study is to determine effectiveness of the Health4Me text message program to improve adolescent's physical activity or nutrition behaviours among adolescents over 6-months, compared to usual care.

METHODS

Health4Me is a virtual, two-arm, single-blind randomised controlled trial, delivering a 6-month healthy lifestyle text message program with optional health counselling. Recruitment will be through digital advertising and primary care services. In total, 330 adolescents will be randomised 1:1 to intervention or control (usual care) groups. The intervention group will receive 4-5 text messages per week for 6-months. All text messages have been co-designed with adolescents. Messages promote a healthy lifestyle by providing practical information, health tips, motivation and support for behaviour change for physical activity, nutrition, mental health, body image, popular digital media and climate and planetary health. Virtual assessments will occur at baseline and 6-months assessing physical health (physical activity, nutrition, body mass index, sleep), mental health (quality of life, self-efficacy, psychological distress, anxiety, depression, eating disorder risk) and lifestyle outcomes (food insecurity and eHealth literacy).

DISCUSSION

This study will determine the effectiveness of a 6-month healthy lifestyle text message intervention to improve physical activity and nutrition outcomes in adolescents.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622000949785 , Date registered: 05/07/2022.

Anxiety among Adolescents and Young Adults during COVID-19 Pandemic: A Multi-Country Survey

(1) Background: Adolescents-and-young-adults (AYA) are prone to anxiety. This study assessed AYA's level of anxiety during the COVID-19 pandemic; and determined if anxiety levels were associated with country-income and region, socio-demographic profile and medical history of individuals. (2) Methods: A survey collected data from participants in 25 countries. Dependent-variables included general-anxiety level, and independent-variables included medical problems, COVID-19 infection, age, sex, education, and country-income-level and region. A multilevel-multinomial-logistic regression analysis was conducted to determine the association between dependent, and independent-variables. (3) Results: Of the 6989 respondents, 2964 (42.4%) had normal-anxiety, and 2621 (37.5%), 900 (12.9%) and 504 (7.2%) had mild, moderate and severe-anxiety, respectively. Participants from the African region (AFR) had lower odds of mild, moderate and severe than normal-anxiety compared to those from the Eastern-Mediterranean-region (EMR). Also, participants from lower-middle-income-countries (LMICs) had higher odds of mild and moderate than normal-anxiety compared to those from low-income-countries (LICs). Females, older-adolescents, with medical-problems, suspected-but-not-tested-for-COVID-19, and those with friends/family-infected with COVID-19 had significantly greater odds of different anxiety-levels. (4) Conclusions: One-in-five AYA had moderate to severe-anxiety during the COVID-19-pandemic. There were differences in anxiety-levels among AYAs by region and income-level, emphasizing the need for targeted public health interventions based on nationally-identified priorities.

Psychosocial Wellbeing of Schoolchildren during the COVID-19 Pandemic in Berlin, Germany, June 2020 to March 2021

The COVID-19 pandemic and related restrictions have affected the wellbeing of schoolchildren worldwide, but the extent and duration of specific problems are still not completely understood. We aimed to describe students’ psychosocial and behavioral parameters and associated factors during the COVID-19 pandemic in Berlin, Germany. Our longitudinal study included 384 students from 24 randomly selected Berlin primary and secondary schools, assessing psychosocial wellbeing at four time points between June 2020 and March 2021. We analyzed temporal changes in the proportions of anxiety, fear of infection, reduced health-related quality of life (HRQoL), physical activity and social contacts, as well as sociodemographic and economic factors associated with anxiety, fear of infection and HRQoL. During the observation period, the presence of anxiety symptoms increased from 26.2% (96/367) to 34.6% (62/179), and fear of infection from 28.6% (108/377) to 40.6% (73/180). The proportion of children with limited social contacts (<1/week) increased from 16.4% (61/373) to 23.5% (42/179). Low physical activity (<3 times sports/week) was consistent over time. Low HRQoL was observed among 44% (77/174) of children. Factors associated with anxiety were female sex, increasing age, secondary school attendance, lower household income, and the presence of adults with anxiety symptoms in the student´s household. Fear of infection and low HRQoL were associated with anxiety. A substantial proportion of schoolchildren experienced unfavorable psychosocial conditions during the COVID-19 pandemic in 2020/2021. Students from households with limited social and financial resilience require special attention.

Personal and Witnessed Cyber Victimization Experiences Among Adolescents at the Beginning of the COVID-19 Pandemic

Personal experiences with cyber victimization among adolescents have been consistently associated with well-being problems. Few studies have examined the impact of witnessing cyber victimization on adolescent well-being. The current study examines adolescents' personal and witnessed experiences with cyber victimization during the beginning stages of the coronavirus disease 2019 (COVID-19). The main aim of the study is to test whether witnessing cyber victimization incidents among peers strengthens or weakens the association between personal cyber victimization incidents and adolescents' feelings of anxiety. Adolescents from the United States were recruited via social media site advertisements. An online survey was completed by 992 adolescents (M age = 16.09, SD = 1.24) from ethnically diverse backgrounds (49% White, 18% Asian/Asian-American, 14% Latinx, 9% Black/African-American, and 10% Other). The key results revealed a significant moderating role of witnessed cyber victimization incidents. Among adolescents who witnessed low levels of cyberbullying, the more they were personally cyber victimized, the higher their levels of anxiety. However, for adolescents who witnessed higher levels of cyberbullying incidents, the association between personal cyber victimization and anxiety was not significant. The findings suggest that adolescents who personally experience cyber victimization may feel less alone in their plight and thus, less anxious if they also witness others being targeted online.

Validation of brief screening instruments for internalizing and externalizing disorders in Mozambican adolescents

BACKGROUND

Mental disorders are the leading cause of disability for youth worldwide. However, there is a dearth of validated, brief instruments to assess mental health in low- and middle-income countries (LMIC). We aimed to facilitate identification of mental disorders in LMIC contexts by adapting and validating measures of internalizing and externalizing disorders for adolescents in Mozambique, an LMIC in southeastern Africa.

METHODS

We selected instruments with good support for validity in high-income and other LMIC settings: the Patient Health Questionnaire Adolescent (PHQ-A), Generalized Anxiety Disorders 7 (GAD-7), and Strengths and Difficulties Questionnaire (SDQ). Instruments were adapted by local and international mental health specialists followed by cognitive interviews (n = 48) with Mozambican adolescents. We administered the instruments along with the Miniature International Neuropsychiatric Interview for Children and Adolescents (MINI-KID)to 485 adolescents aged 12-19 years attending two secondary schools in Maputo City, Mozambique. One week later, we re-administered instruments to a randomly selected sample of 49 adolescents.

RESULTS

Participants were 66.2% (n = 321) female and the average age was 15.9 (S.D = 1.7).Internal consistency (alpha = 0.80, PHQ-A; 0.84, GAD-7; 0.80, SDQ) and test-retest reliabilty (ICC = 0.74, PHQ-A; 0.70, GAD-7; 0.77, SDQ) were acceptabe for the PHQ-A, GAD-7, and the full SDQ. The SDQ internalizing subscale showed poor test-retest reliability (ICC = 0.63) and the SDQ externalizing subscale showed poor internal consistency (alpha = 0.65). All instruments demonstrated good sensitivity and specificity (> 0.70). Youden's index identified optimal cutoff scores of 8 for the PHQ-A, 5 for the GAD-7, 10 for the SDQ internalizing and 9 for the SDQ externalizing subscales, though a range of scores provided acceptable sensitivity and specificity.

CONCLUSIONS

Our data supports reliability and validity of the PHQ-A, GAD-7, and SDQ instruments for rapidly assessing mental health problems in Mozambican adolescents. Use of these tools in other contexts with limited specialists may asist with expanding mental health assessment. Specific instrument and cutoff selection should be based on screening goals, treatment resources, and program objectives.

The impact of stay-at-home regulations on adolescents' feelings of loneliness and internalizing symptoms

INTRODUCTION

The COVID-19 pandemic disrupted the daily social lives of adolescents by severely limiting social interactions which likely heightened levels of loneliness and a variety of internalizing symptoms. However, little is known about how social distancing adherence and subsequent stress caused by the novel social regulations impact adolescents' feelings of loneliness, and later mental health difficulties, including anxiety and depression.

METHOD

To close this gap, we examined the impact of social distancing regulations on adolescents' (N = 79; M_age  = 16.16, SD = 1.15; 47 females; 23 males) depression and anxiety symptoms through loneliness by using data from a 5-week longitudinal study conducted on adolescents in the United States during the initial phases of COVID-19.

RESULTS AND CONCLUSIONS

Findings provided evidence that loneliness plays a unique mediating link between social distancing and symptoms of anxiety and depression. Overall, the present study highlights how social distancing during the COVID-19 pandemic has impacted adolescents' mental health during a developmental period that is considered a turning point for psychopathology.

The psychological impact of COVID-19 on university students in China and Africa

The COVID-19 pandemic is alarmingly a global health catastrophe that has created an unprecedented mental health decline especially in young adults, who have been noted to be a vulnerable population. In this study, we investigated the prevalence of depression and anxiety in university students in China and Africa during the COVID-19 pandemic, the significant factors contributing to the prevalence of anxiety and depression, the differences in factors affecting the different groups being investigated and to emphasize that psychological intervention are as important as the physical interventions during and after the pandemic. The study was conducted through online surveys, with 684 participants using Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 standardized scales. Comparing all groups combined, of the 636 participants, 361 (56.8%) had depression and 227 (35.7%) had anxiety. Chi squared tests at significance level (P<0.05) showed that country of citizenship, religion, parents’ educational background, household monthly income and, having family members with COVID-19 variables were strongly associated with depression and anxiety. In contrast, age, gender, educational background, and major showed no significant association. Comparing the individual groups separately using chi square (P<0.05), the Chinese students in China group had 35.6% with depression and 13.1% with anxiety. The variable associated with both depression and anxiety was education major, with depression only was parent’s educational background and with anxiety only was gender. The African students in China group had 70.3% with depression and 45.0% with anxiety. Gender was strongly associated with both depression and anxiety, and religion and having family members with COVID-19 with anxiety only. Africans in Africa had 66.0% with depression and 50.5% with anxiety. Educational background was strongly associated with depression. There was no statistically significant variable for anxiety. Chi square test showed a statistically significant difference in depression and anxiety levels with the Chinese group compared to both African groups, and no significant difference between both African groups. Our findings demonstrated that COVID-19 had a negative psychological impact on university students. Therefore, more attention should be put on youth’s mental health during this pandemic.

Depressive Anxiety Symptoms in Hospitalized Children with Chronic Illness during the First Italian COVID-19 Lockdown

COVID-19 is continuing to spread around the world, having a direct impact on people's daily lives and health. Although the knowledge of the impact of the COVID-19 pandemic on mental health in the general population is now well established, there is less information on its effect on specific and vulnerable populations, such as children with chronic illness (CI). We conducted a multi-centered cross-sectional study among pediatric patients in six public children's hospitals in Italy during the first lockdown, with the aim of assessing the proportion of children with CI presenting anxiety and depressive symptoms, and the clinical and demographic characteristics affecting such symptomatology. We included children with at least one chronic condition, with no cognitive delay, aged between 11 and 18 years. Brief standardized questionnaires were administered during medical scheduled visits to screen anxiety and depressive symptoms. We found a very high proportion of children showing mild to severe depressive and anxiety symptomatology (approximately 68% and 63%, respectively). Our results highlight the need of ensuring tailored psychological interventions to protect children with CI from the effect of the pandemic (and related restrictive measures such as quarantine and social distancing), with the final aim of promoting mental health and psychological well-being in this vulnerable population.