Editors' Note and Special Communication: Research Priorities in Child and Adolescent Mental Health Emerging From the COVID-19 Pandemic

Long-Term Trends and Sociodemographic Inequalities of Emotional/Behavioral Problems and Poor Help-Seeking in Adolescents During the COVID-19 Pandemic

PURPOSE

During the first 3 years of the coronavirus disease (COVID-19) pandemic, we investigated the long-term trends of emotional/behavioral problems and poor help-seeking behavior in adolescents and examined the sociodemographic inequalities in these trends.

METHODS

A multiwave cross-sectional survey was conducted in Japan from October-November 2020, June-July 2021, and June-July 2022 using an anonymous questionnaire. Trends of emotional/behavioral problems (e.g., emotional symptoms, hyperactivity/inattention, and total difficulties) and poor help-seeking were tested using a chi-squared test with Bonferroni correction. The effects of sociodemographic factors (grade, gender, country of origin, and number of parents) on emotional/behavioral problems and poor help-seeking were examined by two mixed-effect logistic regression models: (1) with fixed effects for years and sociodemographic factors and (2) stratified by years if the interaction terms between years and each sociodemographic factor were significant.

RESULTS

The prevalence of total difficulties and emotional symptoms was the highest in 2021. The number of adolescents reporting hyperactivity/inattention and poor help-seeking increased between 2020 and 2021 and remained high in 2022. Inequalities in emotional/behavioral problems and poor help-seeking behavior were found with respect to all sociodemographic factors.

DISCUSSION

Despite the persistent emotional/behavioral problems, the results suggested that the number of adolescents who were unable to seek help increased during the COVID-19 pandemic. Additionally, heterogeneities in the trends with respect to grade, gender, country of origin, and number of parents were detected. Prioritized supports targeting those with sociodemographic disadvantages may be needed to mitigate these inequalities in response to the pandemic.

Changes in Internalizing Symptoms During the COVID-19 Pandemic in a Transdiagnostic Sample of Youth: Exploring Mediators and Predictors

The COVID-19 pandemic is a chronically stressful event, particularly for youth. Here, we examine (i) changes in mood and anxiety symtpoms, (ii) pandemic-related stress as a mediator of change in symptoms, and (ii) threat processing biases as a predictor of increased anxiety during the pandemic. A clinically well-characterized sample of 81 youth ages 8-18 years (M = 13.8 years, SD = 2.65; 40.7% female) including youth with affective and/or behavioral psychiatric diagnoses and youth without psychopathology completed pre- and during pandemic assessments of anxiety and depression and COVID-related stress. Forty-six youth also completed a threat processing fMRI task pre-pandemic. Anxiety and depression significantly increased during the pandemic (all ps < 0.05). Significant symptom change was partially mediated by pandemic stress and worries. Increased prefrontal activity in response to neutral faces pre-pandemic was associated with more intense parent-reported anxiety during the pandemic (all Fs(1.95,81.86) > 14.44, ps < 0.001). The present work extends existing knowledge on the mediating role of psychological stress on symptoms of anxiety and depression in youth.

The impact of COVID-19 on children and adolescents attending Child and Youth Mental Health Services in Queensland, Australia

OBJECTIVE

This explorative study aims to provide insight into impacts of the COVID-19 pandemic and associated restrictions, on mental health of children and adolescents treated at Child and Youth Mental Health Services, and their parents.

METHOD

The COVID-19 Mental Health Survey was disseminated to parents of children and adolescents under treatment at community Child and Youth Mental Health Services (Brisbane, Australia) between July-November 2020 throughout different stages of COVID-19 related restrictions. Parents of 110 children participated.

RESULTS

Most reported child's symptoms were sadness (46%), anxiety (60%), lack of focus (61%), lack of joy in their usual activities (38%) and reduction in sleep (42%). Parental emotions were significantly correlated with their child's emotions. Parent's lack of enjoyment of usual activities had the overall strongest average correlation (0.27) but this was no longer significant once other variables were controlled for. Children who attended school remotely for some of the days had a significantly (p < .05) higher risk of having more reported symptoms. Interestingly, in later stages of the lockdown with further easing of restrictions, symptoms also tended to be more severe.

CONCLUSION

Cross-sectional data on children and adolescents in Queensland, Australia with pre-existing mental health issues suggests mental health continued to deteriorate through the pandemic even as restrictions eased. Changes in schooling seem to be an especially important risk factor.

The Association between exposure to COVID-19, internalizing symptoms, and Dispositional Mindfulness in Adolescents: a longitudinal pre- and during-pandemic study

This study examined the association between contact with COVID-19 and internalizing symptoms in Spanish adolescents, and the moderation and mediation roles of dispositional mindfulness. Adolescents (N = 383; 58% female; Mage = 15.62, SD = 1.32) completed measures of dispositional mindfulness (MAAS-A) and internalizing symptoms (DASS-21), other stressors different from COVID-19, and contact with COVID-19 twice, in October 2019 and 2020. Three profiles emerged according to their contact with COVID-19: (1) little/no contact, (2) knowing someone close (outside home) who was infected, hospitalized, or died, and (3) being or someone at home being infected and/or hospitalized. Compared to little/no contact, both contact profiles predicted dispositional mindfulness and anxiety; and profile 2 predicted stress. Dispositional mindfulness mediated the association between both contact profiles and depression and stress. This study suggests that contact with COVID-19 predicts increased internalizing symptoms in adolescents, which could be partially explained by the decrease in mindfulness levels.

Research Priorities for Pediatric Emergency Care to Address Disparities by Race, Ethnicity, and Language

Importance

Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking.

Objective

To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations.

Design, Setting, and Participants

In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks.

Outcome

Consensus agenda of research priorities to identify and address health care disparities in PEC.

Results

PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation.

Conclusions and Relevance

These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

Factors associated with mental health symptoms among UK autistic children and young people and their parents during the COVID-19 pandemic

LAY ABSTRACT

What is already known about the topic: The COVID-19 pandemic and the associated restrictions impacted all of society. There is emerging evidence showing a range of impacts on autistic children and young people and their families. Further research that looks at how individuals coped during the pandemic while considering how they were doing before the pandemic is needed.What this paper adds: This article explores whether how well autistic youth were doing before the pandemic influenced how they coped during the pandemic. It also looked at how well their parents were doing during the pandemic and whether any pre-pandemic factors influenced how they coped. Samples of both primary-school-aged autistic children and autistic teenagers and their parents were surveyed to answer these questions. More engagement and enjoyment in education provision during the pandemic and getting outside more were linked with better child and parental mental health during the pandemic. More attention deficit hyperactivity disorder before the pandemic was linked with more attention deficit hyperactivity disorder and behavioural problems during the pandemic in primary-school-aged autistic children, and more emotional problems during the pandemic in autistic teenagers. Parents with more mental health problems during the pandemic had more mental health problems before the pandemic.Implications for practice, research or policy: Encouraging engagement and enjoyment in education and promoting physical exercise are key intervention targets. Ensuring access to attention deficit hyperactivity disorder medication and support is important, especially if this is managed jointly across school and home.

The Coronavirus Impact Scale: Construction, Validation, and Comparisons in Diverse Clinical Samples

Objective

This report is of the construction and initial psychometric properties of the Coronavirus Impact Scale in multiple large and diverse samples of families with children and adolescents. The scale was established to capture the impact of the coronavirus pandemic during its first wave. Differences in impact between samples and internal structure within samples were assessed.

Method

A total of 572 caregivers of children and adolescents or expecting mothers in diverse clinical and research settings completed the Coronavirus Impact Scale. Samples differed in regard to developmental stage, background, inpatient/outpatient status, and primary research or clinical setting. Model free methods were used to measure the scale's internal structure and to determine a scoring method. Differences between samples in specific item responses were measured by multivariate ordinal regression.

Results

The Coronavirus Impact Scale demonstrated good internal consistency in a variety of clinical and research populations. Across the groups studied, single, immigrant, predominantly Latinx mothers of young children reported the greatest impact of the pandemic, with noteworthy effects on food access and finances reported. Individuals receiving outpatient or inpatient care reported greater impacts on health care access. Elevated scores on the Coronavirus Impact Scale were positively associated with measures of caregiver anxiety and both caregiver- and child-reported stress at a moderate effect size.

Conclusion

The Coronavirus Impact Scale is a publicly available scale with adequate psychometric properties for use in measuring the impact of the coronavirus pandemic in diverse populations.

The corona pandemic and participatory governance: Responding to the vulnerabilities of secondary school students in Europe

Adolescents in secondary schools have limited susceptibility to the SARS-COV-2 virus, but paradoxically are considered to be carrying the highest psychosocial burden during this pandemic. The aim of our European multi-country qualitative research was to investigate the COVID-19 crisis response in secondary schools and the role of national, regional, and local stakeholders in contributing to a participatory governance approach. We carried out 11 months of qualitative fieldwork, which included 90 respondents from the Netherlands, Ireland, and Finland for in-depth interviews and/or group discussions. Participant observation was conducted in four secondary schools to explore the interplay of day-to-day formal and informal practices of crisis governance. Our findings contribute to a better understanding of what efforts were made to facilitate participatory governance and where a bottom-up approach would have served useful in successfully implementing the COVID-19 mitigation strategies. Moreover, we show how these mitigation strategies have led to unintended consequences, such as students' difficulties with isolation and associated mental health problems, and the struggles of socialization when returning to a physical school environment. Our findings highlight the importance of the school environment in the socio-emotional developments of adolescents. We introduce the TAPIC-R model to analyze good governance, advancing the existing TAPIC model with an emphasis on the role of resilience in shaping participatory governance. We argue this is urgently needed during crises to strengthen engagement of the community, including vulnerable groups and achieve positive outcomes within and across policy structures and action domains.

Age-specific determinants of psychiatric outcomes after the first COVID-19 wave: baseline findings from a Canadian online cohort study

BACKGROUND

Canadians endured unprecedented mental health (MH) and support access challenges during the first COVID-19 wave. Identifying groups of individuals who remain at risk beyond the acute pandemic phase is key to guiding systemic intervention efforts and policy. We hypothesized that determinants of three complementary, clinically actionable psychiatric outcomes would differ across Canadian age groups.

METHODS

The Personal Impacts of COVID-19 Survey (PICS) was iteratively developed with stakeholder feedback, incorporating validated, age-appropriate measures. Baseline, cross-sectional online data collected between November 2020-July 2021 was used in analyses. Age group-specific determinants were sought for three key baseline MH outcomes: (1) current probable depression, generalized anxiety disorder, obsessive-compulsive disorder and/or suicide attempt during COVID-19, (2) increased severity of any lifetime psychiatric diagnosis, and (3) inadequate MH support access during COVID-19. Multivariable logistic regression models were constructed for children, youth (self- and parent-report), young adults (19-29 years) and adults over 29 years, using survey type as a covariate. Statistical significance was defined by 95% confidence interval excluding an odds ratio of one.

RESULTS

Data from 3140 baseline surveys were analyzed. Late adolescence and early adulthood were identified as life phases with the worst MH outcomes. Poverty, limited education, home maker/caregiver roles, female and non-binary gender, LGBTQ2S + status and special educational, psychiatric and medical conditions were differentially identified as determinants across age groups.

INTERPRETATION

Negative psychiatric impacts of COVID-19 on Canadians that include poor access to MH support clearly persisted beyond the first wave, widening pre-existing inequity gaps. This should guide policy makers and clinicians in current and future prioritization efforts.

Enhancing empowerment in young adults during the COVID-19 era in Italy through the Photovoice technique

The spread of COVID-19 has led to increasingly stringent containment measures. After the first period of lockdown, there has been an easing of measures worldwide. However, this choice has helped bring about a second wave to be faced by many states. The present research was conducting during the period in which it was necessary for the population to find strategies for living with COVID-19. The proposed action research envisaged the use of Photovoice and, due to social distancing, was carried out online. A total of 250 young adults were involved with the aim of bringing out individual and community solutions for effective coexistence with COVID-19. The data, collected through a triangulation process, were analysed on the basis of grounded theory and the support of NVivo 12. The results highlight how online Photovoice is an effective tool for implementing individual and community empowerment and for identifying solutions to live with COVID-19.

Impacts of COVID-19 on Mental Health Safety Net Services for Youths: A National Survey of Agency Officials

OBJECTIVE

Mental health agencies provide critical safety net services for youths. No research has assessed impacts of the COVID-19 pandemic on services these agencies provide or youths they serve. This study sought to characterize agency officials' perceptions of the pandemic's impacts on youths and challenges to providing youth services during the pandemic and to examine associations between these challenges and impacts.

METHODS

Surveys were completed in September-October 2020 by 159 state or county mental health agency officials from 46 states. Respondents used 7-point scales (higher rating indicated more severe impact or challenge) to rate the pandemic's impact on youth mental health issues, general service challenges, and telepsychiatry service challenges across patient, provider, and financing domains. Multiple linear regression models estimated associations between service challenges (independent variables) and pandemic impacts (dependent variables).

RESULTS

Most agency officials perceived the pandemic as having disproportionately negative mental health impacts on socially disadvantaged youths (serious impact, 72%; mean rating=5.85). Only 15% (mean=4.29) perceived the pandemic as having a seriously negative impact on receipt of needed youth services. Serious service challenges were related to youths' lack of reliable equipment or Internet access for telepsychiatry services (serious challenge, 59%; mean=5.47) and the inability to provide some services remotely (serious challenge, 42%, mean=4.72). In regression models, the inability to provide some services remotely was significantly (p≤0.01) associated with three of five pandemic impacts.

CONCLUSIONS

Officials perceived the COVID-19 pandemic as exacerbating youth mental health disparities but as not having a dramatic impact on receipt of needed services.

Impact on Child Psychiatry

The American pediatric mental health system is in crisis; the COVID-19 pandemic highlighted and exacerbated existing gaps. All youth were affected by the pandemic, an impact medicated by mental illness, the closing of schools, reduced access to mental health services, loss and bereavement, and financial and emotional stress on families. The pandemic's fallout is likely to be felt for years to come as today's youth move through successive developmental stages. Improvements in health care systems for youth, innovations in how care is delivered, and ongoing community support for recovery and resilience are needed moving forward.

A longitudinal study of mental health in at-risk adolescents before and during the COVID-19 pandemic

Although cross-sectional studies have shown that the COVID-19 pandemic has negatively affected the mental health of adolescents, the effect of the pandemic on adolescents with pre-pandemic symptoms is unclear. We, therefore, tested the hypothesis that adolescents had increased emotional and behavioral problems during the lockdowns imposed during the pandemic.This study included three measurements in a prospective cohort of 1022 adolescents who were oversampled based on their high risk of developing psychopathology. Before the pandemic, we assessed depressive, anxiety, stress, oppositional defiant problems, psychotic experiences and suicidality, using the Youth Self-Report; 445 and 333 of these 1,022 adolescents subsequently completed the online questionnaire in the first lockdown (in April 2020) and in the second lockdown (in January 2021), respectively. Multilevel random intercept regression models were used to determine the change in psychiatric symptoms, including an interaction term to assess whether these changes differed based on the severity of symptoms prior to the pandemic. Throughout the pandemic, the majority of the participating adolescents reported having emotional and behavioral symptoms that were within the normal range. Moreover, the mean symptom scores for all six outcomes decreased significantly among adolescents with high clinical severity prior to the pandemic.In contrast to our original hypothesis, the effects of the COVID-19 pandemic may not necessarily be detrimental, at least among a specific subgroup of adolescents with pre-existing mental health problems. Moreover, our finding that most adolescents in this at-risk sample did not report experiencing clinically relevant symptoms during the pandemic reflects their resilience during the pandemic.

HIV and SRH healthcare delivery experiences of South African healthcare workers and adolescents and young people during COVID-19

While substantial research has emerged from the frontlines of the COVID-19 pandemic, as well as from studies with adolescent populations, there has been a dearth of research focused in South Africa on the context-specific experiences of healthcare workers (HCWs) and the adolescents and young people (AYP) to whom they provide services. This article documents the experiences of provision and receipt of HIV and sexual and reproductive health (SRH) services during the COVID-19 pandemic from the perspective of South African HCWs (n = 13) and AYP (n = 41, ages 17-29). Findings highlight several barriers to accessing comprehensive HIV and SRH services during the pandemic including lockdown-related mobility restrictions (reported by HCWs), prioritisation of COVID-19 above other healthcare needs, longer health facility waiting times, poor treatment by HCWs (reported by AYP), discomfort and perceived stigma from having to queue outside health facilities, and fear of contracting COVID-19 (reported by both groups). While HCWs reported that HIV and SRH services continued to be available during the pandemic, AYP described seeking these services - such as long-acting reversible contraception, check-ups for their babies and medical refills - and being told that because they were not considered emergency cases, they should return on a different date. By capturing diverse experiences and perspectives from both groups, our findings reiterate the growing call for health system investments to strengthen the delivery of adolescent services, including investing in appropriate channels of communication between young people and their healthcare providers (for example, through adolescent peer supporters or community healthcare workers) and differentiated models of service delivery (for example, multi-month ART refills and community pick-ups). Closing the gap between the experiences and needs of adolescents and the healthcare workers who serve them may support young people and HCWs in buffering against changes brought about by the COVID-19 pandemic.

Self-reported Mental and Physical Health Among Norwegian Adolescents Before and During the COVID-19 Pandemic

Importance

The COVID-19 pandemic and resulting conditions may negatively affect adolescents.

Objective

To examine aspects of self-reported mental and physical health among adolescents in Norway before and during the pandemic, including the role of pandemic-associated anxiety.

Design, Setting, and Participants

This cohort study examined a diverse nationwide sample of grade 11 students from the longitudinal MyLife study in Norway. The original study recruitment of all 8th, 9th, and 10th graders from the same middle schools facilitated identification of 2 sociodemographically comparable cohorts assessed in October to December 2018 and 2019, before the COVID-19 pandemic, and October to December 2020, during the pandemic. School entry and enrollment in Norway is determined by the birth year, and students usually start high school (11th grade) during the fall of the year of their 16th birthday. Data were analyzed from March to June 2021.

Exposures

The COVID-19 pandemic and associated conditions in Norway.

Main Outcomes and Measures

In grades 10 and 11, adolescents reported their depression symptoms using the Patient Health Questionnaire-9 (cutoff scores for moderate/severe depression, ≥15), number of close friends, physical health, and organized sports participation. Cohort differences were examined with a set of nested regression models, incrementally controlling for sociodemographic covariates and grade 10 outcomes.

Results

A sample of 2536 adolescents (1505 [59.4%] girls) was analyzed, including 1621 adolescents before the pandemic and 915 adolescents during the pandemic, of whom 158 adolescents (17.3%) reported high pandemic anxiety. The only significant difference in outcomes between the COVID-19 cohort and the pre-COVID-19 cohort were lower odds of organized sports participation (adjusted odds ratio [aOR], 0.69; 95% CI, 0.56-0.87). However, in subanalyses comparing adolescents with high anxiety during the COVID-19 pandemic with adolescents in the pre-COVID-19 cohort, adolescents with high pandemic anxiety were more likely to experience clinical-level depression symptoms (aOR, 2.17; 95% CI, 1.39-3.37) and poor physical health (aOR, 1.53; 95% CI, 1.01-2.31).

Conclusions and Relevance

In this cohort study of Norwegian adolescents, adolescents who started high school during the pandemic year had lower odds of organized sports participation in late 2020, but were otherwise comparable in terms of self-reported mental and physical health with their pre-COVID-19 counterparts. However, adolescents in the COVID-19 cohort experiencing high pandemic-related anxiety had significantly greater odds of poorer mental and physical health than adolescents in the pre-COVID-19 cohort. Strategies aiming to mitigate the impact of COVID-19 may benefit from identifying youth disproportionally affected by the pandemic conditions.

We Hear You

In June and July of last year, members of the JAACAP editorial team recruited researchers and clinicians around the globe to complete an open-ended online questionnaire about their perceptions of the pandemic's effects on children and adolescents and which of these issues deserved immediate attention in future research. In May, JAACAP published the survey results.¹ In keeping with these findings, the Book Forum has turned its focus to reviewing resources specific to the concerns raised by these participants.