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CAPMH Corner (Updated Sep 2022)

By: Lakshmi Sravanti, India | Associate Editor, CAPMH 

Child and Adolescent Psychiatry and Mental Health (CAPMH) is the official IACAPAP Journal. The "CAPMH Corner" of the September 2022 issue of IACAPAP Bulletin summarizes the following three studies recently published in CAPMH – Increase in admission rates and symptom severity of childhood and adolescent anorexia nervosa in Europe during the COVID‑19 pandemic: data from specialized eating disorder units in different European countries (Gilsbach et al., 2022), Meeting the 24‑h movement guidelines and health‑related outcomes among youth with autism spectrum disorder: a seven‑country observational study (Li et al., 2022) and identifying multilevel and multisectoral strategies to develop a Theory of Change for improving child and adolescent mental health services in a case‑study district in South Africa (Babatunde et al., 2022).

Gilsbach et al., (2022) note the adverse impact of the COVID-19 pandemic on eating disorders (ED) in children and adolescents hailing from different countries like Australia, Canada, Israel, New Zealand, and the US. They discuss the possible causes and highlight the need to gather data in the European context. They assess the rates of inpatient admissions for anorexia nervosa (AN) across several European countries (Germany, France, Italy, Spain, Sweden, and the Netherlands) and gather impressions of mental health clinicians about ED symptom severity through their study. 

The study team collects some clinical details, data pertaining to the total number of patients presenting with typical and atypical AN as per DSM-5 and inpatient admissions for AN in 2019 (1 January 2019–31 December 2019) and 2020 (1 January 2020–31 December 2020), and time frames of local lockdowns and school closures. In addition, they interview ten mental health clinicians for their subjective global impressions of a possible change in symptom severity of the ED during the COVID-19 pandemic and their explanation for this change using the modified version of the Isolation Eating Scale (CIES) (Fernández-Aranda et al., 2020). The authors report an increase in total (outpatient and inpatient) admissions in four out of six ED centres and a substantial increase in inpatient admissions in three out of six centres. They note the greatest increase in admissions at the beginning of the second lockdown in all ED departments and an increase in waiting times for hospital admissions in five out of six centres. They record shorter waiting times during the lockdowns in the Netherlands, which they attribute to the “crisis management” initiative by respective departments. They record an increase in the amount of daily practised physical exercise, followed by concerns about weight, diet and body image, and social media use from the qualitative interviews of the clinicians. 

The team speculates several possible explanations for the rise in ED symptoms and general psychopathology during the pandemic such as – disruptions in daily structure (including that of mealtimes), an interruption in regular sports activities, too much spare time, more exposure to triggering social media, a lack of social contacts with a negative impact on mood, and a reduction in treatment offers. Based on their study findings, the authors recommend engaging paediatricians and health care workers to regularly monitor the weight of adolescents during their routine visits as assessment of weight is not guaranteed by telepsychiatry consultations. They acknowledge the limitations of their study viz. - missing sociodemographic and clinical data due to the retrospective nature of the study; lack of baseline data on symptom severity prior to the pandemic, which means that the increase in ED reported is based on the subjective impressions of the clinicians and lack of data on new cases and relapse of previously diagnosed cases during the pandemic. They suggest further research to determine the exact pandemic-associated factors contributing to the development and burden of eating disorders, especially in young people, and how to offer rapid support. 

Li et al., (2022) underscore the importance of meeting the 24-h movement guidelines (Tremblay et al., 2016) among youth in general and the need to research this topic in youth with autism spectrum disorder (ASD). They conduct a cross-sectional study to examine the prevalence of meeting individual and combined guidelines for physical activity, screen time, and sleep duration among youth with ASD in seven countries and regions - Brazil, Finland, Hong Kong, Mainland China, Singapore, South Korea, and the US. They also examine associations between meeting none, one, two, or three of the 24-h movement guidelines and three health-related outcomes (i.e., BMI, general health, and quality of life) in the same subgroup of the population. 

The team recruits parents or guardians of youth with ASD through ASD associations, direct contact with special school principals, and social media by convenience sampling for the survey. They adopt the survey items from the 2018 National Survey of Children’s Health (NSCH) (Child and Adolescent Health Measurement Initiative, 2021). They identify three outcome variables (i.e., BMI, and general health and quality of life measured using zBMI and on a Likert scale respectively) and dichotomize each movement behavior variable into “meeting the guideline” vs. “not meeting the guideline”. They excluded incomplete observations and continuous outliers (z > 3.29 or z < − 3.29) and calculate descriptive statistics, means (M), standard deviation (SD), or frequencies and percentages. They conduct a series of multiple linear regression analyses and trend analyses to further analyse their data. They report that only a small proportion of the sample of 1165 youth with ASD (7.2%, range = 1.5% [South Korea] to 15.1% [Mainland China]) met the physical activity guideline; about half of the sample met the screen time guideline (46.4%, range = 20.2% [Brazil] to 81.2% [South Korea]) and the sleep guideline (55.9%, range = 43.8% [Singapore] to 68.0% [Finland]). They observe that the largest proportion of youth met only one guideline (49.4%, range = 39.3% [Singapore] to 60.1% [Brazil]) and compared with meeting all three guidelines, meeting no guidelines was associated with poorer general health (B = − 0.46, P = 0.02) and a lower quality of life score (B = − 0.47, P = 0.02).  

The authors acknowledge the strengths (international culturally and geographically diverse sample; a number of health-related outcomes examined in this understudied group), and limitations (selection bias due to convenience sampling; lack of generalizability due to the difference in the number of participants among countries; the possibility of response bias due to the use of parental proxy-reports; and inability to draw causal inferences owing to the cross-sectional design) of their study. They recommend more robust research in this area by a prospective or experimental study design to infer causality and using objective measures (like accelerometers) to improve validity. The team lays emphasis on the concept that “the whole day matters” and reinforces the need to develop, test, and implement intervention programs that seek to improve the patterns of physical activity, sedentary behavior, and sleep in youth with ASD. They conclude by highlighting the dose-response relationships between the number of 24-h guidelines met and more favorable health-related outcomes (all Ptrend < 0.05), a low adherence to all three guidelines (especially physical activity), and a strong association between guideline adherence and health-related outcomes in an international (7-country/region) sample of youth with ASD and emphasizing the urgent need to promote the adoption of all the guidelines in this group. 

Babatunde et al., (2022) highlight the challenges that child and adolescent mental health (CAMH) services are facing in many low- and middle-income countries (LMICs) and the need to adopt a community participatory approach to identify contextually appropriate strategies that could be used to develop a collaborative system of care. Babatunde et al., (2020) earlier carried out a situational analysis of the existing CAMH services in a district in the province of KwaZulu-Natal (South Africa) and identified six major bottlenecks – poor governance structures; poor identification, screening, and assessment procedures; poor referral pathways; specialist vertical services; limited community-based CAMH interventions, and limited CAMH promotion and awareness. In their current study, they aim to i) Co-identify causal factors and potential strategies with key stakeholders to effectively address bottlenecks identified during the formative phase; and ii) Co-develop a Theory of Change (ToC, Breuer et al., 2015) to feasibly increase access to CAMH services that could be used for the development of a district mental health care plan. 

The resource-constrained district of Amajuba District Municipality is comprised of rural and peri-urban communities with children and adolescents constituting 51% of the population. The authors employ a participatory action research (PAR) approach and conducts a workshop with key stakeholders (n = 40) from the Departments of Health (DoH), Basic Education (DBE), and Social Development (DSD) and three community-based organisations offering CAMH services in the district. They recruit 40 participants (district mental health coordinator, school directors, and service providers, including nurses, clinical psychologists, occupational therapists, pharmacists, social workers, and educators) by purposive sampling. The authors compare and consolidate stakeholders’ accounts regarding the context-specific causal factors and possible strategies to address the bottlenecks recorded (audio recordings, participants and researcher notes) in the workshop. They conduct a thematic analysis to analyse it. They also develop a ToC map based on the data and refine it by conducting a follow-up virtual workshop with stakeholders (n = 15).  

The team elaborates on the causal factors for poor identification, screening and assessment procedures, to address inappropriate referral pathways, to address limited CAMH promotion and awareness, to address limited community‑based CAMH interventions, to address poor management structures and to address limited specialists and vertical services. They identify key multilevel and multisectoral task-sharing strategies that include the development of (i) community awareness programs and user-friendly CAMH psychoeducation and screening tools to strengthen mental health literacy and facilitate early identification at the community level; (ii) an intersectoral working group to facilitate intersectoral collaboration (iii) a functional district CAMH referral system, (iv) youth-friendly CAMH care packages. The team also maps out a ToC with the medium-term outcomes as early identification of CAMH conditions, appropriate referral and prompt access to CAMH services, development of CAMH care packages (for early initiation of treatment and interventions), and intersectoral governance; and the long-term outcome as improved CAMH services. They state that the medium-term outcomes cut across different levels of care (community, primary health care, and hospitals) and identify interventions and strategies for each level of care and some cross-cutting interventions including – strengthening CAMH assessment, training service providers, empowering families, support visits etc. 

The authors appreciate that their study findings lack generalisability (as it is a single district case study) and mention that their recommendations should be read as flexible guidelines that will be regularly updated in consultation with district stakeholders. They state that the process of developing the ToC model is complex, expensive and time-consuming and therefore in the current study they developed it using the information obtained from the formative studies and the strategies identified by the participants in the workshop. They put forth their intention to develop a district CAMH plan and conclude that it is feasible to work in scarce-resource contexts collaboratively with key stakeholders using a task-sharing approach. 

REFERENCES:  
 

  • Gilsbach, S., Plana, M.T., Castro-Fornieles, J. et al. Increase in admission rates and symptom severity of childhood and adolescent anorexia nervosa in Europe during the COVID-19 pandemic: data from specialized eating disorder units in different European countries. Child Adolesc Psychiatry Ment Health 16, 46 (2022). https://doi.org/10.1186/s13034-022-00482-x   
     
  • Fernández-Aranda F, Munguía L, Mestre-Bach G, Steward T, Etxandi M, Baenas I, et al. COVID Isolation Eating Scale (CIES): Analysis of the impact of confinement in eating disorders and obesity—a collaborative international study. In: European Eating Disorders Review. John Wiley and Sons Ltd; 2020. p. 871–83. 
     
  • Li, C., Haegele, J.A., Sun, F. et al. Meeting the 24-h movement guidelines and health-related outcomes among youth with autism spectrum disorder: a seven-country observational study. Child Adolesc Psychiatry Ment Health 16, 50 (2022). https://doi.org/10.1186/s13034-022-00488-5.  
     
  • Tremblay MS, Carson V, Chaput J-P, Connor Gorber S, Dinh T, Duggan M, et al. Canadian 24-hour movement guidelines for children and youth: an integration of physical activity, sedentary behaviour, and sleep. Appl Physiol Nutr Metab. 2016;41(6 Suppl 3):S311–27. 
     
  • Child and Adolescent Health Measurement Initiative. “Fast Facts: 2018–2019 National Survey of Children’s Health.”: Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau; 2021. URL: https://www.childhealthdata.org (Accessed 3 July). 
     
  • Babatunde, G.B., van Rensburg, A.J., Bhana, A. et al. Identifying multilevel and multisectoral strategies to develop a Theory of Change for improving child and adolescent mental health services in a case-study district in South Africa. Child Adolesc Psychiatry Ment Health 16, 45 (2022). https://doi.org/10.1186/s13034-022-00484-9   
     
  • Babatunde GB, Bhana A, Petersen I. Planning for child and adolescent mental health interventions in a rural district of South Africa: a situational analysis. J Child Adolesc Ment Health. 2020;32(1):45–65. 
     
  • Breuer E, Lee L, De Silva M, Lund C. Using Theory of Change to design and evaluate public health interventions: a systematic review. Implement Sci. 2015;11(1):63.