European Child & Adolescent Psychiatry

BackgroundResearch suggests a link between acquired head injury and signs of conduct disorder, with a majority of findings based on retrospective reports and comparison samples. The relationship between head injuries and conduct problems and how they may influence one another during development is currently unclear. This study aimed to investigate direct and indirect associations between head injury and conduct problems through to early adolescence. MethodsData from the UK Millennium Cohort Study was used to investigate the relationship between conduct problems as assessed by the Strengths and Difficulties Questionnaire and parent reported head injury over time, at ages 9 months, 3, 5, 7, 11 and 14 years, using a cross-lagged path analysis. This is data from 18,552 children, participating in a UK cohort study that is representative of the UK population. We included 7,041 (3,308 male) children, who had full information about head injuries and conduct problems at age 14. ResultsWe found a mutual association between childhood head injuries and conduct problems but with distinct timings: Head injury between 5-7 years predicted greater chance of conduct problems at age 11 and 14 years, while greater conduct problems at 5 years predicted a significantly greater chance of a head injury at age 7-11 years. ConclusionsThese findings have important implications for the timing of preventive and ameliorative interventions. Prior to school entry, interventions aiming to reduce conduct problems would appear most effective at reducing likelihood of head injuries in future years. However, equivalent interventions targeting head injuries would be better timed either as children are entering formal primary education, or soon after they have entered.

This study identified latent trajectories of physical aggression from infancy to preschool age and tested for (a) early parent, parenting and child predictor effects on trajectory membership and (b) trajectory-effects net of parent, parenting, and child predictor effects on Grade 2 social, behavioral and academic functioning. We used data from the Behavior Outlook Norwegian Developmental Study (BONDS), comprising 1,159 children (559 girls). Parents reported on risk and protective factors, and on physical aggression from 1 to 5 years; teachers reported on Grade 2 outcomes. We employed latent class growth curve analyses to identify nine aggression trajectories. In fully adjusted models testing simultaneously all associations among predictors, trajectories, and outcomes, maternal and paternal harsh parenting, child gender, and sibling presence predicted trajectory membership, which significantly predicted Grade 2 externalizing. Child gender had a pervasive influence on all outcomes as well as on trajectory membership. This is the first trajectory study that attempts to sort out which predictors are most proximal, more distal, or just confounded, with their relative direct effect sizes, and to link early paternal as well as maternal harsh parenting with childrens development of physical aggression from infancy to preschool age. Our findings underscore the need to include fathers in developmental research and early prevention and intervention efforts.

SARS-CoV-2 was declared a global pandemic by the World Health Organization (WHO) and was met with lockdown policies to curb the spread of the disease. This meant that 890 million students in 114 countries would be affected by the closure of their educational institutes, affecting their mental health. Mental health disorders are suggested to have a well-correlated link to suicide, which is the third most leading cause of death worldwide amongst children aged 15-19 years. According to WHO, "health is a state of complete physical, mental and social wellbeing and not merely the absence of disease." Hence the isolation brought about by SARS-CoV-2 is postulated to cause anxiety, fear, and depression amongst the pediatric population, due to the loss of socialization and separation from friends. In this systematic review and meta-analysis, we highlight the major mental health issues in children aged 2-18 years, along with their causes, effects, and potential solutions to tackle these problems.

Background Although an expansive body of evidence exists on children's mental health during the COVID-19 pandemic, it is largely restricted to the early phases and lockdowns. This study examines longitudinal changes in child and youth mental health symptoms across two years of the COVID-19 pandemic, with data collection strategically timed to capture variability in pandemic restrictions. Methods A population-based longitudinal study of 1,261 children and youth aged 4-17 years followed prospectively from January 2021 to December 2022, with five waves of data collected in Ontario, Canada. Latent growth curve modelling was used to estimate trajectories of parent-reported mental health symptoms and identify baseline and time-varying covariates associated with variable trajectories. Findings Mental health symptoms were elevated and stable during lockdowns, followed by significant reductions as pandemic restrictions loosened, particularly for oppositional defiant and inattention/hyperactivity symptoms compared to internalizing symptoms. Children without pre-existing clinician diagnosed physical, mental or neurodevelopmental conditions and those not in lockdown at baseline demonstrated relative increases in mental health symptoms during lockdowns; and girls, compared to boys, demonstrated smaller reductions in internalizing symptoms as restrictions loosened. Concurrent and lagged associations between parental distress and children's mental health symptoms varied across the pandemic. Interpretation Variation in symptom trajectories by mental health domain, gender, pandemic restrictions and pre-existing diagnosed conditions underscores the need for tailored, equity-informed pandemic planning and response. Policies designed to optimize the balance between the need to reduce viral community transmission whilst limiting pandemic lockdowns may mitigate adverse impacts on child and youth mental health. Funding Ontario Ministry of Health

IntroductionEarly life adversity (ELA) is associated with increased internalizing and externalizing behavior in high-income cohorts. It is unclear to what extent these associations generalize to low- and middle-income countries (LMICs). We examined the association between ELA and internalizing and externalizing behaviors in children across three LMIC cohorts. MethodsData from three LMIC cohorts, the Brazilian High-Risk Cohort (BHRC; n = 1111), Sustainable Programme Incorporating Nutrition and Games (SPRING; n = 601), and Drakenstein Child Health Study (DCHS; n = 708) were pooled. Children (7-10 years) were assessed using the Strengths and Difficulties Questionnaire (SDQ). ELA (first 24 months) was assessed using a cumulative index. Ordinary Least Squares linear regression models were run to examine the associations of adversity with internalizing and externalizing behaviors while adjusting for child age, sex, and cohort, and to test interactions with child age and cohort. ResultsMeasurement invariance did not hold across cohorts, necessitating within-cohort analyses. 2420 children (53.9% boys) were included in analyses. ELA was associated with higher SDQ total scores (B = 1.97, 95% CI: 1.16, 2.78, p < .001), internalizing (B = 0.84, 95% CI: 0.41, 1.27, p < .001), and externalizing behaviors (B = 1.13, 95% CI: 0.62, 1.64, p < .001) in the full sample. Cohort-specific associations were strongest in the BHRC, with attenuated effects in SPRING and DCHS. Girls and older children exhibited fewer behavior problems. Interaction analyses indicated that the associations of adversity with behavior were stronger at younger ages and varied across cohorts. ConclusionIn cohorts from the Global South, while there is an association between early life adversity and psychopathology, there are also important context-dependent differences across cohorts.

Background and aimsProblematic gaming has been linked to increased levels of psychotic-like experiences (PLEs) in youth, but the role of environmental factors remains unclear. Using affordance theory, this study aimed to examine the association of problematic gaming with PLEs and the role of environmental factors. MethodsParticipants were 6492 youth (39.2% female) who reported playing video games, from the Adolescent Brain Cognitive Development Study in the U.S. Measures included problematic gaming, peer environment (number of close friends), school environment (teachers, activities, etc.), family environment (parental monitoring), and PLEs. We examined whether the peer, school, and family environments at age 12 were associated with problematic gaming and moderated its association with PLEs at age 13. ResultsHigher protective scores for the school and family environments at age 12 were independently associated with lower levels of problematic gaming at age 12 (respectively B=-0.15; 95% CI: -0.21, -0.10 and B=-2.39; 95% CI: -2.71, -2.07) and age 13 (B=-0.05; 95% CI: -0.10, -0.00 and B=-0.79; 95% CI: -1.11, -0.47). The peer environment was not associated with problematic gaming. Higher levels of problematic gaming at age 12 were associated with higher levels of PLEs at age 13 (B=0.13; 95% CI: 0.09, 0.17), with no significant interaction with the environmental variables. Discussion and conclusionsPositive school and family environments may be protective against problematic gaming in adolescence but do not appear to attenuate the putative effect of problematic gaming on PLEs. The results provide partial support to an affordance-based conceptualization of problematic gaming.

IntroductionSelective Mutism (SM) is an anxiety disorder affecting some children starting school. Usual presentation is lack of speech at school, contrasting with confident speech at home. Estimated prevalence is 0.7%, rising to 2.2% for children who are second language learners. Long-term impacts include complex mental health conditions for children not receiving timely intervention. There are calls for effective treatments as part of a multi-modal care pathway. Case study research describes music therapy leading to generalised speech, but an evidenced-based approach is currently lacking. This study evaluates acceptability and feasibility of a manualised music therapy intervention for children with SM. MethodsFour children with SM in early years school settings were offered manualised music therapy over a 14-week period. In-depth qualitative interviews were conducted with the music therapist, a school staff member and a parent of each child (n=12). Interviews were analysed using a framework grounded in well-theorised constructs of acceptability and feasibility. ResultsAcceptability was high for all participant groups, with clear comprehension and confidence in an intervention viewed as appropriate for the early years population. Need for cultural competence in delivery was highlighted. Analysis of feasibility demonstrated rapid recruitment, practicality and fit with the school environment, and a strong sense of perceived effectiveness including anxiety reduction, improved emotional well-being, increased self-expression and generalised speech. DiscussionThis study has added to the methodological literature on evaluating acceptability and feasibility in music therapy interventions and has indicated the appropriateness of moving to experimental testing of the SM intervention evaluated here.

BackgroundAdolescent mental health issues were surging during COVID-19 pandemic. Yet it is unclear whether the pandemic amplified pre-existing vulnerabilities for psychiatric disorders. MethodsUsing the longitudinal data from Adolescent Brain Cognitive Development (ABCD) Study(C) (n = 7,560, 2[~]3 waves of assessments before pandemic and 2[~]3 waves after first nation-wide pandemic lock-down), we evaluated associations of the pandemic, genetic liabilities to psychiatric disorders, and their interactions with 20 different measures of psychopathology. Genomic common factor models aggregated genomic effects across eight psychiatric disorders, summarizing into four latent factors. Analyses were stratified by genetic ancestry and sex. ResultsIn European-like ancestry adolescents, each 1 standard deviation increase in Neurodevelopmental (ND) or Internalizing (INT) PRS significantly associated with increment in most psychopathologies by 3% to 19%. After controlling for individuals PRS, pandemic periods were significantly associated with accelerated rates in parent-reported Child Behavior Checklist (CBCL) withdrawn depressed and rule-breaking syndrome scores, CBCL DSM-oriented conduct, somatic, and attention deficit/hyperactivity problems, and all corresponding youth-reported Brief Problem Monitor (BPM-Y) scores. In sex stratified analysis, CBCL DSM-oriented affective problem scores significantly worsened in early pandemic among females (21% increase; 95%CI 13%-29%; P=2.6x10{square}{square}) but not males. Females have stronger associations between INT PRS and rate of increment on CBCL DSM-oriented affective problem scores (15%; 95%CI 10%-21%; P=6.4x10{square}{superscript 1}{square}), comparing to males (10%; 95%CI 6%-15%; P=4.2x10{square}{square}). The multiplicative interactions between PRS and pandemic periods were at-most trending, showing positive interactions between ND PRS and early pandemic among females for CBCL conduct (15%; 95%CI 7%-23%; P=5.17x10{square}{square}) and aggressive behavior scores (9%; 95%CI 4%-14%; P=5.09x10{square}{square}). ConclusionA wide range of adolescent mental health symptoms intensified during the pandemic period. Both genetic vulnerabilities and pandemic-related factors are associated with increased psychiatric symptoms. The genetic liability and the pandemic periods were associated with mental health issues independently, meaning genetically at-risk individuals saw a higher relative increase in mental problems during the pandemic. Females exhibited higher levels of mental health symptoms and more sustained increases across the duration of the pandemic compared to males. Youth with genetic vulnerability to neurodevelopmental phenotypes required special attention due to heightened mental health risks during stressors like COVID-19.

ImportanceCOVID-19 public health mitigation measures are likely to have detrimental effects on emotional and behavioural problems in children. However, longitudinal studies with pre-pandemic data are scarce. ObjectiveTo explore trajectories of childrens emotional and behavioural difficulties during the COVID-19 pandemic. Design and settingData were from children from the third generation of a birth cohort study; the Avon Longitudinal Study of Parents and Children - Generation 2 (ALSPAC-G2) in the southwest of England. ParticipantsThe study population comprised of 708 children (median age at COVID-19 data collection was 4.4 years, SD=2.9, IQR= [2.2 to 6.9]), whose parents provided previous pre-pandemic surveys and a survey between 26 May and 5 July 2020 that focused on information about the COVID-19 pandemic as restrictions from the first lockdown in the UK were eased. ExposuresWe employed multi-level mixed effects modelling with random intercepts and slopes to examine whether childrens trajectories of emotional and behavioural difficulties (a combined total difficulties score) during the pandemic differ from expected pre-pandemic trajectories. Main outcomesChildren had up to seven measurements of emotional and behavioural difficulties from infancy to late childhood, using developmentally appropriate scales such as the Emotionality Activity Sociability Temperament Survey in infancy and Strengths and Difficulties Questionnaire in childhood. ResultsThe observed normative pattern of childrens emotional and behavioural difficulties pre-pandemic, was characterised by an increase in scores during infancy peaking around the age of 2, and then declining throughout the rest of childhood. Pre-pandemic, the decline in difficulties scores after age 2 was 0.6 points per month; but was approximately one third of that in post-pandemic trajectories (there was a difference in mean rate of decline after age 2 of 0.2 points per month in pre vs during pandemic trajectories [95 % CI: 0.10 to 0.30, p <0.001]). This lower decline in scores over the years translated to older children having pandemic difficulty scores higher than would be expected from pre-pandemic trajectories (for example, an estimated 10.0 point (equivalent of 0.8 standard deviations) higher score (95% CI: 5.0 to 15.0) by age 8.5 years). Results remained similar although somewhat attenuated after adjusting for maternal anxiety and age. Conclusion and relevanceThe COVID-19 pandemic may be associated with greater persistence of emotional and behavioural difficulties after the age 2. Emotional difficulties in childhood predict later mental health problems. Further evidence and monitoring of emotional and behavioural difficulties are required to fully understand the potential role of the pandemic on young children. Key FindingsO_ST_ABSQuestionC_ST_ABSHow has the COVID-19 pandemic influenced emotional difficulties in young children? FindingsUsing repeated longitudinal data from before and during the pandemic we provide evidence that emotional difficulty scores of primary school aged children are higher by an estimated 10.0 points (0.8 standard deviations) (95% CI: 5.0 to 15.0) by age 8.5 years than would be expected based on pre pandemic data. MeaningThe level of difference in emotional difficulties found in the current study has been linked to increased likelihood of mental health problems in adolescence and adulthood. Therefore, this increase in difficulties needs careful monitoring and support.

BackgroundThe COVID-19 pandemic had serious effects on the mental health of children and adolescents. However, it is unclear how the pandemic may have affected treatment effects and outcomes in youth care. We investigated if treatment effects and externalizing and internalizing problems of children and adolescents receiving youth care were affected by the COVID-19 pandemic. MethodsWe used data from children and adolescents in youth care (N = 1,090, Mage = 12.85 (SD = 2.83; range = 8-18 years)). Internalizing and externalizing problems were assessed at the start and end of treatment using the Child Behavior Checklist. We inspected change in internalizing and externalizing problems and clinical status at the end of treatment to investigate treatment effects, and the level of problems at the start and end of treatment. Outcomes were compared between three groups: children treated entirely before the COVID-19 pandemic, children who experienced the transition into COVID-19 measures during treatment, and children treated entirely during the pandemic. ResultsWe did not find evidence that the pandemic affected treatment effectiveness. However, fewer children who were treated during the pandemic recovered from externalizing problems compared to children treated before the pandemic. Children who received treatment entirely during the pandemic also showed more internalizing and externalizing problems at both the start and end of their treatment, and children who experienced the transition into the pandemic showed elevated externalizing problems at both timepoints. ConclusionsAlthough the change in internalizing and externalizing problems from start to end of treatment was not affected by the pandemic, our findings that children are entering and leaving care with more problems suggest that child mental health has deteriorated since the pandemic.

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition, commonly associated with differences in attention, and/or hyperactivity and impulsiveness. A lesser known, but highly impactful characteristic of ADHD is emotional dysregulation, which causes difficulties in emotional expression and identification. An aspect of emotional dysregulation which remains relatively unexplored in ADHD, is rejection sensitivity. In people who experience rejection sensitivity, perceived rejection and/or criticism can evoke extreme dysphoria. To investigate the lived experience of rejection sensitivity in ADHD individuals, five undergraduates participated in focus-group interviews. The subsequent thematic analysis revealed three key themes which encapsulated the experience; withdrawal, masking, and bodily sensations. The participants explained how rejection sensitivity elicited unpleasant bodily sensations, anxiety, and misery, and how, in turn, they used masking to camouflage these feelings. They then discussed how the use of masking had caused them to become dissociated from themselves and to withdraw from others, which often resulted in loneliness. It was apparent that rejection sensitivity significantly impacts mental wellbeing, eliciting feelings such as anxiousness, despair, and embarrassment. In turn, social function is significantly impaired, alongside career opportunities, and daily life. Our findings indicate a need for deeper understanding of ADHD traits and emotional dysregulation, which may in turn lessen the presence of rejection sensitivity in ADHD individuals.

BackgroundScreen time has been linked with inattention/hyperactivity symptoms, but studies often do not distinguish within-from between-person associations over long developmental periods. MethodsData were drawn from the Brazilian High-Risk Cohort for Mental Health Conditions, a school-based cohort with assessments at baseline (2010) and follow-ups in 2013-2014 and 2018-2019, 76% retention. The sample included 2,511 children (mean age = 10.2 years at baseline, 54.7% males). Daily screen time (hours spent exposed to computer, television or video games) was obtained by asking the parent or the primary caregiver (94.9% mothers). Inattention/hyperactivity symptoms were assessed with the Strengths and Difficulties Questionnaire (SDQ). Analysis was carried out using random intercept cross-lagged panel models, adjusting for sample representativeness, attrition, and demographic covariates. Sensitivity analysis was carried out using the Attention Scale of the Child and Behavior Checklist (CBCL), harmonized with the Adult Behavior Checklist (ABCL). ResultsWe found no within-person relationship between screen time and inattention/hyperactivity symptoms from childhood to early adulthood. Significant between-person associations were found in the SDQ but not in the adjusted SDQ models (respectively: {beta} = 0.25; 95%CI = 0.02, 0.45; p = 0.029, and {beta} = 0.22; 95%CI = -0.00, 0.45; p = 0.052). For instance, the history of primary caregivers psychiatric diagnoses was associated with higher average screen time ({beta} = 0.16; 95% CI, 0.07, 0.25; p < 0.001) and inattention/hyperactivity symptoms ({beta} = 0.27; 95% CI, 0.21, 0.34; p < 0.001). Findings were replicated in the CBCL-ABCL model. ConclusionWe found no longitudinal association between increasing screen time exposure beyond an individuals average and inattention/hyperactivity symptomatology. Furthermore, between-person associations were absent after covariate adjustment and results werent sensitive to the questionnaire.

ImportanceSocial determinants of health (SDoH) have well-characterized associations with child mental health outcomes. Their complex, multilevel influences on child mental health are less well understood. ObjectiveTo identify patterns across multiple domains of SDoH and estimate their associations with child mental health and suicidality outcomes over time. DesignPanel study of 11 810 children aged 9 to 10 years who were enrolled in the Adolescent Brain Cognitive Development (ABCD) study and followed from September 1, 2016, and April 24, 2021. SettingNationally-representative, population-based study across 21 sites in the U.S. ParticipantsABCD participants and their participating parents/guardians. Exposures84 structural SDoH factors at baseline across 9 domains (discrimination, crime and drug use, education, health and environment, family type and disability, housing and transportation, minority status and language, socioeconomic status, and urbanization). We used unsupervised machine learning to identify patterns of clustering underlying the SDoH data. Main Outcomes and MeasuresChild mental health was measured with the parent-report Child Behavior Checklist. Suicidal ideation and suicide attempts were measured with child- and parent-report computerized versions of the Kiddie Schedule for Affective Disorders and Schizophrenia. ResultsOf 10 504 children included at baseline (median [SD] age, 9.9 [0.6] years), 5510 [52.5%] were boys and 4994 [47.5%] were girls; 229 (2.2%) were Asian, 1468 (14.0%) were Black, 2128 (20.3%) were Hispanic, 5565 (53.0%) were White, and 1108 (10.5%) were multiracial. Four SDoH patterns were identified: affluence (SDoH Pattern I); structural racism and discrimination (SDoH Pattern II); socioeconomic deprivation (SDoH Pattern III); and high crime, low education, and populated (SDoH Pattern IV) areas. Children with High Socioeconomic Deprivation at baseline (SDoH Pattern III) reported higher rates of externalizing ({beta}, 1.43, 95% CI, 0.83, 2.02), internalizing ({beta}, 0.75, 95% CI, 0.14, 1.37), and total ({beta}, 1.16, 95% CI, 0.50, 1.81) problems, but these trajectories decreased over time. Children with High Structural Racism and Discrimination at baseline were the only group showing increasing trajectories of suicide attempts (OR, 1.42, 95% CI, [1.04, 1.93]) and depression ({beta}, 0.19, 95% CI, 0.08, 0.29) over time. In contrast, living in affluent communities (SDoH Pattern I) was associated with lower rates of all internalizing and externalizing problems at baseline, but increasing trajectories of depression ({beta}, 0.17, 95% CI, 0.09, 0.25), anxiety ({beta}, 0.10, 95% CI, 0.02, 0.18), and withdrawal ({beta}, 0.09, 95% CI, 0.01, 0.17) over time. Conclusions and RelevanceMultiple domains of SDoH are associated with child mental health outcomes in cross section and over time. Targeted structural interventions may improve mental health outcomes and reduce suicide attempts among children. Key PointsO_ST_ABSQuestionC_ST_ABSWhat are the social determinants of mental health, suicidal ideation, and suicidal behavior among children in the U.S.? FindingsIn this cohort of 10 504 children, we used machine learning to identify four patterns of social determinants of health (SDoH). At baseline, socioeconomic deprivation was associated with internalizing and externalizing problems. Over follow-up, structural racism and discrimination were associated with suicide attempts. MeaningMultiple dimensions of structural interventions targeting different SDoH are needed to improve child mental health outcomes.

ObjectiveThis study investigated whether chronotype (biobehavioral preference for sleep and wake timing) across early adolescence impacts mental health symptoms at age 13-14. This is a relationship with growing correlational evidence but limited causal exploration. MethodsParticipants were 7,489 adolescents (aged 9-10 at baseline; 13-14 at the fifth assessment wave) from the Adolescent Brain Cognitive Development Study (ABCD). Marginal structural models with machine learning-based weight estimation were used to assess the causal impact of chronotype at ages 11-12 and 12-13, as measured by the youth-reported Munich Chronotype Questionnaire, on several dimensions of mental health symptoms at age 13-14 (parent-reported Child Behavioral Checklist internalizing and externalizing values; child-reported Prodromal Psychosis Scale). ResultsThere was no effect of chronotype at age 11-12 on any outcome. However, later chronotype at age 12-13 was associated with more severe externalizing symptoms (b=.31, p=.02) and prodromal psychosis symptoms at age 13-14 (b=.06, p<.01), but not with more severe internalizing symptoms. Post-hoc analyses indicated the lack of relationship with internalizing held for both anxiety and depression symptoms and in both sexes. ConclusionsThere are likely causal effects of adolescent chronotype on mental health symptoms, but these are dependent on the dimension of mental health and period of adolescence. The typically-reported association between later chronotype and more severe internalizing symptoms may not manifest until later adolescence (such as with the common post-pubertal shift in chronotype).

Health professionals in Greece face barriers in assessing child and adolescent mental health conditions due to the lack of instruments with evidence of validity in local samples. This study addresses this gap by evaluating the psychometric properties and establishing common norms for six globally recognized mental health tools in Greece: the Child and Adolescent Trauma Screen-2 (CATS-2), Pediatric Symptoms Checklist-17 (PSC-17), Revised Childrens Anxiety and Depression Scale-25 (RCADS-25), Swanson, Nolan, and Pelham Scale (SNAP-IV), Modified Checklist for Autism in Toddlers-Revised (MCHAT-R/F), and Child Autism Spectrum Test (CAST). We drew on a nationwide Greek survey comprising 1,756 caregivers and 1,201 children and adolescents (age groups: 1 to 18 years). Using Item Response Theory, we assessed internal consistency and factor models according to Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria for unidimensionality, local independence, monotonicity, and global model fit. Normative references were calculated using standardized metrics recommended by the Patient-Reported Outcomes Measurement Information System (PROMIS). Final sample sizes ranged from 1,356 (PSC-17, caregiver version) to 198 (CATS-2, caregiver version). Internal consistency was rated as good to excellent across all scales. Factor analyses supported all scales except the MCHAT-R/F (failing monotonicity) and CAST (failing monotonicity and unidimensionality). Local normative references were usually consistent with international samples. This toolkit provides essential evidence-based resources for child and adolescent mental health in Greece, offering a scalable model for other underserved settings. Further research with national probabilistic samples is recommended to enhance risk stratification accuracy.

BackgroundChildren diagnosed with ADHD and other comorbid mental health conditions often exhibit more severe functional impairments than those without comorbid conditions, including a tendency for their ADHD symptoms to persist into later developmental stages. We conducted a systematic review and quantitative analysis to investigate the extent to which specific childhood comorbidities (internalizing, externalizing and neurodevelopmental conditions) predict the persistence of childhood ADHD into later developmental stages. MethodsWe extracted data from 26 studies meeting the criteria for inclusion and applied multilevel random effects models to obtain pooled estimates of Cohens d for selected predictors on ADHD persistence. ResultsChildhood comorbid internalizing and externalizing conditions (d=0.19 and d=0.31, respectively), but not neurodevelopmental disorders, were significantly associated with ADHD persistence. After adjusting for covariates (sex, age and other comorbidities), this association diminished for externalizing conditions (dadj=0.24) and was no longer significant for internalizing conditions (dadj=0.05). The association between comorbid externalizing behavior problems and ADHD persistence was found only in studies that used parent-reported data to measure childhood ADHD and externalizing conditions, but not in studies that included teacher-reported childhood symptoms. ConclusionsChildhood comorbid externalizing and, to a lesser extent, internalizing conditions were associated with the persistence of ADHD, but this association may be partially due to confounders. Childhood comorbidity of neurodevelopmental disorders does not appear to increase the likelihood of ADHD persistence.

BackgroundBrazil is home to 50 million children and adolescents, whose mental health needs require context-sensitive research. Although scientific output is growing in the country, publications are scattered and often inaccessible. MethodsThis systematic review compiles prevalence estimates, assessment instruments, and interventions for child and adolescent mental health in Brazil (PROSPERO registration: CRD42023491393). We searched international (PubMed, Web of Science, PsycINFO, Google Scholar) and national (Scielo, Lilacs, Brazilian Digital Library of Theses and Dissertations) databases up to July 2024. Reference lists, reviews, and experts were consulted. Extraction followed Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) and Cochrane manuals. ResultsThis review appraises 734 studies on 2,576 prevalence estimates, 908 studies on 912 instruments, and 192 studies on 173 intervention trials. Point prevalence of any mental disorder ranged from 10.8% (age 12) to 19.9% (ages 7 to 14), although a nationally-representative study is lacking. There is a rise of self-harm notifications, reaching 133.1 in 2019 (per 100,000 aged 10-19). Indigenous youth face suicide rates of 11 (age 10 to 14), far exceeding national averages (0.652). There is severe violence exposure (21% of adolescents reported domestic physical violence in the previous month), disproportionately impacting Black youth and heightening risks for depression and substance use. Reliable instruments exist for assessing psychopathology, yet most lack psychometric and cross-cultural validation. Interventions remain under-implemented; the largest trials adapted international substance-use prevention programs, showing null effects. High-quality studies are mainly funded by public investment. DiscussionThis compilation provides accessible data for professionals, facilitating translation of science to practice. Brazilian sociocultural challenges impact youth mental health, with public health priorities including violence, systemic racism, and indigenous youth suicide. National research must develop culturally-sensitive resources for mental health, including scalable interventions focused on social minorities. FundingThe Stavros Niarchos Foundation.

BackgroundScreen use is linked to adverse mental health outcomes in adolescents, but differences across psychiatric diagnoses, mental symptoms, and types of screen-based activities remain unclear. Moreover, the extent to which genetic factors contribute to these associations is largely unknown. MethodsWe analysed longitudinal data from 23,790 adolescents (14-16 years of age) in the Norwegian Mother, Father, and Child Cohort Study (MoBa), linking questionnaire responses on screen use to registry-based psychiatric diagnoses and self-reported mental symptoms. Using regression models, we assessed associations between mental health outcomes and gaming, social media use, and TV watching. We also evaluated whether genetic liability to major psychiatric disorders, as indexed by polygenic risk scores (PRSs), was associated with screen use, and estimated the degree of genetic confounding using genetic sensitivity analyses. FindingsSpending 3-4 hours/day or more on any screen-based activity was associated with increased odds of a lifetime diagnosis of depressive, anxiety/stress-related, and hyperkinetic disorders. Similarly, minimal social media engagement was associated with increased odds of any psychiatric diagnosis, most strongly with pervasive developmental disorders. Associations with mental symptoms closely followed those observed for clinical diagnoses. The PRSs of major depression, anorexia nervosa, attention-deficit hyperactivity disorder, and autism spectrum disorder were significantly associated with screen use, suggesting shared genetic liability. Genetic sensitivity analyses indicated that a substantial proportion of the observed phenotypic associations may be attributable to genetic factors. InterpretationOur findings suggest a complex, bidirectional relationship between screen use and adolescent mental health, across both mental disorders and traits. Both high and low screen use may reflect underlying mental health vulnerabilities. The associations appear partly driven by shared genetic susceptibility, underscoring the importance of accounting for individual risk. These results support the need for individualized, context-sensitive digital media use guidelines. FundingResearch Council of Norway (Grant N{degrees}324499).

BackgroundFood insecurity (FI) is associated with overall poorer mental health in childhood and adolescence and negatively impacts longer-term health. However, less is known about how differential exposure to FI may shape the development of different mental health symptoms over this period. MethodsWe used data from two population-based UK birth cohorts: the Avon Longitudinal Study of Parents and Children (ALSPAC; n=6,182; born 1991-1992) and Growing Up in Scotland (GUS; n=3,167; born 2004-2005). FI severity at age [~]5 years (No FI/Low FI/High FI) was determined from parent-reported difficulties affording food. Mental health symptoms were parent-reported over the following 10 years using the conduct, emotional, hyperactivity/inattention and peer problem subscales of the Strengths and Difficulties Questionnaire (SDQ). Trajectories were characterised using multilevel growth curve models adjusted for child sex, household income, maternal mental health and multiple deprivation index. FindingsHigh FI at age [~]5 years was associated with worse trajectories of conduct, emotional, hyperactivity/inattention and peer problems over the following 10 years in both cohorts (vs. No FI). In ALSPAC, differences in conduct and hyperactivity/inattention scores were most pronounced at ages 7 (0.31 [0.11,0.51], padj<.001) and 9 (0.44 [0.09,0.79], padj=.008), respectively; these occurred at ages 13 (0.26 [0.04,0.48], padj=.014) and 15 (0.43 [0.04,0.81], padj=.023) in GUS. For emotional (ALSPAC: 0.46 [0.22,0.69], padj<.001; GUS: 0.38 [0.16,0.59], padj<.001) and peer problems (ALSPAC: 0.34 [0.13,0.55], padj<.001; GUS: 0.25 [0.05,0.45], padj=.01), differences between High and No FI groups were most pronounced at age 9 instead. Low FI was also associated - to a lesser degree - with higher peer problem trajectories (vs. No FI); this was most pronounced at age 13 in ALSPAC (0.13 [0.00,0.27], p=.031) and age 15 in GUS (0.28 [0.04,0.52], p=.016). InterpretationChildren who experienced more severe FI had greater levels of mental health symptoms over the next 10 years, even after adjusting for sociodemographic confounders. FI severity may also display a dose-response effect for peer problems. While replication using more robust FI measures remains necessary, we provide further evidence of the persistent negative impact of FI on youth mental health - particularly during late childhood and mid-adolescence. FundingUniversity of Edinburgh, Wellcome Trust, University of Bristol Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed for studies examining youth mental health trajectories after early food insecurity (FI) using the following terms: (food) AND (insecur*) AND ((child*) OR (youth) OR (young people) OR (adolescen*)) AND (("mental health") OR (distress) OR (emotion*) OR (behavio*) OR (internali*) OR (externali*)) AND ((trajectory) OR (trajectories)). Three studies investigated the relationship between FI and youth mental health trajectories using data from South Africa, USA and Canada; none investigated the potential impact of marginal food security. Two studies found an association between FI and persistently high depressive and hyperactivity/inattention symptoms over 1-3.5 years of follow-up. The third study used latent growth curve analysis to investigate eight patterns of FI exposure (based on binary FI status over three timepoints) and teacher-reported behaviour problems, reporting no associations. This study, however, only examined linear changes in behavioural problems which typically follow a non-linear trajectory - i.e. age-related differences in rates of change were not considered. Added value of this studyTo our knowledge, this is the first study to investigate trajectories of mental health symptoms in two generations of UK children and adolescents following exposure to different levels of FI severity. Across two large, population-based birth cohorts, we found that high FI at age 5 was associated with worse 10-year trajectories of emotional, conduct, hyperactivity/inattention and peer problems compared to the no FI group. Low FI - reflecting marginal food security - also associated with heightened peer problems, suggesting a dose-response relationship. Greatest differences between food-secure and food-insecure children in this study occurred in late childhood and mid-adolescence. Findings additionally highlight that the impact of FI has remained consistent for UK children born in the early 1990s and mid-2000s, despite secular changes in youth mental health problems. Implications of all the available evidenceChildhood food insecurity casts a long shadow on mental health and well-being outcomes throughout the lifespan, as demonstrated by substantial work from the 20th and 21st centuries. Here, we also see that the impact of FI on children and young peoples mental health has remained consistent over two generations of UK youth. If left unchecked, the growing prevalence of FI in the UK will only intensify concerns for the long-term mental health of the nations young people - especially those from low-income and marginalised backgrounds who already face a widening gap in health inequalities.

BackgroundChildren with conduct problems are at high risk of a wide range of mental health problems in later life, making them a priority for early intervention. Group-based parent-training is known to be effective but with a substantial failure rate. Based on evidence on the value of involving children, we developed Reflective Interpersonal Therapy for Children and Parents, (RICAP). We report here, feasibility and outcomes from the first trial of an intervention for children with conduct problems persisting after parent training. In contrast to most other studies, we used both parent and teacher report. MethodsThe sample comprised 105 children and their parents aged 5-10 years referred to UK Child and Adolescent Mental Health Services (CAMHS) with conduct problems. All were offered the Incredible Years (IY) parent training intervention, and parents provided pre- and post-treatment measures (including CBCL, SDQ). Children still above clinical threshold after IY were randomized either to RICAP or to usual CAMHS treatment (CTAU) with follow up 8 months later. Trial Registration Number: ISRCTN25252940. ResultsFeasibility was supported by high retention through the initial IY (102/105) and subsequent RCT phases of the study (58/70 eligible for randomization). The majority of those randomized to RICAP attended for 11/14 or more sessions, reflecting its high acceptability to both children and parents. By parent report RICAP was superior to CTAU on CBCL externalising (d=0.32) and internalising (d=0.42) problems, while by teacher report CTAU was superior on SDQ total problems (d=0.32) and reactive aggression (d = 0.27). ConclusionsWe provide first evidence of the acceptability and effectiveness of a novel intervention for children with persisting conduct problem following parent training. We also find differences between parent and teacher reported outcomes, pointing either to reporter or social context effects, both of which need to be addressed in future research.