Did You Know?

The International Day for the Elimination of Racial Discrimination — marked this year on March 21 — is observed annually on the day the police in Sharpeville, South Africa, opened fire and killed 69 people at a peaceful demonstration against apartheid “pass laws” in 1960.

Since then, the apartheid system in South Africa has been dismantled. But many people continue to suffer from the injustice and stigma brings — even in countries like Canada. This point is brought home by the annual day, which was instituted by the General Assembly of the United Nations in 1979

In the vol 15 no 3 issue of the Children’s Mental Health Research Quarterly we examine racism. We discuss the impact it has on children and we evaluate interventions designed to reduce it.

Even one child being exposed to serious avoidable adversities is one too many. This is particularly true given that there are effective approaches that can reduce children’s exposure to these adversities. Yet when traumatic events have occurred, there are still many ways to help children. The Children’s Health Policy Centre makes four recommendations to help children better cope with trauma:

1. Intervene before mental health symptoms develop. Even after children have experienced a serious adversity such as maltreatment, it is possible to prevent mental health symptoms from developing — and adding further to their distress and burdens. The program Fostering Healthy Futures prevented emotional problems and reduced the need for future mental health interventions for children in foster care. Multisystemic Therapy reduced mental health concerns for children involved with protective services but still living with their parents. And the program It’s My Turn Now helped children who had been exposed to intimate partner violence. Helping parents develop new skills to support their children was a component of these latter two programs.
2. Consider other effective interventions for preventing behaviour problems and substance use. Among the four interventions included in our systematic review, none showed evidence of success in preventing common difficulties associated with childhood trauma, such as problematic behaviour or substance use. But both these challenges can be prevented by using other proven psychosocial interventions, including parent training programs to prevent behaviour problems and Preventure to prevent problematic substance use.
3. Implement prevention programs before maltreatment occurs. The ideal approach is to
   prevent exposure to avoidable serious adverse experiences such as child maltreatment. Prevention also recognizes children’s rights — to safety and to having their basic needs met. Yet Canadian data from 2008 identified more than 236,000 child maltreatment investigations, with approximately 36% of these cases being substantiated. Practitioners can play an important role in prevention by delivering effective parenting programs, including programs that can reduce child injuries.
4. Enact policies to reduce socio-economic disparities. The link between a major
   form of trauma — child maltreatment — and socio-economic disadvantage is well
   So successful prevention also likely involves addressing this larger
   societal issue. Other countries have made progress. For example, Denmark, Finland,
   Iceland and Norway have successfully reduced socio-economic disparities through
   long-standing social programs that redistribute income. Canada can follow suit by enacting similar programs, as the federal government and some provinces and territories have done in recent years. For more information, see Vol. 15, No. 1 of the Children’s Mental Health Research Quarterly.

Critical incident debriefing (or simply debriefing) typically involves a single-session intervention where participants describe their experiences very soon after witnessing or being a victim of a traumatic event and then discuss strategies for coping. While debriefing was initially designed for adults, its use with children has increased. However, the limited number of studies conducted on debriefing with children found limited or no benefit.

As well, cautions about debriefing have also emerged from adult studies. This includes some studies finding adverse events, such as increased long-term distress. Given almost no evidence of benefits, coupled with the potential for harm, debriefing should not be used with children unless better studies emerge showing positive results.  For more information, see Vol. 15, No. 1 of the Children’s Mental Health Research Quarterly.

The last Wednesday in February — this year, Feb. 22 — signifies a national stand against bullying. Helping children learn to self-regulate — by paying attention and inhibiting impulsivity — is an important step in reducing bullying. Parents can promote this skill by responding to their children’s needs, providing positive feedback during challenging tasks, and supporting older children and teens to be more autonomous. For more information, see Vol. 15, No. 4 of the Children’s Mental Health Research Quarterly. Titled Childhood bullying: Time to stop, the issue describes the basics of bullying and provides a review of eight bullying interventions, including five that produced some positive effects.

Indigenous communities in Canada have long displayed strength and resilience in the face of multiple adversities associated with colonialism and its legacies. These legacies have included the forced removal of children into residential schools, the multi-generational aftermath of these policies, continuing overrepresentation of Indigenous children in the child protection and youth justice systems, and ongoing exposure to individual and systemic racism.

To redress these legacies, in 2015 the Truth and Reconciliation Commission issued 94 calls to action. In particular, these calls to action address the deep social and health disparities Indigenous children and families experience in Canada — which are preventable forms of serious adversity. Reducing these adversities is essential to enable all Indigenous children to flourish.

All Canadians can support this flourishing by engaging in reconciliation. For example, we can express support for the Commission’s calls to action and call on federal and provincial or territorial governments to enact them. As well, Canadians can become aware of resources that promote wellness for Indigenous young people, such as those provided by BC’s First Nations Health Authority. For more information, see Vol. 15, No. 1 of the Children’s Mental Health Research Quarterly.

Research has emerged on factors that help young people cope with having experienced serious trauma such as the death of a loved one or witnessing a violent event. A meta-analysis that combined findings from more than 100 studies identified various factors that buffered the negative effects of experiencing or witnessing trauma. These buffers include family, peer and school support. Family support includes having a warm and accepting parent as well as a cohesive family. Peer support refers to receiving emotional and social encouragement and being satisfied with one’s friendships. School support involves having teachers and other school staff to help children and young people feel valued and safe. For more information, see Vol. 15, No. 1 of the Children’s Mental Health Research Quarterly.

A study of 2,000 Welsh and English youth at age 18, showed that young people who had faced trauma were at much higher risk of specific mental disorders. These included:

• substance use disorder (other than alcohol or cannabis) — 3.5 times higher odds
• conduct disorder — 2.3 times higher odds
• cannabis use disorder — 2.3 times higher odds
• generalized anxiety disorder — 2.2 times higher odds
• depression — 2.2 times higher odds
• attention-deficit/hyperactivity disorder — 1.9 times higher odds
• alcohol use disorder — 1.5 times higher odds.
• self-harm —3.5 times higher odds.
• attempting suicide — 5 times higher odds
• committing a violent offense — 1.5 times higher odds.

In a similar study with US youth, all traumatic exposures assessed were associated with up to double the risk for developing a substance use disorder. As well, exposure to interpersonal violence more than doubled the risk for girls developing conduct disorder. For more information, see Vol. 15, No. 1   of the Children’s Mental Health Research Quarterly.

Experiencing a significant injury. Witnessing the death of a loved one. Being sexually assaulted. These are just a few of the serious traumas children may experience, which are also commonly referred to as adverse childhood experiences. To support children who have experienced such extreme adversities, it is important to understand the prevalence of the problem. We identified two studies providing prevalence data, based on large, representative samples of young people. The first involved interviews with 2,000 Welsh and English youth at age 18. Some 31% reported experiencing at least one trauma during their lifetime.

The most frequent trauma was learning details about a traumatic event affecting someone close to them, without directly witnessing it (27.9%). Being assaulted or threatened with assault, including maltreatment by adults, was also common (21.5%). As well, many youth described experiencing significant accidents or illnesses (19.0%).

The second study involved interviews with nearly 6,500 American youth aged 13 to 17 years. In this study, 61.8% reported being exposed to at least one potentially traumatic event during their lifetime. Experiencing the unexpected death of a loved one was the most frequent trauma (28.2%), followed by experiencing disasters (14.8%) and witnessing death or injury (11.7%). Adding to this burden, 14.1% of youth reported experiencing two traumatic events, and 18.6% reported being exposed to three or more. For more information, see Vol. 15, No. 1 of the Children’s Mental Health Research Quarterly.

Psychosis can cause great distress concerning symptoms and substantial costs for young people and their families and communities — including the costs of lost human potential when healthy development is interrupted. Research shows that interventions can mitigate the distress and symptoms, particularly if young people receive these early in the disorder’s course. The Children’s Health Policy Centre suggests three recommendations to guide the treatment of psychosis:

1. Ensure careful assessment and diagnosis. Some causes of psychosis, such as substance use, are reversible. Some causes, such as seizures or infections, are also treatable. So, a first step is always to find out what is causing the presenting problem. Diagnosis can then guide treatment planning, for example, considering whether longer-term antipsychotic medications are needed, as with schizophrenia. After the diagnosis has been established, ongoing monitoring is also crucial — to assess a youth’s symptoms, functioning and response to treatment, including any adverse effects.
2. Use antipsychotic medications carefully. Antipsychotics are a mainstay in treating psychosis in young people — both short and long term. Aripiprazole and olanzapine stood out in this review, with two RCTs for each medication showing benefits in young people. Yet adverse events were common and severe, so both choice of medication and dosing need to be carefully monitored to ensure that benefits outweigh harms. Guidelines from the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children address monitoring for six antipsychotic medications, including aripiprazole and olanzapine. These guidelines need to be closely followed for any youth who is prescribed antipsychotics.
3. Offer psychosocial interventions as well. All youth with psychosis should be offered early psychosis intervention (EPI) programs, as they lead to reduced hospitalizations and psychotic symptoms. EPI programs typically included a range of psychosocial interventions, such as cognitive behavioural therapy, social skills training and family interventions. As well, some youth will have challenges that antipsychotics do not address and these psychosocial interventions will likely benefit them, as well.

For more information, see Vol. 14, No. 4 https://childhealthpolicy.ca/wp-content/uploads/2020/11/RQ-14-20-Fall.pdf  of the Children’s Mental Health Research Quarterly.

Psychosocial interventions for psychosis may be helpful when used along with antipsychotic medications. For example, the programs Cognitive Remediation Therapy and Computer-Assisted Cognitive Remediation both improved selected cognitive skills, and the Think Program reduced emergency room visits for mental health concerns. But additional studies are still needed to expand treatment options. For example, a form of cognitive-behavioural therapy (CBT) shows promise with first-episode psychosis, according to a recent pilot study in youth aged 14 to 18 years. This form of CBT involved setting individual goals and helping young people achieve them. Although too few youth were recruited to definitively assess the impact, initial findings suggested that CBT may reduce psychotic symptoms. Further evaluation of CBT is therefore warranted. Expanding the psychosocial treatment options for youth with psychosis is particularly important given the severe side effects of antipsychotic medications. For more information, see Vol. 14, No. 4  of the Children’s Mental Health Research Quarterly.