Did You Know?

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.

The Children’s Health Policy Centre found two studies for medications for psychosis — aripiprazole and olanzapine — each suggesting benefits, with aripiprazole leading to greater remission rates. Yet both medications also led to adverse events that require close monitoring. Our review of medications has two concerning implications that should be addressed in future research. First, neither of these medication studies was conducted at arm’s length from the drug manufacturers. Future studies need to be conducted independently, particularly given the safety profiles of antipsychotics. Second, we did not find any evidence from randomized controlled trials meeting our criteria for risperidone (brand name Risperidal), which is commonly prescribed for young people. Other researchers have raised concerns about the poor quality of trials on risperidone (and other antipsychotics). It is therefore important that new trials be conducted to expand the evidence on effective medications for treating young people who have psychosis. For more information, see Vol. 14, No. 4  of the Children’s Mental Health Research Quarterly

Investing in the future means investing in children — which is why the United Nations has designated every November 20 as Universal Children’s Day. It’s a time to promote togetherness around the world, awareness of the problems children face in every corner of the globe, and improve the welfare for all children. The day was established in 1954 to promote international togetherness and awareness among children worldwide. UNICEF, the United Nations Children’s Fund, promotes and coordinates this special day, which also works towards improving children’s welfare. On this day, the Children’s Health Policy Centre would like to draw attention to the importance of children’s mental heath. A recent paper by the Centre, published in the journal Evidence-Based Mental Health, has shown that one in eight children have mental disorders at any given time, causing symptoms and impairment, therefore requiring treatment. Yet even in high-income countries, including Canada most children with mental disorders are not receiving services for these conditions. The paper can be seen here.

For psychotic disorders, age of onset typically peaks at 22 years for males and 25 for females. Onset of psychotic symptoms or disorders is very rare prior to the teen years, yet early symptoms sometimes emerge in adolescence. Therefore, treatment services for young people with psychosis need to be readily available. Intervening early is crucial for youth with psychosis, given the strong association between duration of untreated symptoms and poorer short- and long-term outcomes. For more information, see Vol. 14, No. 4  of the Children’s Mental Health Research Quarterly.

Sometimes the cause of psychosis can be clearly identified, for example, when episodes are a result of substance use or medical conditions. Yet many questions remain about other causes of psychotic disorders. Researchers have put considerable effort into identifying the causes of schizophrenia given its lifelong consequences. Current evidence suggests that schizophrenia likely results from complex interactions occurring over time among thousands of genes and multiple environmental risk factors — none of which cause schizophrenia on their own.  And while genetics play a big role, it does not play the only one.  For example, having a first-degree relative with schizophrenia increases the risk, yet most people with this disorder do not have an affected relative. Paradoxes like this have led scientists to look at environmental factors that can influence both gene expression and overall development. Prenatal exposure to infections and perinatal complications such as hypoxia appear to increase risk.  Important risks — such as heavy cannabis use — can also occur later in a young person’s development. Overall, schizophrenia likely arises as a result of atypical brain development due to multiple genetic changes and environmental risks occurring over time. For more information, see Vol. 14, No. 4 of the Children’s Mental Health Research Quarterly.

All psychotic disorders include delusions as a core symptom. These false beliefs are persistently maintained despite the absence of evidence to support them. Hallucinations are another feature of most psychotic disorders and involve sensations such as hearing voices or seeing objects that others do not perceive. A meta-analysis that included more than 1,500 youth with psychosis found that auditory hallucinations were the most common symptom that these young people struggled with. Psychosis may also include disorganized thinking that impairs communication and disorganized behaviour that interferes with daily living.  For more information on psychosis, see Vol. 14, No. 4 of the Children’s Mental Health Research Quarterly.

October 10 is World Mental Health Day — an annual acknowledgement by the World Health Organization that mental health is an urgent priority. In 2019, an estimated one in  eight people globally were living with a mental disorder. Since the beginning of the COVID-19 pandemic, those numbers have become worse. Estimates put the rise in both anxiety and depressive disorders at more than 25% during the first year of the pandemic. At the same time, mental health services have been severely disrupted and the treatment gap for mental health conditions has widened.

The theme for this year’s world mental health day is “making mental health and wellbeing for all a global priority,” a priority strongly endorsed by the Children’s Health Policy Centre. We encourage governments to put adequate funding into public health so that children, in particular, do not bear the brunt of undiagnosed and untreated mental disorders, especially ones that are preventable. For more information on the prevalence of childhood mental disorders in high-income countries, see here.

Psychotic symptoms are a central feature of several different mental disorders including schizophrenia. They may also appear as a result of delusional, brief psychotic, schizophreniform and schizoaffective disorders, all of which are classified as psychotic disorders. As well, psychotic symptoms can also occur in some mood disorders, including depression and bipolar disorder. Substances, such as cannabis, and medical conditions, such as infections or epilepsy, can also cause psychotic symptoms. Regardless of cause, ongoing psychosis is associated with a high degree of impairment — and now ranks as the 19th cause of disability worldwide. For more information, see Vol. 14, No. 4  of the Children’s Mental Health Research Quarterly.