CAPMH Corner (Updated Mar 2026)

Child and Adolescent Psychiatry and Mental Health (CAPMH) is the official IACAPAP Journal. The "CAPMH Corner" of the March 2026 issue of IACAPAP Bulletin summarizes the following three studies recently published in CAPMH – Age of onset of self-harm in children and adolescents: a scoping review (Wiggin et al., 2025), Emotion regulation as a transdiagnostic link between ADHD and depression symptoms: evidence from a network analysis of youth in the ABCD study (Tharaud et al., 2025), and Off-label drug use in children and adolescents treated with antidepressants and antipsychotics: results from a prospective multicenter trial (Taurines et al., 2025).

Wiggin et al., (2025) establish a need to review the age of onset of self-harm in children and adolescents and set out to do a scoping review to map the age of onset literature alongside the definitions, operationalisation, and research methods used to determine onset. 

The team defines self-harm behaviours which is inclusive of suicide attempt and non-suicidal self-injury (NSSI) and the population of interest as young people aged ≤18 years, or people 19 years or older exclusively reporting on self-harm first experienced aged ≤ 18 years. They conduct electronic searches on Medline (EBSCO), PsycInfo (EBSCO), Embase (Elsevier), CINAHL Plus (EBSCO), and Web of Science (Clarivate) from inception to 26th June 2023. They also include grey literature sources including Google Scholar, BASE (Bielefeld Academic Search Engine), and reports from the World Health Organization’s suicide and suicide prevention publications and other prominent organizations working in this area. They assess the quality of the included studies using the Quality Assessment with Diverse Studies (QuADS) tool. They identify a total of 9074 records from all sources, of which 3420 are duplicates, leaving 5654 titles and abstracts for screening. They screen 360 of the 390 full texts sought that were accessible and include 42 records for their review (36 identified by database and grey literature searches, three identified from the reference lists of included studies, and three known to the review team). 

The authors note that 81% of studies used cross-sectional methods and 71% were retrospective reports.  They report a range of the mean ages of onset of 9 to 18 years for entire sample, 10 to 15 years for NSSI and 9 to 18 years for suicide attempts; the modal onset age as 13 years (n = 17), followed by 12 years (n = 16), and 14 years (n = 13). They note a study reported early initiation of self-harm (≤12 years) in 36% and non-early initiation (13–18 years) in 59% of the sample, and that studies with a younger sample tended to report a younger age of onset. 

The authors acknowledge that their search strategy that was created in consultation with and validated by a librarian is a strength of their review, besides the fact that the included studies underwent quality assessment. They also mention the limitations – findings are generalizable only to the age group of ≤18 years; some studies may have not been detected by the search strategy or screening process; the eligibility criteria were amended to specifically include studies that report age of onset as a measure of central tendency that may have resulted in excluding studies which used other methods to report age of onset of self-harm. 

The team concludes by highlighting the age range of 12 to 14 years as the typical onset period for self-harm and emphasize the importance of timely prevention and intervention to reduce distress and self-harm. They suggest future research to utilise self-harm surveillance systems or registers to enable the provision of more robust estimates of self-harm age of onset and 
studies to prospectively explore trajectories of self-harm behaviour, including escalation, cessation, and help-seeking, with a sufficient sample size.  

Tharaud et al. (2025), discuss the multidimensional nature of the construct of emotion regulation (ER) and describe it as a transdiagnostic construct. They aim to identify which ER domain(s) most strongly link symptoms of ADHD and depression in a network model spanning late childhood to early adolescence in the ABCD cohort (Saragosa-Harris et al., 2022).  

The team draws on a sample of 11,868 youth selected to be diverse and nationally representative. They collect baseline data when participants are 9–10 years old. Nearly all participants (n = 11,866; 99.9%) contribute at least one data point across time points for analysis. Of these, 4,460 participants (93.8% of those with available depression symptoms at year 4; 37.6% of the total sample) provide complete data, including ADHD measures at baseline, year 1, and/or year 2; ER at year 3; and depression measures at year 4. They record basic demographic information. They assess difficulties in emotion regulation using the Difficulties in Emotion Regulation Scale – Parent Report (DERS-P) at ages 12–13 (follow-up year 3), with caregivers reporting their perceptions of adolescents’ ER difficulties. They collect caregiver reports on youth behavioural problems annually using the ASEBA Child Behavior Checklist 6–18 (CBCL), additionally assess ADHD, and parent report using Kiddie Schedule for Affective Disorders and Schizophrenia – Computerized version (KSADS-COMP) ADHD module yearly across all time points. They classify youth as having a positive history of ADHD if they meet current or past diagnostic criteria for ADHD, or if they report a prior ADHD diagnosis at baseline or during follow-up years 1 or 2. Additionally, the team derives an ADHD Polygenic Score (PGS). The PGS represents a continuous measure of an individual’s genetic liability for ADHD, aggregating common genetic variants previously identified in large genome-wide association studies (GWAS). They conduct exploratory network analyses to examine associations among ADHD symptoms, emotion regulation domains, and later depressive symptoms. 

The authors report that Catastrophize and Distracted emerge as the most important emotion regulation (ER) bridge dimensions linking earlier ADHD symptoms to later depressive symptoms within the network. They identify two distinct pathways. Inattentive ADHD symptoms link to depressive symptoms (e.g., poor eating and feelings of worthlessness) through the Distracted ER dimension. In contrast, hyperactive-impulsive ADHD symptoms connect to depressed mood and anhedonia through the Catastrophize ER dimension. Network centrality analyses indicate that Catastrophize is significantly more influential in the overall network than the other ER domains. Using bridge centrality metrics, the authors determine that Distracted shows the highest bridge expected influence, followed by Catastrophize, Attuned, and Negative Secondary Emotions. Network invariance testing reveals significant structural differences between youth with a history of ADHD and those without such a history (p = .008). Additionally, centrality invariance analyses indicate significantly greater strength and expected influence of all ADHD items in the high polygenic score network (all ps = .004). 

The authors highlight the potential clinical implications of their findings as a strength, noting that bridge symptoms may help identify mechanisms underlying the co-occurrence of psychological disorders and represent promising targets for treatment and preventive interventions. They acknowledge several limitations – lower sample size for depression symptoms at year 4 due to attrition and incomplete data in ABCD Release 5.1; inability to conduct longitudinal network models as ER data were not widely collected until year 3, limiting tighter control over temporal effects; reduced power to detect significant differences in network comparisons by sex and ADHD diagnosis due to subgroup sample size reductions; use of a more inclusive method for estimating ADHD diagnosis, which may have attenuated network differences; conservative estimates resulting from correction for multiple comparisons; and limited ancestral diversity in polygenic score derivation samples, which were primarily based on individuals of European ancestry. 

The team concludes that their findings provide evidence for two distinct pathways linking ADHD symptoms to later depressive symptoms through emotion regulation difficulties in early adolescents from the ABCD Study. Specifically, they demonstrate that hyperactive-impulsive symptoms connect to later depression through catastrophizing when upset, whereas inattentive symptoms connect to depression through distractibility when upset. 

Taurines et al. (2025) address the frequent off-label use of psychotropic medications in child and adolescent psychiatry, noting that, for ethical reasons, psychopharmacotherapy cannot be withheld when clinically indicated. They highlight that psychotropic drugs are commonly prescribed off-label (i.e., outside marketing authorization with regard to age, indication, or duration), underscoring the need for further research and economic and legal incentives to encourage registration of off-patent drugs for pediatric populations. They conduct a multicenter study within the TDM-VIGIL consortium (Egberts et al., 2022) to investigate the frequency and types of off-label prescribing of antidepressants and antipsychotics in youth treated in routine clinical practice. They aim to characterize off-label use and identify potential correlates, including age, sex, diagnosis, illness severity, and treatment setting (outpatient versus inpatient; university versus non-university center). 

The team collects prospective data via a secure internet-based patient registry between October 2014 and December 2018 across 10 university hospitals, 7 state child and adolescent psychiatric hospitals in Germany, Switzerland, and Austria, and one private specialist practice. They include all inpatients, day-unit patients, and outpatients aged 4–18 years for whom clinicians initiate a new antidepressant or antipsychotic (including medication switchers). Exclusion criteria include absolute clinical contraindications and participation in another clinical trial. They include 700 patients (66.6% girls; 77.4% inpatients; 8.6% children <12 years) from a total of 710 TDM-VIGIL participants and follow them for a mean of 5.1 months. Clinicians code diagnoses according to ICD-10-GM. They assess illness severity using the Clinical Global Impression–Severity (CGI-S) scale and follow patients at a minimum of five time points from baseline to six months after discharge or end of outpatient treatment. They define four categories of off-label use: off-label by age, by indication, by treatment duration, and by both age and indication. They use single-level backward stepwise multivariable logistic regression analyses, and hierarchical logistic regression models for statistical analyses. 

The authors report that 70.0% of patients receive at least one off-label antidepressant or antipsychotic during the study. Overall, 66.7% (40 of 60) of children (age < 12 years) and 70.3% of adolescents (450 out of 640) (p = 0.659) had at least one treatment episode classified as being off-label. Off-label prescribing occurs in 55.2% of antidepressant episodes (51.1% by age; 37.4% by indication; 11.5% by both) and 81.7% of antipsychotic episodes (29.4% by age; 33.2% by indication; 37.4% by both). The most common reason for off-label use across medications is age (39.5%), followed by indication (35.1%). Polypharmacy is common, with 43.6% of patients receiving more than one psychotropic medication simultaneously. 

They find that sex, age (<12 versus ≥12 years), and illness severity do not significantly moderate off-label use. In antidepressant treatment, depression and obsessive-compulsive disorder diagnoses are associated with reduced off-label prescribing, whereas suicidality at admission is associated with increased off-label prescribing. In antipsychotic treatment, schizophrenia diagnoses are linked to reduced off-label use, while treatment in university hospitals is associated with increased off-label prescribing. They observe no significant moderating effect of suicidality in the overall sample. 

As strengths, the authors note that the study is conducted in specialized child and adolescent psychiatric centers, primarily inpatient settings, supporting diagnostic accuracy and treatment stratification. They also emphasize the prospective multicenter design and detailed individual-level data obtained through an internet-based registry. They acknowledge limitations – difficulty generalizing findings to all youth receiving psychotropic medications; lack of assessment of off-label use by dose; evaluation of Swiss treatment episodes according to German authorization regulations despite possible differences in Swissmedic approvals; and that the study is not designed to compare efficacy or safety of on-label versus off-label prescribing. 

The team concludes that they demonstrate a high frequency of off-label prescribing of antidepressants (approximately 55%) and particularly antipsychotics (approximately 82%) with respect to age and indication in specialized child and adolescent psychiatric centers across three European countries. They emphasize the need for economic and legal incentives to support testing and registration of psychotropic medications for pediatric indications. 

REFERENCES:  

• Egberts, K. M., Gerlach, M., Correll, C. U., Plener, P. L., Malzahn, U., Heuschmann, P., et al. Serious adverse drug reactions in children and adolescents treated on- and off-label with antidepressants and antipsychotics in clinical practice. Pharma­copsychiatry (2022). https://doi.org/10.1055/a-1716-1856.
• Saragosa-Harris, N. M., Chaku, N., MacSweeney, N., Guazzelli Williamson, V., Scheu­plein, M., Feola, B., et al. A practical guide for researchers and reviewers using the ABCD study and other large longitudinal datasets. Dev Cogn Neurosci 55, 101115 (2022). https://doi.org/10.1016/j.dcn.2022.101115
• Taurines, R., Gerlach, M., Correll, C.U. et al. Off-label drug use in children and adolescents treated with antidepressants and antipsychotics: results from a prospective multicenter trial. Child Adolesc Psychiatry Ment Health19, 110 (2025). https://doi.org/10.1186/s13034-025-00957-7
• Tharaud, J.B., Nikolas, M.A. Emotion regulation as a transdiagnostic link between ADHD and depression symptoms: evidence from a network analysis of youth in the ABCD study. Child Adolesc Psychiatry Ment Health19, 113 (2025). https://doi.org/10.1186/s13034-025-00966-6
• Wiggin, D., Ní Dhálaigh, D., McMahon, E. et al. Age of onset of self-harm in children and adolescents: a scoping review. Child Adolesc Psychiatry Ment Health 19, 128 (2025). https://doi.org/10.1186/s13034-025-00982-6
   

IACAPAP Bulletin, Issue 81