CAPMH Corner

By: Lakshmi Sravanti, India, Associate Editor, CAMPH

Child and Adolescent Psychiatry and Mental Health (CAPMH) is the official journal of the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP). It is an open-access journal that publishes clinically relevant research from around the world. IACAPAP Bulletin is introducing “CAPMH Corner”, a column to summarize prominent studies published in CAPMH. The first article under this column summarizes three studies – examining the effectiveness of a school-based universal preventive programme (Urao et al., 2021), estimating PTSD symptoms in adolescents from LMICs (Stupar et al., 2021), and exploring impact of COVID-19 pandemic on Child and Adolescent Psychiatrists (DiGiovanni et al., 2021) respectively.

Urao et al., (2021) note the importance of school-based universal preventive programmes, especially CBT-based interventions to reduce psychiatric morbidity in children. They highlight the inconsistencies in establishing efficacy of the WHO-recommended FRIENDS programme by laying focus on studies done in the Japanese population. The team had developed a CBT-based universal preventive program for children called “Journey of the Brave” (Urao et al., 2016). The primary objective of their current study is to examine its effectiveness when it is carried out by teachers during school hours. They conduct a large scale non-randomized study enrolling 27 elementary schools from three prefectures.

Journey of the Brave (JOB) consists of ten standardized CBT (Cognitive Behavioural Therapy) sessions, each of 45min duration. Teachers undergo training in a 6-hour facilitator workshop to deliver the programme. The primary outcome is changes in the SCAS (Spence Children’s Anxiety Scale) – Japanese version scores. Fifth or sixth graders (n = 2745) are assigned to intervention arm (programme sessions and SCAS surveys) or control arm (regular classes and SCAS surveys) and followed-up one to three months later. The team analyses data using mixed-effects model for repeated measures (MMRM). Authors report a significant reduction in the anxiety scores in the intervention group as compared to the control group from baseline to follow-up. They state that this is the first large scale controlled trial of the JOB, however the follow-up duration of three months is relatively short, objective tools were not used and the programme fidelity was not measured. In view of these methodological limitations, they suggest a more robust long-term follow-up study or a cluster randomised control trial (c-RCT) to confirm effectiveness of the programme.

Stupar et al., (2021) emphasize the need for epidemiological studies to estimate the prevalence of post-traumatic stress disorder (PTSD) in trauma-exposed adolescents in low-and middle income countries (LMICs) due to limited data available from these countries. They emphasize the need for judicious use of the inadequate health resources in LMICs and highlight that prevalence estimates can inform resource allocation. The team carry out a large project with an objective to assess multiple aspects of adolescent psychopathology with the support of International Child Mental Health Study Group (ICMH – SG). A part of their project seeks to assess the types of traumatic events experienced and the presence and predictors of PTSD symptoms in adolescents exposed to traumatic event/s in the preceding year.

Adolescents (12-18yrs old) are recruited by simple random sampling from at least five secondary schools from each location (with equal distribution of rural and urban communities) identified as a local, administrative or a political zone in 10 LMICs (Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, the Palestinian Territories, the Philippines, Romania, and Serbia) and one high-income country (Portugal) that serves as a reference. A sample (n = 3370) with history of traumatic events is assessed for PTSD symptoms using the UCLA PTSD Reaction Index for DSM-5 (PTSD – RI – 5) modified to ensure cultural acceptance. Authors use analysis of variance (ANOVA) and chi-square test to evaluate age and gender differences respectively. The estimates of a likely diagnosis of PTSD range from 6.2% (Indonesia) to 15.3% (Palestine and Nigeria). Approximately half of the study sample (n = 1725; 51.2%) report three or more traumatic events experienced in the year preceding data collection. Death of a close person (69.7%) is the most frequently reported traumatic event.

Authors conclude that younger adolescents, and those with a history of exposure to war or having been forced to have sex or with more severe PTSD symptoms (especially avoidance) are at a greater risk of having PTSD. They infer from this study that there is a need for collaboration between health and social care services sector to devise joint policies and care pathways and suggest a stepped care approach to reduce strain on the limited health care services available in LMICs. They attribute the observed differences in traumatic events and symptoms between their findings and previous studies to neurobiological and cross-cultural variations and recommends future research to focus on the cultural differences in PTSD propensity.

DiGiovanni, Weller, and Martin (2021) set out to speculate the direction of possible changes in the CAMHS (child and adolescent mental health services) post-pandemic. They view the pandemic as a catalyst that could open up ways to new possibilities and child and adolescent psychiatrists (CAPs) as being in a unique position who deliver services to manage the psychosocial impact of the ongoing crisis. Authors describe the response to the pandemic and a surge in social justice activism on a background of systemic racism as competing urgencies in the United States. Thus, they establish a context to explore the impact of COVID-19 pandemic on personal and professional lives of child and adolescent psychiatrists by conducting a qualitative study.

They conduct in-depth semi-structured interviews, with a component of photo-elicitation and a reflective exercise using sensitizing questions in a purposive sample (n=24) to explore what is a uniquely American experience. They analyse the transcripts using Braun and Clarke’s six-step method of thematic analysis, adopting an inductive approach and identify “pivot points” (“the shifting of existing momentum in a new direction”). Unsettling (“who have we been?”), adaptation (“who are we now?”) and reimagination (“who will we become?”) are the three overarching themes that emerge from their analysis. Participants envision improved practices arising from dissatisfactions exposed by the pandemic.

The team concludes that the pandemic has assisted CAPs in realizing the field’s strengths with a renewed sense of purpose to stay committed to their profession. It has also brought the underlying discontents to the forefront and accelerated the need for a shift in practices toward a reimagined future. Pandemic-driven posttraumatic growth will depend on the way CAP leadership handles the discontents and hopes identified. Authors recommend a follow-up study as the impact of factors such as participant’s age, career stage and family status on the nature of response to the pandemic and social justice activism remain unexplored.

DiGiovanni, M., Weller, I. & Martin, A. Pivoting in the pandemic: a qualitative study of child and adolescent psychiatrists in the times of COVID-19. Child Adolesc Psychiatry Ment Health 15, 32 (2021).

Stupar, D., Stevanovic, D., Vostanis, P. et al. Posttraumatic stress disorder symptoms among trauma-exposed adolescents from low- and middle-income countries. Child Adolesc Psychiatry Ment Health 15, 26 (2021).

Urao, Y., Yoshinaga, N., Asano, K. et al. Effectiveness of a cognitive behavioural therapy-based anxiety prevention programme for children: a preliminary quasi-experimental study in Japan. Child Adolesc Psychiatry Ment Health 10, 4 (2016).

Urao, Y., Ohira, I., Koshiba, T. et al. Classroom-based cognitive behavioural therapy: a large-scale non-randomised controlled trial of the ‘Journey of the Brave’. Child Adolesc Psychiatry Ment Health 15, 21 (2021).


IACAPAP Bulletin, Issue 63