CAPMH Corner (Updated Mar 2025)

Child and Adolescent Psychiatry and Mental Health (CAPMH) is the official IACAPAP Journal. The "CAPMH Corner" of the March 2025 issue of IACAPAP Bulletin summarizes the following three studies recently published in CAPMH – Cannabinoids for treating psychiatric disorders in youth: a systematic review of randomized controlled trials (Köck et al., 2024), The apple does not fall far: stable predictive relationships between parents’ ratings of their own and their children’s self-regulatory abilities (Kneidinger et al., 2024), and Predictors of treatment outcome in higher levels of care among a large sample of adolescents with heterogeneous eating disorders (Reilly et al., 2024).

Köck et al., (2024) discuss the increasing use of medicinal cannabis (MC) for mental health conditions in the context of a global trend towards relaxing regulatory restrictions. They set out to evaluate the impact of cannabinoids on mental health outcomes and their safety in children, adolescents, and young adults by focusing on RCTs. They describe the endocannabinoid (EC) system and the pharmacokinetics and pharmacodynamics of tetrahydrocannabinol (THC) and cannabidiol (CBD).  

The authors conduct a systematic review of randomized controlled trials (RCT) conducted in human samples (until a maximum mean age of 25 years) where cannabinoids have been used for therapeutic purposes in the field of child, adolescent, and transitional age psychiatry published until 30th of June 2024 following the PRISMA guidelines. They conduct electronic searches on PubMed, Europe PubMed Central and EMBASE databases for their study. They use the Cochrane Risk of Bias 2 (RoB 2)-tool and assessment guidelines for analysis of risk of bias. They consider pre- and post-intervention measures and effect sizes as primary outcomes and dosages and adverse events as secondary outcomes. They conduct a meta-analysis for effect sizes of primary outcomes. They carry out subgroup analyses by treatment type, study duration (short- vs. long-term), and clinical indication. They use Q-statistics, I², and τ² to assess heterogeneity and correlation coefficients (r = 0.3, 0.7) for sensitivity analyses. They use R packages, including ‘correlation’ (Spearman rank), ‘ggplot2’ (visualization), ‘dplyr,’ and ‘tidyr’ (data processing) for analyses of dosage-effect and age-effect relationships. They also analyse age-stratified variations controlling for confounders. 

The team identifies 7603 records, of which eight independent clinical trials (reported in nine publications) met the pre-established eligibility criteria, comprising 474 unique participants (245 treatment, 229 control). They report a modest positive overall effect for symptom improvement or normalization of brain physiology (Hedges’ g = 0.308, 95% CI: 0.167, 0.448). Autism spectrum disorder studies showed the most consistent evidence (g = 0.264, 95% CI: 0.107, 0.421), while other conditions showed wider confidence intervals. Age-stratified analysis showed that adult populations (mean age 23.3 years, n = 5 outcomes) demonstrated higher effect sizes (g = 0.463, SD = 0.402) compared to pediatric populations (mean age 11.8 years, n = 8 outcomes; g = 0.318, SD = 0.212). Whole plant preparations (g = 0.328, 95% CI: 0.083, 0.573) and pharmaceutical cannabinoids (g = 0.292, 95% CI: 0.069, 0.515) showed comparable effects. CBD dosages ranged from 17.5 mg to 600 mg per day, with no significant correlation between dosage and effect size (ρ = -0.014, p = 0.963). They report mild to moderate side effects but no serious adverse events. The risk of bias assessment ranged from low (n = 3) to high (n = 5). 

The authors mention that this is the first review in the field of child, adolescent and young adult psychiatry assessing the RCTs of therapeutic use of cannabinoids. They conclude that there is a modest positive overall effect, and the use of cannabinoids is associated with few side effects and is generally well tolerated. However, they suggest that these results should be interpreted carefully due to the underlying heterogeneity in outcome measures, study populations, and intervention protocols. They add that varying approaches to outcome measurement and reporting strongly limit the evidential strength of their review. They suggest larger, well-controlled trials with standardized outcome measures to be conducted following a rigorous methodology, adequate sample sizes and longer-term follow-up. 

Kneidinger et al., (2024) describe self-regulatory abilities emphasizing their importance in human development and functioning including academic achievement and socio-emotional development. They highlight and describe the role of executive function and delay aversion and their susceptibility to interpersonal dynamics between caregivers and children. They discuss the role of family environment and parental characteristics in the development of children’s executive functions and the need to study this during the COVID-19 pandemic as parents additionally stepped in as surrogates for teachers. 

The authors establish a context to study the relationship between how parents view their own self-regulation skills and their perceptions of their child’s self-regulation. They set out to estimate the latent correlation between parents’ assessments of their own and their children’s executive functions and delay aversion and temporal stability of these ratings. They collect data from seven European countries through an anonymous digital survey (Leiner, 2024). For the present manuscript, they exclusively analyze the German data subset, as Germany was the only country where data was collected across two measurement time points. They distribute the survey to parents through various channels during timepoint-1 (T1) –via social media, school blackboards, parent networks, and support groups, and by email invitations during timepoint-2 (T2). They recruit 1,767 parents at T1 (April 28th to November 1st, 2020) and 1,082 at T2 (December 6th, 2020, to February 25th). They exclude mismatched data, entries with errors, and parents with children aged older than 18 years, and analyse data from 1,655 participants at T1 and 537 participants at T2. 

In addition to asking parents to rate their own and their children’s self-regulatory skills by indicating their agreement or disagreement on a Likert scale of a series of statements, the authors use the abbreviated versions of Childhood Executive Functioning Inventory (CHEXI), Adult Executive Functioning Inventory (ADEXI), Quick Delay Questionnaire (QDQ) instruments for assessments. They use hierarchical structural equation models (SEM) to estimate the latent correlation across multiple measurements and cross-lagged panel models to assess the directional influence of parents’ initial ratings on their later scores. 

The team reports the average age of the children was 11.45 years at T1 and 12.01 years at  T2, female children constituted 47.92% of the sample at T1 and 47.67% at T2, the mean age of parents was 43.04 years at T1 and 43.73 years at T2, with females comprising 85.86% of the sample at T1 and 87.15%  at T2. They report a substantial latent correlation (r = 0.48, p < 0.001) between parents’ and children’s executive function problems, indicating a shared variance of approximately 23%, and a latent correlation of r = 0.53 (p < 0.001) for delay aversion with significant within-timepoint and temporal stability. They found significant cross-lagged effects with parental executive functions at T1 predicting child executive functions at T2 (β = 0.16, p = 0.005) but no cross-lagged effects for delay aversion.  

While mentioning that this is the first study to examine intergenerational connections longitudinally, the authors acknowledge its strengths – a large sample size, sampling multiple age groups and including both parents, timing of the study during school closures that can provide real-time insights, and studying both the constructs of executive function and delay aversion. They also acknowledge its limitations – reliance on parental self-report measures, not using extensive standardized, validated measurements, and use of a correlational approach. They suggest future studies to incorporate multi-informant assessments, direct observations and neuropsychological testing and to explore the impact of other environmental factors to address these limitations. They conclude by emphasizing the role of family dynamics in shaping self-regulatory skills during childhood and adolescence. They highlight its clinical implications for interventions aimed at promoting positive developmental outcomes in children. 

Reilly et al., (2024) highlight the chronicity of eating disorders (EDs) and the role of higher levels of care (HLOCs) (including intensive out¬patient program (IOP), partial hospitalization program (PHP), residential (RES), and inpatient (IP) psychiatric and medical stabilization treatment programs) for treating individuals EDs. They discuss the need for empirically driven approaches that can drive clinical decision making and to address the research gaps, they set out to study the effectiveness of different HLOCs. Treatments were provided at the IP, RES, PHP, and IOP levels of care. 

The authors conduct a study to evaluate changes in self-reported ED symptoms, depression, anxiety, and objectively measured body weight in adolescents with transdiagnostic EDs during intensive treatment. They also test predictors of change in outcome variables (ED symptoms; depression; anxiety; body weight; binge eating episodes; self-induced vomiting), including anorexia nervosa subtype, psychiatric comorbidities, ED diagnosis, age, and severity of ED symptoms at admission. They recruit 1,971 participants aged 9–18 years (M = 14.84, SD = 1.64) who enrolled in an ED treatment center at one of 25 geographically distinct treatment locations across the United States. They use semi-structured interviews informed by the Diagnostic and Statistical Manual for Mental Disorders, 5th Edition criteria, Eating Disorder Examination Questionnaire (EDE-Q), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), a measure of percentage of estimated body weight for data collection at intake to treatment, first step-down to a lower level of care, and discharge from treatment (i.e., within 7 days of discharge) controlling for age at admission and length of stay. 

The team uses the r2glmm package in R to estimate effect sizes, expressed as a partial R. They calculate the percentage of participants reporting reliable change in symptoms, we used the reliable change index (RCI) outlined by Jacobson and Truax. They use Bonferroni correction for determining the statistical significance threshold (0.05/17 = 0.003) for the different models tested across aims. They also conduct post-hoc analyses exploring the effect of geographical region of treatment site, coded as a dummy variable based on U.S. Census regions (e.g., Midwest; Northeast; South; West, with South as the reference group) controlling for levels of care within these analyses. 

The sample comprised of mostly white (80.6%), cisgender females (85.3%) diagnosed with anorexia nervosa (60.6%). The total mean length of stay was 79.97 days (SD = 49.56 days), and the mean length of stay at each level of care ranged from 25.93 days for IP treatment (SD = 20.76) to 45.49 days in IOP (SD = 22.16). The authors report that participants at admission reported ED symptoms at levels that were around 1.5 standard deviations above adolescent community norms, endorsed a mean level of depressive symptoms in the moderately severe range and anxiety symptoms in the moderate range. They note a decrease in eating disorder symptoms (in 50% of the sample) and depression and anxiety (in 30% of the sample) from intake to discharge. Based on their predictor analyses, they suggest that psychiatric comorbidity, primary diagnosis, age, and eating disorder symptoms at admission consistently predicted treatment-related change, although patterns in findings varied across symptoms. 

The authors mention that this is the largest study to date characterizing treatment outcomes in HLOCs for adolescent EDs. They also acknowledge its limitations – homogeneous (in gender, race, and ethnicity) sample limiting generalizability of the results, lack of follow-up, use of self-report measures, and missing data. Overall, results indicated that adolescents demonstrated decreases in ED symptoms, anxiety, and depression over time, with the most consistent clinically significant benefit occurring for ED cognitive symptoms and weight, indeed the main indication for their admission. They conclude that adolescents enrolled in higher levels of care report clinical benefit; however, these effects are heterogenous, and a significant portion of individuals may not report reliable change in symptoms. 

REFERENCES:  

• Kneidinger, J., García Alanis, J.C., Steinmayr, R. et al. The apple does not fall far: stable predictive relationships between parents’ ratings of their own and their children’s self-regulatory abilities. Child Adolesc Psychiatry Ment Health 18, 125 (2024). https://doi.org/10.1186/s13034-024-00814-z.  
• Köck, P., Badek, A., Meyer, M. et al. Cannabinoids for treating psychiatric disorders in youth: a systematic review of randomized controlled trials. Child Adolesc Psychiatry Ment Health 18, 158 (2024). https://doi.org/10.1186/s13034-024-00846-5.   
• Leiner, D.J. SoSci Survey [Internet]. 2024. https://www.soscisurvey.de.  
• Reilly, E.E., Gorrell, S., Duffy, A. et al. Predictors of treatment outcome in higher levels of care among a large sample of adolescents with heterogeneous eating disorders. Child Adolesc Psychiatry Ment Health 18, 131 (2024). https://doi.org/10.1186/s13034-024-00819-8.  

IACAPAP Bulletin, Issue 77