CAPMH Corner (Updated Sep 2024)

Child and Adolescent Psychiatry and Mental Health (CAPMH) is the official IACAPAP Journal. The "CAPMH Corner" of the Sep 2024 issue of IACAPAP Bulletin summarises the following three studies recently published in CAPMH – The importance of mother-child interaction on smart device usage and behavior outcomes among toddlers: a longitudinal study (Chakranon et al., 2024), Acute response to the October 7th hostage release: rapid development and evaluation of the novel ReSPOND protocol implementation within a children’s hospital (de la Fontaine et al., 2024) and Subclinical patterns of disordered eating behaviors in the daily life of adolescents and young adults from the general population (Peschel  et al., 2024).

Chakranon et al., (2024) highlight the need to investigate the impact of screen time and media content exposure during the ages of 1–3 years on children’s behavioral performance at 3 years. They explore the modifying effects of mother–child interactions considering confounders like parental age, maternal education, maternal depression, parity, the child’s sex, and pregnancy outcomes including preterm birth and low birthweight status. 

The authors use data from the Longitudinal Examination Across Prenatal and Postpartum Health in Taiwan (LEAPP-HIT), an ongoing prospective study initiated in 2011 in Taipei, Taiwan. Data were collected during early pregnancy (before 16 gestational weeks – baseline) and at four postnatal time points (1 month, 1 year, 2 years, and 3 years postpartum). The sample includes children born between November 2016 and July 2020, expected to complete the CBCL questionnaire at age 3 (n = 506). Among these participants, 229 were lost to follow-up, leaving 277 participants remaining for the final analysis. A comparison between the included and excluded participants reveals no significant differences in parental sociodemographic or child characteristics. They employ Group-based trajectory modeling (GBTM) to determine changes in children’s screen time and mother–child interaction patterns at ages 1, 2, and 3 years. They carry out descriptive statistics – two-sample t tests for continuous variables and chi-squared or Fisher’s exact tests for categorical variables; repeated-measures analysis of variance (ANOVA) to examine changes in smart device usage between ages 1-3 years; multiple linear regression models to evaluate the association between screen time trajectories, media content consumption, and children's behavioral performance at age 3. 

The authors report a high proportion of children with extensive screen time had unemployed mothers (p = 0.02) and fathers with low education levels (p = 0.002); children with higher exposure to communication content tended to have younger and more multiparous mothers (p < 0.001). They report that usage significantly increased from 60 min/day at age 1 to 142 min/day by age 3 (p < 0.001) and that the proportions of exposure to educational, cartoon, and communication content all exceeded 40% by the age of three years. They note that between the ages of 1 and 3 years, compared with a slight increase in screen time, a considerable increase in screen time was associated with poorer behavioral outcomes. This finding was particularly evident when mother-child interaction levels were lower. In children with higher mother–child interaction levels, higher exposure to educational content was associated with fewer somatic complaints (aβ = −0.42, 95% CI = − 0.83 to − 0.01, p = 0.02). Conversely, in children with lower levels of mother–child interaction, higher exposure to educational content was associated with more aggressive behaviors (aβ = 4.38, 95% CI = 0.59 to 8.16, p = 0.04) and more externalizing behaviors (aβ = 5.19, 95% CI = 0.67 to 9.70, p = 0.03). 

The team acknowledges strengths such as the longitudinal design, evaluation of behavioral challenges across domains, and inclusion of sociodemographic and depression variables, along with limitations like shared variance bias, difficulty distinguishing specific applications (e.g., YouTube), limited generalizability, social desirability & recall bias from self-reports, and a high attrition rate (54%). They conclude by highlighting the crucial role of mother-child interactions in ameliorating the effects of early smart device usage – including screen time and media content like games and cartoons, starting from 1 year. They recommend future research on children’s self-regulation in managing smart device usage, the impact of father-child interactions, and longitudinal studies through adolescence for a comprehensive understanding of the related pathways. 
 

de la Fontaine et al., (2024) pointing to the shortcomings of the existing protocols that did not meet the needs of hospitals handling hostages from the October 7th, 2023 Hamas attack emphasize the need to enhance hospitals’ preparedness for delivering effective emergency responses to victims of terrorism and mass casualty events. They aim to outline the principles guiding Safra Children’s Hospital at Sheba Medical Center in treating Israeli hostages held for over 50 days and discuss the development of a new protocol for receiving and caring for both child and adult hostages in a children’s hospital setting. 

The team forms an interdisciplinary focus group of senior staff, including adult and pediatric physicians, psychiatrists, psychologists, social workers, nurses, and Public Relations personnel, to develop and implement a protocol for the reception and care of hostages. They meet once or twice weekly to define and facilitate the implementation of protocol guidelines, moderated by the Director of the Children’s Hospital. A rapid, non-systematic literature review on captivity and trauma is conducted, incorporating local expert guidelines and international input to develop specific guidelines. The group produces a consensus document outlining key principles for the care of hostages, with attention to the needs of pediatric hostages, parent-child dyads, and families. These guidelines are reviewed by the Israeli Child National Council and further adapted by clinical leaders for staff training. 

The authors develop the ReSPOND protocol, consisting of: Readiness of teams via multifaceted trainings, utilizing live simulations and video debriefings; Specialized professional teams experienced in providing holistic trauma-informed care; Personalized care tailored to individualized and developmentally-informed needs; Optimal safety rooted in creating a secure environment and trauma-informed response to young children, adolescents, caregivers and families; and Navigating Discharge, through coordination with community-based care systems. 

They report admitting twenty-nine hostages, including 8 children (mean age 11.47) and 21 adults (mean age 52.43), to Sheba Medical Center between November 25th and 30th, 2023. Most stayed 24 to 72 hours, except for one child who remained for a week due to her caregiver’s delayed release by Hamas.  

They mention that in the aftermath of providing acute response to returnees, several team members sought professional emotional support, senior psychiatrists and psychosocial staff were readily available to provide support and that supervisors initiated personal check-ins with their teams, and several attempts were made to provide structured group-based support. The team provides personalized care addressing the unique medical and psychological symptoms of the returnees. They ensure optimal safety triaging the care and provide pertinent guidelines to all family members as part of the preparation for returnee arrival and throughout admission. They mention that coordinating discharge was challenging as most returnees lost their homes and communities and were relocated to temporary lodgings across the country. They report conducting multi-agency conferences for each returnee and family to ensure continued care aligned with their personalized needs. 

The authors highlight key strengths, including the decision to provide care for returnees and their families in the Children’s Hospital under the leadership of the child and adolescent team, and the pre-event training, which recognized the diverse needs of returnees and incorporated tailored simulations for hostages across all ages. However, they note limitations such as staff operating during a national mass trauma event, the displacement of returnees to temporary lodgings complicating continued care, and limited contact with returnees post-discharge. They mention that the use of proxy-clinician reports may have underestimated post-captivity symptoms. They conclude by emphasizing the creation of a developmentally informed, multidisciplinary protocol for trauma response, proving effective despite these challenges. 
 

Peschel et al., (2024) discuss the limitations of studies on Disordered Eating Behaviors (DEBs) in adolescents and young people and underscore the need to study the distinct patterns of DEBs in young non-clinical people. They conduct the present study with an aim to explore phenotypes and group sizes of subclinical patterns of DEBs reported in everyday life via smartphone-based ecological momentary assessment (EMA) in adolescents and young adults from the general population without lifetime EDs.  

The authors analyse baseline data from the first cohort of the Behavior and Mind Health (BeMIND) study (Beesdo-Baum et al., 2020). The BeMIND study is a comprehensive cross-sectional and longitudinal cohort study investigating health and disease in adolescents and young adults aged 14–21 from Dresden, Germany. In 2015, a random age- and sex-stratified sample was drawn from the city’s population registry and contacted by mail, with up to two reminders. The team recruits a total of N = 1,180 participants at baseline (participation/response rate: 21.7%), most frequent reasons indicated for non-participation were lack of time and lack of interest. From the initial sample of 1,180, they excludes 111 (9.4%) due to a lifetime ED or other specified ED/UFED diagnosis; 103 for methodological reasons, such as incomplete or unreliable EMA data. The final sample included 966 participants (81.9% of the total), with 537 females and 429 males. 

Participants undergo a comprehensive baseline assessment, including diagnostic (Munich Composite International Diagnostic Interview), experimental, and biomarker procedures; two in-person appointments, about 7 days apart, involving self-report questionnaires on a tablet; between appointments; and complete EMA and an online assessment with additional questionnaires. Questionnaires used for assessment include the – German version of the depression module of the Patient Health Questionnaire (PHQ-9), German version of the Cross-Cutting Dimensional Anxiety Scale (Cross-D), German version of the Childhood Trauma Questionnaire (CTQ), short scale for Measuring General Self-efficacy Beliefs (ASKU), single-Item Self- Esteem Scale (SISE), the Emotion Regulation Skills Questionnaire (ERSQ), Relationship Questionnaire (RQ) and the Oslo-3-Items-Social-Support Scale. They assess self-reported severities of four distinct DEBs throughout the EMA period. The team uses the Bayesian information criterion (BIC) and sample size-adjusted BIC (SABIC) for the exploratory Latent Profile Analyses (LPA), test two model specifications: (a) equal variances/covariances and (b) varying variances/covariances. Since (a) produced poor entropy values (<0.55), (b) was retained. Continuous correlates were z-standardized, with beta-coefficients interpreted as Cohen’s d. Effect sizes: 0.2–<0.5 (small), 0.5–<0.8 (medium), >0.8 (large).  

They categorize profiles as no DEBs (females n = 173, 32.2%; males n = 160, 37.3%), high-mixed DEBs (females n = 168, 31.3%; males n = 117, 27.3%), and low-mixed DEBs (females n = 196, 36.5%; males n = 152, 35.4%). In "no DEBs" group, all DEBs were near zero. "High-mixed DEBs" had elevated levels, especially restrained eating, while "low-mixed DEBs" showed mildly elevated levels of all DEBs. Validation analyses for females revealed that, compared to the no DEBs profile, the low- and high-mixed profiles had higher depressive symptoms, lower body satisfaction, social support, and higher physical neglect. The low-mixed profile showed increased maternal indifference, while the high-mixed profile had higher anxiety, dieting, eating as a means of coping, poor emotion regulation, and attachment issues. Effect sizes were small. Validation analyses for males showed that both the high- and low-mixed profiles had higher odds of dieting and higher scores in preoccupied attachment compared to the no DEBs profile. The high-mixed profile also had greater lifetime weight-, shape-, and eating concerns, lower body satisfaction, higher physical neglect, and elevated maternal/paternal abuse, indifference, and paternal over-control compared to the no DEBs-profile. Effect sizes were mostly small. 

The authors acknowledge limitations including the cross-sectional nature of the study, a short EMA-assessment period, limited DEB indicators, and a lack of sampling weights. Additionally, the sample had high education levels, more females, and fewer older participants, affecting generalizability. They conclude that subclinical DEBs are common in adolescents and linked to increased risk factors and impaired psychological functioning warranting clinical attention for DEBs, even at non-clinical levels. 
 

REFERENCES:  

• Beesdo-Baum K, Voss C, Venz J, Hoyer J, Berwanger J, Kische H, et al. The behavior and Mind Health (BeMIND) study: methods, design and baseline sample characteristics of a cohort study among adolescents and young adults. Int J Methods Psychiatr Res. 2020;29(1):e1804.  
• Chakranon, P., Huang, JP., Au, HK. et al. The importance of mother-child interaction on smart device usage and behavior outcomes among toddlers: a longitudinal study. Child Adolesc Psychiatry Ment Health 18, 79 (2024). https://doi.org/10.1186/s13034-024-00772-6.  
• de la Fontaine, N., Silberg, T., Fegert, J.M. et al. Acute response to the October 7th hostage release: rapid development and evaluation of the novel ReSPOND protocol implementation within a children’s hospital. Child Adolesc Psychiatry Ment Health 18, 76 (2024). https://doi.org/10.1186/s13034-024-00767-3.  
• Peschel, S.K.V., Sigrist, C., Voss, C. et al. Subclinical patterns of disordered eating behaviors in the daily life of adolescents and young adults from the general population.Child Adolesc Psychiatry Ment Health 18, 69 (2024). https://doi.org/10.1186/s13034-024-00752-w. 
   

IACAPAP Bulletin, Issue 75