To what extent is the association between disability and mental health in adolescents mediated by bullying? A causal mediation analysis

Parental Report of Signs of Anxiety and Depression in Children and Adolescents with and Without Disability in Middle- and Low-Income Countries: Meta-analysis of 44 Nationally Representative Cross-Sectional Surveys

Population-based studies undertaken in high-income countries have indicated that children and adolescents with disabilities are more likely than their non-disabled peers to experience emotional difficulties such as anxiety and depression. Very little is known about the association between disability and emotional difficulties among children growing up in low and middle-income countries (LMICs). We aimed to estimate the strength of association between disability and two forms of emotional difficulties (anxiety, depression) in a range of LMICs and to determine whether the strength of this relationship was moderated by child age and gender. Secondary analysis of data collected in Round 6 of UNICEF's Multiple Indicator Cluster Surveys undertaken in 44 LMICs (combined n = 349,421). Data were aggregated across countries by both mixed effects multi-level modelling and restricted maximum likelihood meta-analysis. Young people with disabilities, when compared with their non-disabled peers, were approximately two and a half times more likely to be reported by parents to show daily signs of either anxiety or depression. The level of risk among young people with disabilities was highest in upper middle-income countries and lowest in low-income countries. We estimated that approximately 20% of young people with frequent anxiety or depression also had a disability. All approaches to mental health interventions (from primary prevention to clinical interventions) need to make reasonable accommodations to their services to ensure that the young people with emotional difficulties who also have a disability are not 'left behind'.

Disability-related inequalities in health and well-being are mediated by barriers to participation faced by people with disability. A causal mediation analysis

Large inequalities in health and well-being exist between people with and without disability, in part due to poor socio-economic circumstances, and potentially also related to societal factors including issues associated with accessibility and participation. To better understand the contribution of societal factors, we used a unique longitudinal survey of disability in Great Britain to quantify the extent to which barriers to participation contribute to poorer health and well-being. We used data from 2354 individuals who participated in three waves of the Life Opportunities Survey between 2009 and 2014 and compared five health and well-being outcomes (self-rated health, anxiousness, life satisfaction, life worth, happiness) between adults who acquired an impairment and those who remained disability-free. Causal mediation analysis was conducted to quantify how much of the effect of disability acquisition on each outcome was explained by barriers to participation in employment, economic life, transport, community, leisure and civic activities, social contact, and accessibility. People who recently acquired a disability had poorer health and well-being compared to people with no disability. Barriers to participation explained 15% of inequalities in self-rated health, 28% for anxiousness, 32% for life satisfaction, 37% for life worth, and 70% for happiness. A substantial proportion of the inequalities in health and well-being experienced by people with recently acquired disability were socially produced, driven by barriers to participation in different life domains. Furthermore, there was evidence that barriers to participation mediated the effect of well-being measured to a greater extent than the more clinically aligned measures, self-reported health and anxiousness. These findings highlight modifiable factors amenable to public health interventions that could lead to substantial improvements in health and well-being for people with disability.

"Because I've Got a Learning Disability, They Don't Take Me Seriously:" Violence, Wellbeing, and Devaluing People With Learning Disabilities

For people with learning disabilities, targeted violence has become routinized. In this article, we seek to explore the impact pervasive victimization has on their experience of community and participation and, through this, their health and wellbeing. People with learning disabilities experience significant inequality in health and wellbeing compared to their non-disabled peers, and the role of violence and victimization remains mostly neglected. By drawing on in-depth qualitative interviews with people with learning disabilities, we argue that abuse, disrespect and devaluing profoundly erode wellbeing. The complex forms of violence experienced by people with learning disabilities are critical to understanding the significant inequalities in health and wellbeing experienced by people with learning disabilities. We focus on community and misrecognition to move the focus from one that examines causation towards one that uncovers the layers of invisibility, and the complex relations that structure experiences from the perspective of people with learning disabilities themselves. By doing this, we locate violence and victimization as health and wellbeing concerns and seek to add a more comprehensive and holistic understanding of the social determinants of health. For the inequalities that structure the lives of people with learning disabilities to be holistically understood, they must be reframed as an issue of social justice, and violence must be identified as a central contributor to these inequalities.

The association between disability and risk of exposure to peer cyber victimisation is moderated by gender: Cross-sectional survey

BACKGROUND

Little is known about the exposure of youth with disability to cyber victimisation.

OBJECTIVE

/Hypothesis: To estimate the prevalence of peer cyber and non-cyber victimisation in a nationally representative sample of 14-year-old adolescents with and without disability and to determine whether gender moderates the relationship between disability and exposure to victimisation.

METHODS

Secondary analysis of data collected in Wave 6 of the UK's Millennium Cohort Survey on 11,726 14-year-old adolescents living in the UK.

RESULTS

Adolescents with disability had higher prevalence of cyber and non-cyber victimisation than those with no disability. For cyber victimisation there was a statistically significant interaction between gender and disability, with evidence of increased cyber victimisation for adolescents with disability compared to those with no disability among girls, but not boys. For non-cyber victimisation there was no evidence of an interaction between gender and disability.

CONCLUSIONS

The prevalence of both cyber and non-cyber victimisation was higher among adolescents with disability than those with no disability. The association between disability and risk of exposure to peer cyber victimisation appears to be moderated by gender.

Creating Learning Environments Free of Violence in Special Education Through the Dialogic Model of Prevention and Resolution of Conflicts

Violence suffered by children is a violation of human rights and a global health problem. Children with disabilities are especially vulnerable to violence in the school environment, which has a negative impact on their well-being and health. Students with disabilities educated in special schools have, in addition, more reduced experiences of interaction that may reduce both their opportunities for learning and for building protective social networks of support. This study analyses the transference of evidence-based actions to prevent violence in schools - the dialogic model of prevention and resolution of conflicts (DMPRC) - in the context of a special school, and its impact on the reduction of violence, the creation of egalitarian relationships, and the prevention of bullying. A case study with a communicative approach was conducted including in-depth interviews and communicative focus groups with the diverse participants to analyze the process of transformation carried out in the school and the main actions that give students a voice in the management and creation of egalitarian non-violent relationships. The results show that the inclusion of the students' voices in the resolution and prevention of conflicts reduces violence, empowers special education students, strengthens friendship relationships, caring behavior, and active positioning among the community. The positive impact of the transference of the DMPRC to special schools contributes to students' well-being and healthy development by offering safe and protective educational spaces and quality emotional education, also contributing to the achievement of the Sustainable Development Goals related to the elimination of all forms of violence in childhood.

What Do We Know about Bullying in Schoolchildren with Disabilities? A Systematic Review of Recent Work

Bullying is a serious problem that particularly affects schoolchildren with disabilities. However, studies in this group have been carried out on smaller cohorts and the results obtained are, therefore, less representative and sometimes inconclusive. The purpose of this paper is to perform a systematic review of the work carried out in recent years, including the analysis of several variables related to the sample, the methodology applied and the type of bullying. The guidelines set down by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement were followed in three phases. The total sample consisted of 55 children who fulfilled the inclusion criteria. The results reveal that half the studies were conducted in cohorts of less than 250 schoolchildren and drew no distinctions between the different types of disabilities. Furthermore, there is no consensus regarding the methodology used, and no specialized instruments were used. Hardly any specific interventions have been performed into the type of bullying investigated, in which victimization is the predominant mode. We concluded that there is an urgent need to increase the number of studies, including a larger number of individuals and using specialized instruments, in order to obtain more solid results. Such studies will allow us to create specific prevention and intervention programs to address the bullying of schoolchildren with disabilities.

Assessment of School Anti-Bullying Interventions: A Meta-analysis of Randomized Clinical Trials

IMPORTANCE

Bullying is a prevalent and modifiable risk factor for mental health disorders. Although previous studies have supported the effectiveness of anti-bullying programs; their population impact and the association of specific moderators with outcomes are still unclear.

OBJECTIVE

To assess the effectiveness of school anti-bullying interventions, their population impact, and the association between moderator variables and outcomes.

DATA SOURCES

A search of Ovid MEDLINE, ERIC, and PsycInfo databases was conducted using 3 sets of search terms to identify randomized clinical trials (RCTs) assessing anti-bullying interventions published from database inception through February 2020. A manual search of reference lists of articles included in previous systematic reviews and meta-analyses was also performed.

STUDY SELECTION

The initial literature search yielded 34 798 studies. Included in the study were articles that (1) assessed bullying at school; (2) assessed the effectiveness of an anti-bullying program; (3) had an RCT design; (4) reported results; and (5) were published in English. Of 16 707 studies identified, 371 met the criteria for review of full-text articles; 77 RCTs were identified that reported data allowing calculation of effect sizes (ESs). Of these, 69 independent trials were included in the final meta-analysis database.

DATA EXTRACTION AND SYNTHESIS

Random-effects and meta-regression models were used to derive Cohen d values with pooled 95% CIs as estimates of ES and to test associations between moderator variables and ES estimates. Population impact number (PIN), defined as the number of children in the total population for whom 1 event may be prevented by an intervention, was used as an estimate of the population impact of universal interventions targeting all students, regardless of individual risk.

MAIN OUTCOMES AND MEASURES

The main outcomes are the effectiveness (measured by ES) and the population impact (measured by the PIN) of anti-bullying interventions on the following 8 variable categories: overall bullying, bullying perpetration, bullying exposure, cyberbullying, attitudes that discourage bullying, attitudes that encourage bullying, mental health problems (eg, anxiety and depression), and school climate as well as the assessment of potential assocations between trial or intervention characteristics and outcomes.

RESULTS

This study included 77 samples from 69 RCTs (111 659 participants [56 511 in the intervention group and 55 148 in the control group]). The weighted mean (range) age of participants in the intervention group was 11.1 (4-17) years and 10.8 (4-17) years in the control group. The weighted mean (range) proportion of female participants in the intervention group was 49.9% (0%-100%) and 50.5% (0%-100%) in the control group. Anti-bullying interventions were efficacious in reducing bullying (ES, -0.150; 95% CI, -0.191 to -0.109) and improving mental health problems (ES, -0.205; 95% CI, -0.277 to -0.133) at study end point, with PINs for universal interventions that target the total student population of 147 (95% CI, 113-213) and 107 (95% CI, 73-173), respectively. Duration of intervention was not statistically significantly associated with intervention effectiveness (mean [range] duration of interventions, 29.4 [1 to 144] weeks). The effectiveness of anti-bullying programs did not diminish over time during follow-up (mean [range] follow-up, 30.9 [2-104] weeks).

CONCLUSIONS AND RELEVANCE

Despite the small ESs and some regional differences in effectiveness, the population impact of school anti-bullying interventions appeared to be substantial. Better designed trials that assess optimal intervention timing and duration are warranted.

Efficacy of a Web-Enabled, School-Based, Preventative Intervention to Reduce Bullying and Improve Mental Health in Children and Adolescents: Study Protocol for a Cluster Randomized Controlled Trial

Introduction: Bullying is a major preventable risk factor for mental disorders. Available evidence suggests school-based interventions reduce bullying prevalence rates. This study aims to test the efficacy of a web-enabled, school-based, multicomponent anti-bullying intervention to prevent school bullying and to assess its effects on mental health and quality of life. Methods and analysis: Cluster randomized controlled trial conducted in 20 publicly funded primary and secondary schools in Madrid, Spain. Schools are randomly allocated to either the intervention arm (n = 10) or conventional practices arm (n = 10). The web-enabled intervention (LINKlusive) lasts ~12 weeks and consists of three main components: (i) an online training program for teachers and parents, (ii) a web-guided educational program for students, focusing on promoting respect for diversity, empathy, and social skill development, and (iii) a web-guided, teacher-delivered, targeted intervention program for bullying situations identified based on peer-support strategies and individual intervention for those involved (i.e., bullying victims and perpetrators). The primary objective is to compare differences between peer-reported bullying victimization in the intervention and control arms at the end of the intervention. Secondary outcome measures are additional measures of bullying victimization and perpetration, mental health symptoms, self-esteem, and quality of life. A follow-up assessment is conducted 1 year after the end of the intervention. Treatment effects will be tested using multilevel mixed models, adjusting for school-, classroom-, and student-related covariates. Considering the increased bullying rates in children with special educational needs, a specific subgroup analysis will test the efficacy of the intervention on bullying prevalence, mental health, and quality of life in this particularly vulnerable population. Ethics and Dissemination: The Deontology Commission of the School of Psychology, Universidad Complutense in Madrid, Spain reviewed the study protocol and granted ethical approval on 21st January 2019. The results of the trial will be disseminated in relevant peer-reviewed journals and at conferences in the field. Trial Registration Number: ISRCTN15719015.

Youth with disabilities are more likely than their peers to engage in hazardous child labour

BACKGROUND

Little is known about the extent to which children and adolescents with disabilities are exposed to child labour.

OBJECTIVE

To estimate prevalence rates and adjusted rate ratios of exposure to child labour among children and adolescents with/without disability in middle- and low-income countries and to determine whether these rates vary between functional limitations associated with disability.

PARTICIPANTS AND SETTING

Nationally representative samples involving 142,499 children aged 5-14 from 15 countries.

METHODS

Secondary analysis of data collected in UNICEF's Multiple Indicator Cluster Surveys.

RESULTS

Overall children and youth with disability were not at significantly greater risk of exposure than children without disability to child labour when demographic and contextual factors were taken into account. However, children and youth with disability were at significantly greater risk of exposure than children without disability to hazardous child labour (adjusted relative risk [ARR] = 1.15 [1.10-1.21], P < 0.001). Specifically, children and youth with impairments related to poorer mental health or cognitive functioning were at significantly greater risk of exposure to hazardous child labour (e.g., ARR for learning impairment = 1.27 [1.14-1.42], P < 0.001). In contrast, children with impairments related to sensory functioning, mobility and expressive communication were at no greater risk of exposure than children with no disability.

CONCLUSIONS

Children and youth with disability are at greater risk of exposure to hazardous child labour than children with no disability in middle- and low-income countries. Responses to eradicate hazardous child labour need to take account of the situation of children and youth with disability.

Mental health of adolescents: variations by borderline intellectual functioning and disability

Adolescence is a period of elevated stress for many young people, and it is possible that the challenges of adolescence are different for vulnerable groups. We aimed to document the depressive and anxiety symptoms, emotional-behavioural difficulties and suicidal/self-harming behaviours among adolescents with borderline intellectual functioning (BIF) or a disability, compared to those with neither disability nor BIF. Data were drawn from the nationally representative Longitudinal Study of Australian Children. Participants were 2950 adolescents with complete data for waves 3-6 (years 2008-2014), aged 14-15 years in 2014. Anxiety and depression symptoms and self-harming/suicidal thought/behaviours were self-reported. Emotional-behavioural difficulties items came from the Strengths and Difficulties Questionnaire, and were parent-, and adolescent-reported. Results of logistic regression analyses indicate that the emotional-behavioural difficulties of adolescents with either a disability or BIF, were worse than for those with neither disability nor BIF. While adolescents with a disability reported more anxiety symptoms, no clear associations were observed for self-harming/suicidal thoughts/behaviours or depressive symptoms for those with either BIF or a disability. Adolescents with BIF or a disability are at higher risk of poor mental health than those with neither disability nor BIF, and it is vital that factors contributing to these differences are identified in order to reduce these mental health inequalities.

An intersectional approach to understandings of mental health inequalities among men with disability

Disability is a key social identity or social category that is associated with significant social disadvantage. For men, having a disability can be discordant with their masculine identity. Self-reliance is one component of masculinity that is known to be important to men with disabilities, however it is also known to be associated with adverse mental health outcomes in the broader adult male population. Intersectionality approaches offer a means of examining the way that the effect of self-reliance on mental health might vary between those with and without a disability. Among a sample of 12,052 men aged 18-55 years from the Ten-to-Men study, we used effect measure modification (EMM) to examine the way that self-reliance modifies the relationship between disability and depressive symptoms. Disability was assessed using the Washington Group Short Set of questions, which capture functional limitations. Results showed that men with disabilities who reported higher conformity to self-reliance norms had much worse mental health than non-disabled men with low conformity to self-reliance, as measured in terms of depressive symptoms (PRR: 9.40, 95%CI 7.88, 11.22, p-value<0.001). We found evidence of positive EMM of depressive symptoms by conformity to self-reliance on the additive scale (RERI: 2.84, 95%CI 1.26, 4.42, p-value<0.001). These results provide evidence that high conformity to self-reliance norms exerts a particularly damaging effect on the mental health of men with disabilities. Given that men with disabilities are more likely to rely on help and support from others, these results provide important insights for the delivery of services to men with disability.

Emotional difficulties and self-harm among British adolescents with and without disabilities: Cross sectional study

BACKGROUND

Little is known about the prevalence of emotional difficulties and self-harm among adolescents with a disability.

OBJECTIVE

Our aims were: (1) to estimate the prevalence of emotional difficulties and self-harm among British adolescents with and without disability; (2) to determine whether prevalence varies by gender, severity of disability and type of functional limitation associated with disability.

METHODS

Secondary analysis of age 14 data from the UK's Millennium Cohort Study.

RESULTS

Adolescents with disability reported significantly higher rates of emotional difficulties and self-harm than their non-disabled peers. Among participants with and without disability, prevalence rates were notably higher among girls for most outcomes. The strength of the association between disability and emotional difficulties and self-harm was greater for: maternal report of adolescent emotional difficulties; disabled adolescents with moderate/severe activity limitations; and adolescents with psychosocial impairments.

CONCLUSIONS

There is a clear need for providers of all mental health services to ensure that reasonable accommodations are made to services to ensure that they are responsive to the specific needs of adolescents with disabilities. Further research is needed to determine the extent to which our results can be generalised to adolescents in other settings, to specific subgroups of adolescents with disabilities, to other measures of emotional difficulties and to other informants. Future research is also needed to further explore the consistency and determinants of the intersection between gender by disability regarding adolescent mental health.