Measuring PROMIS® Emotional Distress in Early Childhood

Subclinical, long-term psychological symptoms following sport-related concussion: are athletes more depressed than we think?

INTRODUCTION

In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms.

METHODS

A cohort study was conducted of athletes 12-24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used.

RESULTS

Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247-420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04).

CONCLUSIONS

Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

Evaluation instruments for executive functions in children and adolescents: an update of a systematic review

INTRODUCTION

The aim of this study is to update a systematic review of instruments for evaluating the executive functions (EFs) in a pediatric population to assess their measurement properties.

AREA COVERED

Studies describing evaluation tools of EFs were systematically searched on four electronic databases: PubMed, EBSCO, Scopus, and Web of Science. To be included studies had to be on a population aged 0 to 18 were included. The individuals were either healthy or presented a neurodevelopment disorder. Risk of Bias was evaluated through the Consensus-based Standards to select the health Measurement Instruments (COSMIN).

EXPERT OPINION

The search was conducted on April 2023. Eighty-four papers met the inclusion criteria and were included in the study; the studies refer to 72 different evaluation tools of EFs. Most of the studies analyzed through a methodological quality analysis received an 'adequate' score. The instrument most mentioned was the Behavior Rating Inventory of Executive Function-2 (BRIEF2) in seven articles.

Computerized adaptive testing to screen pre-school children for emotional and behavioral problems

Questionnaires to detect emotional and behavioral (EB) problems in preventive child healthcare (PCH) should be short; this potentially affects their validity and reliability. Computerized adaptive testing (CAT) could overcome this weakness. The aim of this study was to (1) develop a CAT to measure EB problems among pre-school children and (2) assess the efficiency and validity of this CAT. We used a Dutch national dataset obtained from parents of pre-school children undergoing a well-child care assessment by PCH (n = 2192, response 70%). Data regarded 197 items on EB problems, based on four questionnaires, the Strengths and Difficulties Questionnaire (SDQ), the Child Behavior Checklist (CBCL), the Ages and Stages Questionnaire: Social Emotional (ASQ:SE), and the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). Using 80% of the sample, we calculated item parameters necessary for a CAT and defined a cutoff for EB problems. With the remaining part of the sample, we used simulation techniques to determine the validity and efficiency of this CAT, using as criterion a total clinical score on the CBCL. Item criteria were met by 193 items. This CAT needed, on average, 16 items to identify children with EB problems. Sensitivity and specificity compared to a clinical score on the CBCL were 0.89 and 0.91, respectively, for total problems; 0.80 and 0.93 for emotional problems; and 0.94 and 0.91 for behavioral problems.    Conclusion: A CAT is very promising for the identification of EB problems in pre-school children, as it seems to yield an efficient, yet high-quality identification. This conclusion should be confirmed by real-life administration of this CAT. What is Known: • Studies indicate the validity of using computerized adaptive test (CAT) applications to identify emotional and behavioral problems in school-aged children. • Evidence is as yet limited on whether CAT applications can also be used with pre-school children. What is New: • The results of this study show that a computerized adaptive test is very promising for the identification of emotional and behavior problems in pre-school children, as it appears to yield an efficient and high-quality identification.

Future Directions: The Phenomenology of Irritable Mood and Outbursts: Hang Together or Hang Separately1

Recognition of the importance of irritable mood and outbursts has been increasing over the past several decades. This "Future Directions" aims to develop a set of recommendations for future research emphasizing that irritable mood and outbursts "hang together," but have important distinctions and thus also need to "hang separately." Outbursts that are the outcome of irritable mood may be quite different from outbursts that are the trigger or driving force that make youth and his/her environment miserable. What, then, is the relation between irritable mood and outbursts? As the field currently stands, we not only cannot answer this question, but we may also lack the tools to effectively do so. Here, we will propose recommendations for understanding the phenomenology of irritable mood and outbursts so that more directed and clinically useful assessment tools can be designed. We discuss the transdiagnostic and treatment implications that relate to improvements in measurement. We describe the need to do more than repurpose our current assessment tools, specifically interviews and rating scales, which were designed for different purposes. The future directions of the study and treatment of irritable mood and outbursts will require, among others, using universally accepted nomenclature, supporting the development of tools to measure the characteristics of each irritable mood and outbursts, understanding the effects of question order, informant, development and longitudinal course, and studying the ways in which outbursts and irritable mood respond to treatment.

The Emotion Dysregulation Inventory-Young Child: Psychometric Properties and Item Response Theory Calibration in 2- to 5-Year-Olds

OBJECTIVE

The Emotion Dysregulation Inventory (EDI) was designed and validated to quantify emotion dysregulation (ED) in children aged 6+ years. The purpose of this study was to adapt the EDI for use in young children (EDI-YC).

METHOD

Caregivers of 2,139 young children (aged 2-5 years) completed 48 candidate EDI-YC items. Factor and item response theory (IRT) analyses were conducted separately for clinical (neurodevelopmental disabilities; N = 1,369) and general population (N = 768) samples. The best-performing items across both samples were selected. Computerized adaptive testing simulations were used to develop a short-form version. Concurrent calibrations and convergent/criterion validity analyses were performed.

RESULTS

The final calibrated item banks included 22 items: 15 items for Reactivity, characterized by rapidly escalating, intense, and labile negative affect, and difficulty down-regulating that affect; and 7 items for Dysphoria, characterized primarily by poor up-regulation of positive emotion, as well an item each on sadness and unease. The final items did not show differential item functioning based on age, sex, developmental status, or clinical status. IRT co-calibration of the EDI-YC Reactivity with psychometrically robust measures of anger/irritability and self-regulation demonstrated its superiority in assessing emotion dysregulation in as few as 7 items. EDI-YC validity was supported by expert review and its association with related constructs (eg, anxiety, depression, aggression, temper loss).

CONCLUSION

The EDI-YC captures a broad range of emotion dysregulation severity with a high degree of precision in early childhood. It is suitable for use in all children aged 2 to 5 years, regardless of developmental concerns, and would be an ideal broadband screener for emotional/behavioral problems during well-child checks and to support early childhood irritability and emotion regulation research.

Improvements in sleep problems and their associations with mental health symptoms: A study of children and adolescents participating in a digital mental health intervention

Objective

A growing number of youth are utilizing digital mental health interventions (DMHIs) for treatment of mental health problems such as anxiety, depression, and ADHD. Although these mental health symptoms are closely related to sleep problems, it is unknown whether nonsleep DMHIs indirectly confer improvements in sleep. Using retrospective data, the current study assesses (1) whether youth sleep problems improve over participation in a nonsleep DMHI, and (2) whether mental health symptom severity and improvement are correlated with sleep problem severity over time.

Methods

Sleep problems and mental health symptoms were assessed every 30 days among children (ages 5-12) and adolescents (ages 13-17) participating in a pediatric digital mental health intervention (DMHI; N = 1219).

Results

Children and adolescents with elevated sleep problems (39.3%; n = 479) were older (P < .001), more predominantly female (P < .001), and more likely to have elevated anxiety (P < .001), depressive (P < .001) and inattention symptoms (P = .001), as compared to those with nonelevated sleep problems (60.7%; n = 740). From the baseline to last assessment, 77.3% (n = 269) of members with elevated sleep problems exhibited improvements, with sleep problems decreasing significantly over each month in care (P < .001). Members with improvements in anxiety, depressive, and/or ADHD symptoms had larger improvements in sleep over time compared to their peers with no improvement in their mental health symptoms (Months in care*Change type: P < .001 for all).

Conclusions

Our results provide preliminary evidence that participation in a pediatric DMHI is associated with improvements in sleep problems, even when youth are not being treated directly for sleep problems. These findings highlight a valuable secondary benefit of participating in mental health care within pediatric DMHIs and warrant further experimental research.

Exploring the Number of Web-Based Behavioral Health Coaching Sessions Associated With Symptom Improvement in Youth: Observational Retrospective Analysis

BACKGROUND

Rates of anxiety and depression have been increasing among children and adolescents for the past decade; however, many young people do not receive adequate mental health care. Digital mental health interventions (DMHIs) that include web-based behavioral health coaching are widely accessible and can confer significant improvements in youth anxiety and depressive symptoms. However, more research is necessary to determine the number of web-based coaching sessions that confer clinically significant improvements in anxiety and depressive symptoms in youth.

OBJECTIVE

This study uses data from a pediatric DMHI to explore the number of web-based coaching sessions required to confer symptom improvements among children and adolescents with moderate or moderately severe symptoms of anxiety and depression.

METHODS

We used retrospective data from a pediatric DMHI that offered web-based behavioral health coaching in tandem with self-guided access to asynchronous chat with practitioners, digital mental health resources, and web-based mental health symptom assessments. Children and adolescents who engaged in 3 or more sessions of exclusive behavioral health coaching for moderate to moderately severe symptoms of anxiety (n=66) and depression (n=59) were included in the analyses. Analyses explored whether participants showed reliable change (a decrease in symptom scores that exceeds a clinically established threshold) and stable reliable change (at least 2 successive assessments of reliable change). Kaplan-Meier survival analyses were performed to determine the median number of coaching sessions when the first reliable change and stable reliable change occurred for anxiety and depressive symptoms.

RESULTS

Reliable change in anxiety symptoms was observed after a median of 2 (95% CI 2-3) sessions, and stable reliable change in anxiety symptoms was observed after a median of 6 (95% CI 5-8) sessions. A reliable change in depressive symptoms was observed after a median of 2 (95% CI 1-3) sessions, and a stable reliable change in depressive symptoms was observed after a median of 6 (95% CI 5-7) sessions. Children improved 1-2 sessions earlier than adolescents.

CONCLUSIONS

Findings from this study will inform caregivers and youth seeking mental health care by characterizing the typical time frame in which current participants show improvements in symptoms. Moreover, by suggesting that meaningful symptom improvement can occur within a relatively short time frame, these results bolster the growing body of research that indicates web-based behavioral health coaching is an effective form of mental health care for young people.

Factors associated with mental health of young children during the COVID-19 pandemic in the Netherlands

BACKGROUND

The COVID-19 pandemic and accompanying societal measures have impacted children and their families all over the world. Little is known about the factors associated with mental health outcomes in young children (i.e., 1 to 6 years old) during the pandemic. The current study aimed to examine associations with potential risk and protective factors, i.e., direct COVID-19 exposure factors as well as within-family characteristics.

METHODS

Caregivers of children aged 1-6 years old were recruited in the Netherlands to participate in an ongoing longitudinal research project. In the current study, baseline data-collected during the 1st year of the pandemic-are reported. The final sample consisted of 2762 caregivers who answered questionnaires assessing negative and positive dimensions of their children's mental health (i.e., anxiety, depressive symptoms, anger, sleep problems, positive affect, and self-regulation). Furthermore, caregivers provided information regarding: (1) Direct COVID-19 related factors, i.e., parental infection and death of a family member or close friend due to COVID-19, (2) Family related COVID-19 factors, i.e., parental perceived impact of the pandemic and COVID-19 related parent-child emotion regulation strategies (i.e., active, avoidant and information-focused strategies), (3) General caregiver's distress, i.e., parental mental health, parental feelings of rejection towards their child. Regression analyses were used to examine associations with children's mental health.

RESULTS

Direct COVID-19 related factors were not associated with more mental health problems in the children, though parental COVID-19 infections were related with less anger in children. Family related COVID-19 factors and caregiver's distress were related with children's mental health. Higher parental perceived negative impact of the pandemic, lower parental perceived positive impact of the pandemic, more avoidant as well as more active and information-focused parent-child emotion regulation strategies, more caregiver's mental health problems and more parental feelings of rejection towards their child were related with more mental health problems in the child.

CONCLUSION

Direct exposure to COVID-19 was not related with more mental health problems in the child. Family related COVID-19 factors and caregiver's distress appear to play a more important role for young children's mental health. Findings may inform prevention and intervention programs for potential future global crises as well as other stressful events.

Changes in Quality of Life, Sleep, and Physical Activity During COVID-19: A Longitudinal Study of Adolescent Athletes

CONTEXT

The abrupt cessation of school and sport participation during the COVID-19 pandemic may have negative implications for adolescent mental health.

OBJECTIVES

To (1) compare mental, physical, and social health and behaviors during pandemic-related stay-at-home mandates with the same measures collected 1 to 2 years earlier and (2) evaluate the relationships between physical activity and sleep during the pandemic and changes in anxiety, fatigue, and peer relationships between assessment times.

DESIGN

Cohort study.

SETTING

Pediatric sports medicine center.

PATIENTS OR OTHER PARTICIPANTS

A total of 39 high school athletes (25 adolescent girls, 14 adolescent boys; age = 16.2 ± 0.9 years).

MAIN OUTCOME MEASURE(S)

Patient-Reported Outcome Measurement System anxiety, fatigue, and peer relationships short forms and the Pittsburgh Sleep Quality Index were completed twice (initial assessment in May 2018 or 2019, follow-up assessment in May or June 2020). Frequency and duration of physical activity and frequency of interaction with other individuals (family, peers, sport coaches, etc) were self-reported at follow-up assessment for the 2 weeks before school or sport closure and the 2 weeks before questionnaire completion.

RESULTS

Higher levels of anxiety (5.5 ± 4.0 versus 3.6 ± 3.4 points; P = .003) and fatigue (5.4 ± 3.7 versus 2.3 ± 2.5 points; P < .001) and worse sleep quality (6.6 ± 2.9 versus 4.3 ± 2.3 points; P < .001) were observed during the pandemic compared with previous assessments. Reductions in physical activity were noted between assessments (exercise duration: 86.4 ± 41.0 versus 53.8 ± 30.0 minutes; P < .001). Sleep quality but not physical activity during the pandemic predicted changes in fatigue (P = .03, β = 0.44 [95% CI = 0.06, 0.83]) and peer relationships (P = .01, β = -0.65 [95% CI = -1.16, -0.15]) from initial to follow-up assessment.

CONCLUSIONS

Mental and physical health declined during stay-at-home mandates compared with assessments 1 to 2 years earlier. Physical activity behaviors and sources of social interaction underwent changes after school and sport cessation. Sleep quality may have provided some protection against declining adolescent mental health during the pandemic, although this relationship requires further investigation.

Mental Health Difficulties of Turkish Healthcare Workers and Non-Healthcare Workers and Their Young Children During Coronavirus Disease 2019 Pandemic

Background

Young children and their caregivers have faced an increased risk of developing mental health difficulties during the coronavirus disease 2019 pandemic. However, very little is still known about the mental health of children younger than 6 years. Existing research suggests that families with caregiver/s who are healthcare workers may be at increased risk. The primary purpose of the paper is to report on the mental health difficulties experienced by young children and their caregivers in Turkey and to investigate if mental health outcomes are worse for young children and caregivers who are healthcare workers in comparison to non-healthcare workers during the first year of the coronavirus disease 2019 pandemic.

Methods

An online survey was completed by 158 caregivers of children aged 1-5 years during December 2020 in Turkey. Caregivers reported on pandemic related experiences, child and parent mental health.

Results

Up to 30% of caregivers reported their child was experiencing moderate to severe anxiety, depressive symptoms, and sleep disturbances. Between 36.2% and 39.2% of caregivers reported moderate to extremely severe levels of depression, anxiety, and/or stress symptoms. Multivariate analysis of covariance analyses found no significant differences between the healthcare worker and non-healthcare worker groups for child(F(4,131) = 1.037, P >.05) or parent mental health outcomes (F(3,141) = 0.712, P >.05).

Conclusion

Our study showed that one-third of children and their caregivers experienced mental health problems during the coronavirus disease 2019 pandemic unrelated to the caregiver's occupation in the health sector. It is important that all families with young children have access to mental health support during disruptive events.

Psychosocial Outcomes in Children with Cleft Lip and/or Palate: Associations of Demographic, Cleft Morphologic, and Treatment-Related Variables

OBJECTIVE

To determine associations of demographic, morphologic, and treatment protocol parameters with quality of life (QoL), appearance/speech satisfaction, and psychological adjustment.

DESIGN

Observational study utilizing retrospective report of protocol variables and current outcome variables.

SETTING

Six North American cleft treatment clinics.

PARTICIPANTS

Children, ages 8.0-10.99 years, with Cleft Lip ± Alveolus, Cleft Palate, Cleft Lip and Palate, and parents (N = 284).

OUTCOME MEASURES

Pediatric QoL Inventory (PedsQL): Parent, Child, Family Impact Module (FIM); Patient Reported Outcome Measurement Information System (PROMIS); Child Behavior Checklist (CBCL); CLEFT-Q.

RESULTS

Outcome scores were average with few differences by cleft type. Multiple regression analyses yielded significant associations (Ps < .05) between socioeconomic status, race, and age at assessment and parent- and self-reported measures. Females had higher PROMIS Depression (β=.20) but lower CBCL Affective (β = -.16) and PROMIS Stigma scores (β= -.24). Incomplete cleft lip was associated with lower PROMIS Depression, and more positive ratings of CLEFT-Q: Nose, Nostril, Lip Scar; CBCL Competence scores, (βs = -.17 to .17). Younger Age at Lip Closure was associated with higher CBCL School Competence (β= -.18). Younger Age at Palate Closure was associated with higher Child PedsQL Total, Physical, Psychosocial QoL, and better CLEFT-Q Speech Function (βs = -.18 to -.15). Furlow Palatoplasty was associated with more CBCL Externalizing Problems (β = .17) higher CBCL Activities (β = .16). For all diagnoses, fewer Total Cleft-Related Surgeries was associated with lower PROMIS Stigma and higher CBCL Total Competence and Activities (βs = -.16 to .15).

CONCLUSIONS

Demographic characteristics, lip morphology, and treatment variables are related to later psychological functioning.

Using Digital Measurement-Based Care for the Treatment of Anxiety and Depression in Children and Adolescents: Observational Retrospective Analysis of Bend Health Data

BACKGROUND

A growing body of evidence supports the efficacy of measurement-based care (MBC) for children and adolescents experiencing mental health concerns, particularly anxiety and depression. In recent years, MBC has increasingly transitioned to web-based spaces in the form of digital mental health interventions (DMHIs), which render high-quality mental health care more accessible nationwide. Although extant research is promising, the emergence of MBC DMHIs means that much is unknown regarding their effectiveness as a treatment for anxiety and depression, particularly among children and adolescents.

OBJECTIVE

This study uses preliminary data from children and adolescents participating in an MBC DMHI administered by Bend Health Inc, a mental health care provider that uses a collaborative care model to assess changes in anxiety and depressive symptoms during participation in the MBC DMHI.

METHODS

Caregivers of children and adolescents participating in Bend Health Inc for anxiety or depressive symptoms reported measures of their children's symptoms every 30 days throughout the duration of participation in Bend Health Inc. Data from 114 children (age 6-12 years) and adolescents (age 13-17 years) were used for the analyses (anxiety symptom group: n=98, depressive symptom group: n=61).

RESULTS

Among children and adolescents participating in care with Bend Health Inc, 73% (72/98) exhibited improvements in anxiety symptoms and 73% (44/61) exhibited improvement in depressive symptoms, as indicated by either a decrease in symptom severity or screening out of completing the complete assessment. Among those with complete assessment data, group-level anxiety symptom T-scores exhibited a moderate decrease of 4.69 points (P=.002) from the first to the last assessment. However, members' depressive symptom T-scores remained largely stable throughout their involvement.

CONCLUSIONS

As increasing numbers of young people and families seek DMHIs over traditional mental health treatments due to their accessibility and affordability, this study offers promising early evidence that youth anxiety symptoms decrease during involvement in an MBC DMHI such as Bend Health Inc. However, further analyses with enhanced longitudinal symptom measures are necessary to determine whether depressive symptoms show similar improvements among those involved in Bend Health Inc.