Editorial: Equity, diversity and inclusion in child and adolescent mental health - a perspective from the American Academy of Child and Adolescent Psychiatry (AACAP).

Advancing diversity, equity and inclusion (DEI) are key priorities for the American Academy of Child and Adolescent Psychiatry (AACAP). AACAP was founded in 1953. The mission of the AACAP includes promoting the healthy development of all children, adolescents, and families through advocacy, education, and research. AACAP's Presidential Initiative of CAPture Belonging's goal was to prioritize diversity, equity, inclusion and belonging to create transformational and sustainable changes in the organization and child and adolescent psychiatry. The presidential initiative's strategy had three pillars: advancing diversity, equity, inclusion, and belonging (DEIB) in all program and services, creating a pipeline for diverse child and adolescent psychiatrists, and monitoring DEIB activities and progress. A presidential task force was created and charged with implementing a 2-year action plan and strategy. A 5-point action plan prioritized: awareness, advocacy, workforce and professional development, national partnerships, and sustainability. Focusing on DEIB for any organization enriches the work, community and success that can be achieved. AACAP is proud to have committed to this DEIB path and has already experienced success through continuous membership growth, membership engagement, and record attendance at annual meetings and volunteer involvement. These accomplishments can only enhance AACAP's ability to serve the mission of promoting the healthy development of all children, adolescents, and families through advocacy, education, and research.

Editorial: Equity, diversity and inclusion in child and adolescent mental health - equality of opportunities should be every child's right and every society's obligation.

Socio-ecological factors are major determinants of poor mental health across the life span. These factors can lead to health inequalities, which refer to differences in the health of individuals or groups (Kirkbride et al., 2024). Health inequity "is a specific type of health inequality that denotes an unjust, avoidable, systematic and unnecessary difference in health" (Arcaya, Arcaya, & Subramanian, 2015). Among several intersecting social adversities, inequity is one of the most pervasive contributors to poor mental health across all regions (Venkatapuram & Marmot, 2023). Structural inequity creates institutional power structures that marginalise large sections of the population and concentrate resources in the hands of a small minority (Shim, Kho, & Murray-García, 2018). The world is now more prosperous than it has ever been, yet the world is witnessing more within country inequality with the vast majority of the world's resources in the hands of a small minority of individuals or regions (United Nations, 2020).

Parent-child conflict and adolescent health literacy in Mexico: Results from a nationwide dyad study in Mexico.

Research suggests that health literacy (HL) is critical in preventing and managing health problems. However, over half of adults in Mexico report having inadequate health literacy. Research suggests the parent-child relationship can be a key predictor of developmental competencies; however, little research has examined how dyadic family interactions relate to HL. This study examined whether parent-child relationship conflict was associated with adolescent health literacy among families living in Mexico. Data from a parent-child dyads in Mexico were gathered using online surveys (N = 746, 373 parent-child dyads). Our findings suggested that child-reported family conflict-but not parent-reported family conflict - was associated with lower adolescent health literacy. Researchers and practitioners should consider how parent-child conflict may impact adolescent health outcomes, and prioritise child reports in data collection.

Nurse facilitated 5000 m running at Parkrun improves vulnerable adolescent health in a high deprivation area: A matched pair randomized control trial.

OBJECTIVE: To examine the effect of weekly nurse facilitated 5000 m running at Parkrun on markers of health in vulnerable adolescents from a high deprivation area. DESIGN: A matched pair randomized control trial. SAMPLE: Twenty-five adolescents aged 13-18, 90% identifying as Maori/Pasifika ethnicity. INTERVENTION: The intervention (INT) group participated in 6-10 Parkruns within 10 weeks, and a control group (CON) participated in one Parkrun only. A nurse facilitated the intervention offering support and encouragement at each Parkrun. MEASUREMENTS: Pre- and post-intervention testing sessions for cardiorespiratory fitness (CRF), glycated hemoglobin, body mass index (BMI), skeletal muscle mass (SMM), body fat, and hand grip strength (STR) were conducted. RESULTS: Parkrun improved CRF (F = 5.308, p = 0.035) and 5000 m time (t = 2.850, p = 0.019) by 5.5 ± 4.9 min (11.2%). Parkrun conferred a large beneficial effect on CRF (η2 = 0.249) a moderate beneficial effect on glycated hemoglobin levels (η2 = 0.119), and small beneficial effects upon SMM (η2 = 0.037) and body fat (η2 = 0.017). CONCLUSION: A weekly dose of nurse facilitated Parkrun can be recommended as a simple, accessible intervention that confers multiple beneficial effects on markers for health in adolescents from a high deprivation area.

The impact of school-based creative bibliotherapy interventions on child and adolescent mental health: a systematic review and realist synthesis protocol.

BACKGROUND: There is a need to identify evidence-based interventions to be delivered in schools that can be used to improve child and adolescent mental health and wellbeing. Creative bibliotherapy is one proposed intervention. However, there has been, to date, no comprehensive assessment of the evidence for its impact on mental health and wellbeing. To fill this gap, we will conduct a systematic review and realist synthesis. METHODS: A systematic search of the bibliographic databases APA PsycINFO, Medline (via Ovid), CINAHL, ERIC, Education Research Complete (via EBSCOhost) and Web of Science (SCI, SSCI, AHCI, ESCI) for school-based creative bibliotherapy interventions on child and adolescent mental health. Types of study to be included: cohort studies, non-randomised comparative evaluations, randomised controlled trials. The data from all included studies will be summarised descriptively and strength of evidence appraised. This is a potentially large field of practice, with heterogeneous interventions; we will use methods from intervention components analysis to describe and categorise the range of components and approaches used in included interventions. To understand how interventions work and in which contexts, we will use methods from realist synthesis to develop an exploratory account of mechanisms in different settings and for different young people (contexts). DISCUSSION: Findings will assess the range of evidence for the impact of creative bibliotherapy on child and adolescent mental health and wellbeing, the strength of evidence for the impact identified, and describe potential mechanisms. This review will be useful for a wide range of stakeholders considering implementing or developing interventions using creative bibliotherapy in school-based settings. SYSTEMATIC REVIEW REGISTRATION: This protocol was registered at the International Prospective Register of Systematic Reviews ( https://www.crd.york.ac.uk/prospero/ ), registration number CRD42023410333. This review is funded by Wellcome Trust (221457/Z/20/Z).

A qualitative evaluation of stakeholder perspectives on sustainable financing strategies for 'priority' adolescent sexual and reproductive health interventions in Ghana.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) interventions are underfunded in Ghana. We explored stakeholder perspectives on innovative and sustainable financing strategies for priority ASRH interventions in Ghana. METHODS: Using qualitative design, we interviewed 36 key informants to evaluate sustainable financing sources for ASRH interventions in Ghana. Thematic content analysis of primary data was performed. Study reporting followed the consolidated criteria for reporting qualitative research. RESULTS: Proposed conventional financing strategies included tax-based, need-based, policy-based, and implementation-based approaches. Unconventional financing strategies recommended involved getting religious groups to support ASRH interventions as done to mobilize resources for the Ghana COVID-19 Trust Fund during the global pandemic. Other recommendations included leveraging existing opportunities like fundraising through annual adolescent and youth sporting activities to support ASRH interventions. Nonetheless, some participants believed financial, material, and non-material resources must complement each other to sustain funding for priority ASRH interventions. CONCLUSION: There are various sustainable financing strategies to close the funding gap for ASRH interventions in Ghana, but judicious management of financial, material, and non-material resources is needed to sustain priority ASRH interventions in Ghana.

A system dynamics approach to understand Dutch adolescents' sleep health using a causal loop diagram.

BACKGROUND: Healthy sleep is crucial for the physical and mental wellbeing of adolescents. However, many adolescents suffer from poor sleep health. Little is known about how to effectively improve adolescent sleep health as it is shaped by a complex adaptive system of many interacting factors. This study aims to provide insights into the system dynamics underlying adolescent sleep health and to identify impactful leverage points for sleep health promotion interventions. METHODS: Three rounds of single-actor workshops, applying Group Model Building techniques, were held with adolescents (n = 23, 12-15 years), parents (n = 14) and relevant professionals (n = 26). The workshops resulted in a multi-actor Causal Loop Diagram (CLD) visualizing the system dynamics underlying adolescent sleep health. This CLD was supplemented with evidence from the literature. Subsystems, feedback loops and underlying causal mechanisms were identified to understand overarching system dynamics. Potential leverage points for action were identified applying the Action Scales Model (ASM). RESULTS: The resulting CLD comprised six subsystems around the following themes: (1) School environment; (2) Mental wellbeing; (3) Digital environment; (4) Family & Home environment; (5) Health behaviors & Leisure activities; (6) Personal system. Within and between these subsystems, 16 reinforcing and 7 balancing feedback loops were identified. Approximately 60 potential leverage points on different levels of the system were identified as well. CONCLUSIONS: The multi-actor CLD and identified system dynamics illustrate the complexity of adolescent sleep health and supports the need for developing a coherent package of activities targeting different leverage points at all system levels to induce system change.

Indonesian COVID-19 lesson: A mixed-methods study on adolescent health status and health services during pandemic.

TOPIC: The COVID-19 pandemic affected adolescents' physical and psychological health. There must be specific services to cater to the needs of adolescents during COVID-19 in Indonesia. Lessons learned from previous pandemics will be beneficial for nurses and other health professionals to prepare services for future pandemics. PURPOSE: This mixed-method study aimed to examine 459 Indonesian adolescents' health, literacy, preventive measures, and preferred health services during the COVID-19 pandemic. This study also examines sociodemographics, respondent characteristics, health information sources, and media choices. RESULTS: A total of 47.5% of adolescents knew about COVID-19, 26.8% experienced physical health changes, and 61.7% considered wearing masks. Adolescent health information came from teachers (26.6%) and the Internet (32.9%). Psychological changes showed 67.8% irritation. Indonesians preferred online counseling (53.8%) and WhatsApp (45.8%) for pandemic health services. COVID-19 literacy did not affect physical or mental health (p > 0.05). CONCLUSIONS: Most adolescents reported mental and physical health changes during COVID-19. Our data suggest that adolescents' strong COVID-19 knowledge did not prevent anxiety and other psychological difficulties. The longitudinal studies could be utilized if pandemic demands social and physical distance. The government, as well as nurses, might utilize WhatsApp-based remote online treatment for health services.

Guidance on sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian and fragile settings: a scoping review.

INTRODUCTION: Progress related to sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) has stalled. COVID-19, conflict and climate change threaten to reverse decades of progress and to ensure the health and well-being of vulnerable populations in humanitarian and fragile settings (HFS) going forward, there is a need for tailored guidance for women, children and adolescents (WCA). This review seeks to map and appraise current resources on SRMNCAH in HFS. METHODS: In line with the updated Joanna Briggs Institute guidance and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews framework, a manual literature review was conducted of global and regional guidance published between January 2008 and May 2023 from members of the Global Health Cluster, the Global Nutrition Cluster and the Inter-Agency Working Group on Reproductive Health in Crises. A content analysis was conducted. Scores were then calculated according to the Appraisal of Guidelines for Research and Evaluation II scoring tool and subsequently categorised as high quality or low quality. RESULTS: A total of 730 documents were identified. Of these, 141 met the selection criteria and were analysed. Available guidance for delivering SRMNCH services exists, which can inform policy and programming for the general population and WCA. Important gaps related to beneficiaries, health services and health system strengthening strategies were identified. CONCLUSION: The review revealed there is evidence-based guidance available to support interventions targeting WCA in HFS, including: pregnant and lactating women, women of reproductive age, adolescents, newborns, small vulnerable newborns, stillbirths, refugees and internally displaced persons and WCA with disabilities. However, gaps related to beneficiaries, health services and health system strengthening strategies must be addressed in updated guidance that is created, disseminated and monitored in a standardised way that is mindful of the need to respond rapidly in HFS.

National COVID-19 preparedness and response plans: a global review from the perspective of services for maternal, newborn, child and adolescent health and older people.

INTRODUCTION: Infectious disease outbreaks have historically led to widespread disruptions in routine essential health services. Disruptions due to COVID-19 responses led to excess deaths, including among women and children. This review builds on earlier reviews of essential health services in national COVID-19 response and preparedness plans, focusing specifically on maternal, newborn, child, adolescent and ageing health (MNCAAH) in the context of renewed global emphasis on monitoring, recovering and strengthening these services. METHODS: Using Google searches, we identified publicly available COVID-19 response and preparedness plans authored by a national government body or Public Health Institute from any country, territory and/or area, published between January 2020 and December 2022. We assessed whether each plan considered maintenance of MNCAAH services with related activities, costing or monitoring plans, and whether these considerations were integrated into the national incident management system for COVID-19. RESULTS: We identified plans from 110 countries, representing 56% of our sample, in 10 languages. Most plans came from low-income and middle-income countries. Three quarters of dated documents were published between February and April 2020. 22% of plans referenced the impact of COVID-19 on MNCAAH, but only 13% included a planned activity for monitoring or mitigating this impact and less than 5% included relevant indicators, costing or integration of services in the incident management system. CONCLUSION: We propose that unless content specifically related to the services and needs of these populations is integrated, these services will suffer in a future disruptive event. The COVID-19 response demonstrated the need for an interdisciplinary response to address the unforeseen impacts that arose, yet plans continue to have a narrow focus and a generic approach which may be limiting.

Adolescent Cardiorespiratory Fitness and Future Work Ability.

Importance: Although research indicates that low fitness in youth is associated with a higher risk of chronic disability in men, the association of fitness in adolescence with work ability in working men and women remains unknown. Objective: To examine the associations of adolescent health-related physical fitness with future work ability. Design, Setting, and Participants: This 45-year observational cohort study, conducted in Finland, examined the direct and indirect longitudinal associations of objectively measured health-related fitness in adolescence (in 1976) with self-reported work ability and sickness absence in early middle age (in 2001) and the Work Ability Index in late middle age (in 2021). A countrywide stratified random baseline sample included fitness measurements for cardiorespiratory fitness (CRF) (running 1.5 km for girls and 2 km for boys), musculoskeletal fitness (MF; standing broad jump and sit-ups for both sexes, pull-ups for boys, and flexed-arm hang for girls), and height and weight, from which body mass index (BMI) was calculated. Structural equation modeling-based path analysis, adjusted for age and sex at baseline and for educational level, work-related physical strain, and leisure-time physical activity in late middle age, was conducted. Data analysis was performed from January to July 2023. Main Outcomes and Measures: Self-reported work ability was measured with structured questions in early middle age and with the validated Work Ability Index in late middle age. Results: The final sample from longitudinal analyses (1207 individuals; 579 [48%] male individuals) consisted of participants with fitness measurement from age 12 to 19 years, and work ability assessment from age 37 to 44 years and/or age 57 to 64 years. Higher adolescent CRF was associated with higher work ability (839 participants; ß = 0.12; 95% CI, 0.01 to 0.22; P = .03) and lower sickness absence (834 participants; ß = -0.07; 95% CI, -0.12 to -0.02; P = .004) in early middle age and, indirectly, mediated by work ability in early middle age, with a higher work ability at the end of working age (603 participants; ß = 0.04; 95% CI, 0.001 to 0.08; P = .04). The results remained consistent in both sexes and after adjustment for the confounders. Neither MF nor BMI was associated with work ability (MF, 1192 participants; ß = -0.07; 95% CI, -0.17 to 0.03; BMI, 1207 participants, ß = 0.09; 95% CI, -0.004 to 0.19) or sickness absence (MF, 1185 participants, ß = 0.02; 95% CI, -0.03 to 0.06; BMI, 1202 participants, ß = -0.03; 95% CI, -0.09 to 0.03) in early middle age or with late middle age work ability, mediated by work ability in early middle age (MF, 603 participants, ß = -0.02; 95% CI, -0.06 to 0.01; BMI, 603 participants, ß = 0.03; 95% CI, -0.004 to 0.07). Conclusions and Relevance: These findings suggest that low CRF in youth is associated with poor work ability at the middle and end of working life, which highlights the informative and prognostic value of CRF assessment early in youth. Enhancing CRF in the first decades of life might contribute to better work capacity and productivity in the labor force, which would have implications for health, quality of life, society, and the economy.

Adolescent Mental Health Before and During COVID-19: Longitudinal Evidence From the 2004 Pelotas Birth Cohort in Brazil.

PURPOSE: There is great interest in examining the consequences of the COVID-19 pandemic on adolescent mental health, but most studies were conducted in high-income countries. The identification of overall effects and protective factors is essential to understand the determinants of mental wellbeing in contexts of stress. We aimed to study changes in adolescent mental health during the pandemic and the risk and protective factors associated with these changes in a Brazilian birth cohort. METHODS: One thousand nine hundred forty nine adolescents from the 2004 Pelotas Birth Cohort were assessed prepandemic (T1, November 2019 to March 2020, mean age 15.69 years) and mid-pandemic (T2, August to December 2021, mean age 17.41 years). Mental health was assessed using the Strengths and Difficulties Questionnaire. Prepandemic and pandemic-related predictors were examined as predictors of change in multivariate latent change scores models. RESULTS: There was a mean increase in adolescent total mental health difficulties (M = 1.071, p < .001), hyperactivity/inattention (M = 0.208, p < .001), emotion symptoms (M = 0.409, p < .001), and peer problems (M = 0.434, p < .001) during the pandemic. This increase was associated with several negative family context variables, including harsh parenting and maternal depressive symptoms at T2. Higher emotion regulation levels protected against increases in adolescent mental health difficulties related to the COVID-19 pandemic. DISCUSSION: Family-context variables emerged as important risk factors for the deterioration of adolescent mental health during the COVID-19 pandemic. Interventions promoting emotion regulation strategies are a promising approach to protecting adolescent wellbeing in periods of stress.

Safeguarding in adolescent mental health research: navigating dilemmas and developing procedures.

Mental disorders are prevalent during adolescence. Self-harm and suicide are more common in adolescents with a probable mental disorder, with one in four reporting to have attempted self-harm. Research involving adolescents is, therefore, likely to include participants experiencing mental ill health, even if mental health is not the primary focus. Researchers should adopt procedures and principles that safeguard adolescent mental health in their research practice. Yet there are gaps between theory and practice of research with adolescents in relation to their mental health, and limited guidance is available.We discuss emerging safeguarding dilemmas and procedures in adolescent mental health research. Our experiences of safeguarding adolescent mental health are grounded in the UK National Institute for Health and Care Research-funded SMART Schools Study. Drawing from this secondary school-based study, we focus on how our research team encountered and addressed a high prevalence of participants (aged 12-13 and 14-15 years) reporting thoughts and behaviours related to self-harm or suicide (24% of participants). This included reviewing our existing risk mitigation processes and consulting with several committees including young people with lived experiences of mental health.We present the SMART Schools study safeguarding approach for adolescent mental health. This encompasses key safeguarding principles, study procedures and relevant justifications. We address school and university roles and responsibilities, pupil understanding, and efficient, effective and secure communication pathways. We embed guidance throughout this article for researchers working with adolescents in the context of mental health. Lastly, we present five key recommendations to safeguard the mental health of adolescents participating in research, including (1) appointing a safeguarding lead within the research team; (2) codesigning a bespoke study safeguarding approach; (3) adopting a responsive approach to mental health safeguarding; (4) being transparent about the study mental health safeguarding approach and (5) report the implementation and outcomes of safeguarding approaches.Trial registration number ISRCTN77948572.

To what extent did implementing a community-embedded intervention align with the goals and roles of stakeholders in adolescent sexual and reproductive health?

BACKGROUND: Adolescents' sexual and reproductive health (SRH) needs are largely unmet due to poor access to SRH information and services. A multicomponent community-embedded intervention, comprising advocacy to policymakers and community leaders, training of health workers on the provision of youth-friendly SRH services, and establishment of school health clubs, was implemented in Ebonyi State, Nigeria, to improve access to SRH information and services for adolescents aged 13-18 years in selected communities and secondary schools. This study explored the extent to which the intervention aligned with goals and roles of stakeholders in the State. METHODS: Qualitative in-depth interviews (30) were conducted with key stakeholders in adolescent health programming in the State, and community gatekeepers (traditional and religious leaders) in the intervention communities. Sex-disaggregated focus group discussions (10) were conducted with health service providers, parents/guardians of adolescents. Data was analyzed deductively based on fit of strategy and two constructs of the Theoretical Framework for Acceptability - burden, and opportunity cost. The transcripts were coded in NVivo 12, and the subthemes that emerged from each construct were identified. RESULTS: Stakeholders perceived the ASRH intervention activities to align with their individual goals of sense of purpose from serving the community and organizational goals of improving the visibility of adolescent reproductive health programs and aligned with their routine work. Hence, implementing or participating in the interventions was not considered a burden by many. Although the delivery of the interventions constituted additional workload and time commitment for the implementers, the benefits of partaking in the intervention were perceived to outweigh the inputs that they were required to make. Some of the community health workers in the intervention felt that provision of financial incentive will help with making the intervention less burdensome. To participate in the intervention, opportunity cost included forgoing work and business activities as well as family commitments. CONCLUSION: Findings from the study show that the intervention aligned with individual/organizational goals of stakeholders. To improve acceptability of the ASRH interventions, interventions should leverage on existing programs and routine work of people who will deliver the interventions.

Adolescence is a period of transition and marked physical and mental changes with an increased need for sexual and reproductive health services. However, these needs are not usually met as adolescent face challenges in receiving care such as negative attitudes of health workers, fear of consequences of disclosing sexual and reproductive care received to parents amongst other things. An intervention aimed at improving their access to sexual and reproductive health services was implemented in Ebonyi State, Nigeria. This study assessed the alignment of the intervention to the individual and organizational goals of the stakeholders, the burden involved in participating in the intervention as well as the things needed to be forgone. Findings show that the intervention aligned with the stakeholder routine work, organizational work plans and individual goals. Participating in the intervention was not considered bothersome by many stakeholders because the impact their work make in the community makes them feel fulfilled. Participating in the intervention increases workload of the stakeholders. Stakeholders had to forgo work and business engagements to participate and some felt incentives can help to keep them motivated and interested in the project. To improve acceptability of adolescent sexual and reproductive health interventions, interventions should be tailored to the routine work of the implementers of the strategy and plans for incentives be made for stakeholders who deliver interventions.

Using co-design to develop the Adolescent Health Literacy Questionnaire for adolescents in Ireland.

Health literacy measurement studies are important for the success of health promotion efforts targeting adolescents. However, the majority of health literacy measurement tools were originally developed for adult populations and may not be reflective of health literacy in the context of adolescence. The present study sought to co-design a health literacy questionnaire and vignettes for adolescents in Ireland aged 12-18 years. This article describes the qualitative phase of the study. In 2019-2021, eight adolescents from the Irish Heart Foundation's Youth Advisory Panel participated in two concept mapping workshops during which they defined healthy living. Results of the thematic analysis indicated that adolescents defined 'healthy living' as a life that was balanced, prioritizing mental health and sleep. According to their definition, healthy living was comprised of six main constructs, namely, knowledge; sources of quality health information; facilitators and barriers; influence of others; self-efficacy, self-management and resilience; and citizenship and communication. These constructs were used to develop vignettes and items for the Adolescent Health Literacy Questionnaire (AHLQ). These were tested on a sample of 80 adolescents to check whether the respondents understood the items and vignettes as intended. Results of the nine cognitive interviews indicated that the adolescents understood the content of the 10 vignettes and 41 items. While the vignettes and AHLQ were developed with Irish adolescents, the approaches taken can be generalized to adolescents living in other countries. This will allow for the development of tailored and relevant solutions for health literacy development and health promotion for this sub-population.