Matching actions to needs: shifting policy responses to the changing health needs of Chinese children and adolescents.

China is home to the second largest population of children and adolescents in the world. Yet demographic shifts mean that the government must manage the challenge of fewer children with the needs of an ageing population, while considering the delicate tension between economic growth and environmental sustainability. We mapped the health problems and risks of contemporary school-aged children and adolescents in China against current national health policies. We involved multidisciplinary experts, including young people, with the aim of identifying actionable strategies and specific recommendations to promote child and adolescent health and wellbeing. Notwithstanding major improvements in their health over the past few decades, contemporary Chinese children and adolescents face distinct social challenges, including high academic pressures and youth unemployment, and new health concerns including obesity, mental health issues, and sexually transmitted infections. Inequality by gender, geography, and ethnicity remains a feature of health risks and outcomes. We identified a mismatch between current health determinants, risks and outcomes, and government policies. To promote the health of children and adolescents in China, we recommend a set of strategies that target government-led initiatives across the health, education, and community sectors, which aim to build supportive and responsive families, safe communities, and engaging and respectful learning environments. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Assessing Psychological Remission in Adolescent Anorexia Nervosa: A Comparison of Patient and Parent Report.

OBJECTIVE: The definition and assessment of remission in anorexia nervosa (AN) needs greater consensus. Particularly in adolescents, the use of patient-reported composite indices (such as the Eating Disorder Examination [EDE] Global Score) as the sole measure of psychological remission has the potential to obscure patients' true clinical status, given developmental factors and the propensity towards symptom minimization in AN. METHOD: End of treatment (EOT) data from a randomized controlled trial comparing two formats of manualized family-based treatment for adolescents with AN (N = 106) were analyzed. Participants completed the EDE, and their parents completed a parent-as-informant version of the EDE (Parent Eating Disorder Examination; PEDE). Rates of remission were compared across indices (i.e., EDE Global Score vs. diagnostic item analysis) and informant (i.e., adolescent vs. parent), both independently and in combination with the achievement of a percent median body mass index (% mBMI) greater than or equal to 95%. RESULTS: For both adolescent and parent reports, there were higher rates of remission when defined by Global Score than when defined by EDE or PEDE diagnostic items. There were no significant differences in remission rates based on informant. DISCUSSION: In the assessment of remission in AN, the EDE Global Score may not detect some adolescents who continue to exhibit clinically significant psychological symptoms. This study supports a detailed, multidimensional approach to assessing remission in adolescent AN to optimize sensitivity to patients' diagnostic profile. Future research should explore whether parent-child concordance on measures of ED psychopathology varies over the course of treatment.

Health-related quality of life and self-reported health status in adolescents with chronic health conditions before transfer of care to adult health care: an international cohort study.

BACKGROUND: Heath-related quality of life (HRQoL) is lower in adolescents with chronic health conditions compared to healthy peers. While there is evidence of some differences according to the underlying condition and gender, differences by measure and country are poorly understood. In this study we focus on the differences in HRQoL in adolescents with various chronic medical conditions in the year before transfer of care to adult health services. We also study the associations of two different HRQoL measurements to each other and to self-reported health. METHODS: We recruited 538 adolescents from New Children`s Hospital, Helsinki, Finland, and the Royal Children`s Hospital, Melbourne, Australia in 2017-2020. We used two validated HRQoL measurement instruments, Pediatric Quality of Life Inventory (PedsQL) and 16D, and a visual analog scale (VAS) for self-reported health status. RESULTS: In total, 512 adolescents (50.4% female, mean age 17.8 [SD 1.2] years), completed the survey measures. Higher HRQoL was reported in males than females in both countries (PedsQL 79.4 vs. 74.1; 16D 0.888 vs. 0.846), and in adolescents from Finland than Australia (80.6 vs. 72.2 and 0.905 vs. 0.825, p < 0.001 for all). Adolescents with diabetes, rheumatological, nephrological conditions and/or organ transplants had higher HRQoL than adolescents with neurological conditions or other disease syndromes (p < 0.001). PedsQL and 16D scores showed a strong correlation to each other (Spearman correlation coefficient r = 0.81). Using the 7-point VAS (1-7), 52% (248 of 479) considered their health status to be good (6-7) and 10% (48 of 479) rated it poor (1-2). Better self-reported health was associated with higher HRQoL. CONCLUSIONS: The HRQoL of transition aged adolescents varies between genders, diagnostic groups, and countries of residence. The association between self-reported health and HRQoL suggests that brief assessment using the VAS could identify adolescents who may benefit from in-depth HRQoL evaluation. TRIAL REGISTRATION: Trial registration name The Bridge and registration number NCT04631965 ( https://clinicaltrials.gov/ct2/show/NCT04631965 ).

Development and validation of the adolescent behavioural change Counselling Assessment Tool in Indonesia.

BACKGROUND: Primary care provides an important context to engage adolescents and their families in healthy lifestyles with the goal of reducing future behaviour-related health problems. Developing a valid tool to assess health professionals' skills in behavioural change counselling is integral to improving the quality of clinical care provided to adolescents in Indonesia. METHODS: This work was nested within a project to develop a training program to enhance the behaviour-change counselling of adolescents and their parents by Indonesian primary care professionals. Initial item development was based on the content of the training module and the domain structure of the Behavioral Change Counselling Index (BECCI), a commonly used tool to assess counselling quality in healthcare settings. Expert panels were used to test content validity, while face validity was assessed by a group of trained psychologists. Inter-rater agreement was calculated prior to tests of construct validity and reliability, which involved psychologists rating 125 audio-taped counselling sessions between the health professional and adolescent patients, together with a parent. RESULTS: An initial 13-item tool was developed using a 1-5 Likert scale. Validity and reliability testing resulted in the decision to use a 14-item tool with a 0-3 Likert scale. The scale was found to have a Cronbach's α coefficient of 0.839 (internal consistency), and there was strong inter-rater agreement (0.931). CONCLUSION: The assessment tool known as the Adolescent Behavioural Change Counselling Assessment Tool, is a valid and reliable instrument to measure Indonesian health professionals' behavioural-change counselling skills with adolescent patients. The tool provides an evaluation framework for future interventions that aim to improve health professionals' skills in addressing adolescent behaviour-related health problems.

Development of an inpatient protocol for adolescents with avoidant/restrictive food intake disorder: a case study.

Introduction: Avoidant/restrictive food intake disorder (ARFID) is an eating disorder characterised by a pattern of eating that leads to failure to meet appropriate nutritional and/or energy needs. Method: In the absence of evidence-based inpatient guidelines for adolescents with ARFID, we set out to develop and pilot an inpatient protocol for adolescents with ARFID. Identification of the key differences between managing inpatients with ARFID and anorexia nervosa (AN) led to modification of an existing AN protocol with the goals of better meeting patient needs, enhancing alignment with outpatient care, and improving outcomes. A case report of an adolescent with ARFID who had three hospital admissions is presented to highlight these changes. Interviews with this patient and her family were undertaken, together with key staff, to explore the challenges of the AN protocol for this patient and the perceived benefits and any limitations of the ARFID protocol for this patient and others. Results: The new ARFID protocol supports greater choice of meals, without the need for rest periods after meals and bathroom supervision. The similarities with the AN protocol reflect the need to promote timely weight gain through meal support, including a staged approach to nutritional supplementation. The protocol appears to have been well accepted by the patient and her family, as well as by staff, and continues to be used in cases of ARFID. Conclusion: Further evaluation would help identify how well this protocol meets the needs of different adolescents with ARFID.

Introduction: Le trouble évitant/restrictif de la prise alimentaire (TERPA) est un trouble alimentaire caractérisé par un modèle d'alimentation qui entraîne une incapacité à répondre aux besoins nutritionnels et/ou énergétiques appropriés. Méthode: En l'absence de lignes directrices fondées sur des données probantes en milieu hospitalier pour des adolescents souffrant de TERPA, nous avons entrepris de développer et de piloter un protocole en milieu hospitalier pour les adolescents souffrant de TERPA. L'identification des principales différences entre la prise en charge des patients hospitalisés souffrant de TERPA et d'anorexie mentale (AM) a mené à une modification d'un protocole d'AM existant dans le but de mieux répondre aux besoins des patients, d'accroître l'alignement avec les soins des patients ambulatoires, et d'améliorer les résultats. Un rapport de cas d'une adolescente souffrant de TERPA qui a eu trois hospitalisations est présenté pour souligner ces changements. Des entrevues avec cette patiente et sa famille ont été réalisées, de même qu'avec le personnel principal, afin d'explorer les difficultés du protocole d'AM pour cette patiente ainsi que les avantages perçus et toute limite du protocole TERPA pour cette patiente et d'autres. Résultats: Le nouveau protocole TERPA supporte un plus grand nombre de repas, sans le besoin de périodes de repos après les repas et une supervision de la salle de bain. Les similitudes avec le protocole AM reflètent le besoin de promouvoir une prise de poids rapide grâce à un soutien aux repas, y compris une approche par étapes de supplémentation nutritionnelle. Le protocole semble avoir été bien accepté par la patiente et sa famille, ainsi que par le personnel, et continue d'être utilisé dans les cas de TERPA. Conclusion: Une évaluation plus poussée aiderait à identifier dans quelle mesure ce protocole répond aux besoins de différents adolescents souffrant de TERPA.

Transition From Pediatric to Adult Healthcare for Colorectal Conditions: A Systematic Review.

BACKGROUND: Despite surgical advances for complex congenital colorectal conditions, such as anorectal malformation (ARM) and Hirschsprung disease (HD), many adolescents require transfer from specialist pediatric to adult providers for ongoing care. METHODOLOGY: A systematic review of PubMed, MEDLINE and Embase was conducted to identify what is known about the transitional care of patients with ARM and HD (PROSPERO # CRD42022281558). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework guided our reporting of studies that focused on the transition care of 10-30-year-olds with ARM and HD. RESULTS: Eight studies were identified that included patient and parent (n = 188), and/or clinician perspectives (n = 334). Patients and clinicians agreed that transitional care should commence early in adolescence to support transfer to adult care when a suitable level of maturation is reached. There was little evidence from patients that transfer happened in a timely or coordinated manner. Patients felt that clinicians did not always understand the significance of transfer to adult services. No models of transition care were identified. Surgeons ranked ARM and HD as the most common conditions to experience delayed transfer to adult care. Beyond pediatric surgeons, patients also highlighted the importance of general practitioners, transitional care coordinators and peer support groups for successful transition. CONCLUSIONS: There is little research focused on transitional care for patients with ARM and HD. Given evidence of delayed transfer and poor experiences, the development of models of transitional care appears essential.

Changes in health-related quality of life during transition to adult healthcare: an international prospective cohort study.

OBJECTIVE: To study changes in health-related quality of life (HRQoL) in adolescents and young adults (AYAs) with chronic medical conditions across the transfer to adult healthcare and associations of HRQoL with transition readiness and experience of care. METHODS: Participants in this international (Finland, Australia) prospective cohort study were recruited in the year prior to transfer to adult health services and studied 12 months later. In addition to two HRQoL scales (Pediatric Quality of Life inventory (PedsQL), 16D), the Am I ON TRAC for Adult Care Questionnaire and Adolescent Friendly Hospital Survey measured transition readiness and experience of care and categorised by quartile. Data were compared before and after transfer to adult healthcare. RESULTS: In total, 512 AYAs completed the first survey (0-12 months before transfer of care) and 336 AYAs completed it 1 year later (retention rate 66%, mean ages 17.8 and 18.9 years, respectively). Mean total PedsQL scores (76.5 vs 78.3) showed no significant change, although the social and educational subdomains improved after transfer of care. The mean single-index 16D score remained the same, but in Finland, distress increased and the ability to interact with friends decreased after transfer. AYAs within the best quartiles of experience of care and transition readiness had better HRQoL than AYAs within the worst quartiles. CONCLUSIONS: Overall HRQoL of AYAs remained unchanged across the transfer to adult healthcare. Recognising and supporting AYAs with unsatisfactory experience of care and poor transition readiness could improve overall HRQoL during the transition process. TRIAL REGISTRATION NUMBER: NCT04631965.

Prevalence of Eating Disorder Symptoms in Transgender and Gender Diverse Adolescents Presenting for Gender-Affirming Care.

PURPOSE: To describe the prevalence of eating disorder symptoms among adolescents seeking gender-affirming care. METHODS: Cross-sectional study of 660 gender-diverse adolescents who completed the Branched Eating Disorder Test to measure anorexia and bulimia symptoms. RESULTS: 23.9% (95% CI 20.7-27.4) reported both anorexia symptoms, namely overvaluation of weight and fear of (or recurrent interference with) weight gain. 0.9% (95% CI 0.3-2.0) reported all bulimia symptoms, namely overvaluation of weight, recurrent binge eating, and recurrent compensatory behaviors (e.g., weekly purging). For all symptoms, prevalence was higher among i) adolescents assigned female at birth compared to those assigned male at birth, and ii) adolescents who felt unsure about their gender identity compared to those who identified as trans or nonbinary. DISCUSSION: Clinicians should monitor eating disorder symptoms among adolescents presenting for gender-affirming care, especially among those assigned female at birth or who are unsure about their gender identity.

Parent version of the Eating Disorder Examination: Reliability and validity in a treatment-seeking sample.

BACKGROUND: Assessment of eating disorders (ED) in youth relies heavily on self-report, yet persistent lack of recognition of the presence and/or seriousness of symptoms can be intrinsic to ED. This study examines the psychometric properties of a semi-structured interview, the parent version of the Eating Disorder Examination (PEDE), developed to systematically assess caregiver report of symptoms. METHODS: A multi-site, clinical sample of youth (N = 522; age range: 12 to 18 years) seeking treatment for anorexia nervosa (AN) and subsyndromal AN were assessed using the Eating Disorder Examination (EDE) for youth and the PEDE for collateral caregiver report. RESULTS: Internal consistencies of the four PEDE subscales were on par with established ranges for the EDE. Significant medium-sized correlations and poor to moderate levels of agreement were found between the corresponding subscales on each measure. For the PEDE, confirmatory factor analysis of the EDE four-factor model provided a poor fit; an exploratory factor analysis indicated that a 3-factor model better fits the PEDE. CONCLUSIONS: Findings suggest that the PEDE has psychometric properties on par with the original EDE. The addition of the caregiver perspective may provide incremental information that can aid in the assessment of AN in youth. Future research is warranted to establish psychometric properties of the PEDE in broader transdiagnostic ED samples.

Assessments for eating disorders rely primarily on self-report; yet, the denial of symptoms or symptom severity among adolescents with anorexia nervosa can complicate assessment and delay treatment in this population. The Parent Eating Disorder Examination (PEDE) is the first semi-structured interview formally developed to improve childhood eating disorder assessment by including caregiver perspectives. In this study, a large sample of adolescents with anorexia nervosa completed a self-report interview (the Eating Disorder Examination or EDE) and their parents completed the PEDE. The PEDE appeared to measure parents' report of their child's eating disorder symptoms consistently. Results from both interviews were related to one another but did not completely agree. This suggests that in an eating disorder assessment, the PEDE can provide additional information from caregivers that might reduce diagnostic confusion and lead to earlier intervention for youth with anorexia nervosa.

Characteristics of Puberty in a Population-Based Sample of Danish Adolescents.

PURPOSE: To describe the duration, timing, tempo, and synchronicity of puberty, as well as the correlation between timing and tempo of puberty. METHODS: Overall, 15,819 of 22,439 invited children participated in the Puberty Cohort within the Danish National Birth Cohort. Participants completed a web-based questionnaire every 6 months through maturation with questions on current pubertal status. Girls reported current Tanner stage of breast and pubic hair development, and timing of menarche. Boys reported current Tanner stage of genital and pubic hair development, timing of first ejaculation, and vocal changes. While accounting for this interval-censored puberty information, we estimated the duration of puberty. Then, we used a nonlinear mixed effect growth model to estimate timing, tempo, synchronicity of puberty, and correlation between timing and tempo of puberty. RESULTS: In girls, the average duration of breast development was longer, whereas the average tempo was slower than pubic hair development. The average timing of breast development was earlier than the average timing of pubic hair development. The majority of girls had asynchronous puberty. In boys, the average duration was longer and average tempo slower for genital than pubic hair development. The average timing of genital and pubic hair development were comparable; hence, the majority had synchronous pubertal development. Adolescents who had earlier timing also tended to have a faster tempo. DISCUSSION: Being one of the largest puberty cohorts worldwide, these unique contemporary data can help physicians, parents, and children to understand and anticipate expected progression through pubertal development.

Understanding the pubertal, psychosocial, and cognitive developmental trajectories of stunted and non-stunted adolescents: protocol of a multi-site Indonesian cohort study.

Background: The prevalence of stunting among Indonesian children aged 5-12 years decreased from 30.7% in 2013 to 23.6% in 2018 but has remained among the highest rates worldwide. Furthermore, Indonesian children were shorter than the standard reported by the World Health Organization and experienced obesity. The Indonesian government has created many programs to reduce stunting in children under the age of 5 years. An early preventive strategy is necessary because stunting can manifest within the initial 1,000 days of life, including during pregnancy. Therefore, a newer perspective, such as that achieved by addressing stunting in adolescents, has been deemed useful, given that adolescents are in their pubertal stage and are undergoing lifestyle changes. This cohort study was designed to measure these factors comprehensively in stunted and non-stunted children as they pass through adolescence. Methods: For the prospective cohort, 560 individuals will be recruited from DKI Jakarta, DI Yogyakarta, and East Java. The participants will be categorized into stunted and non-stunted groups, then undergo annual examinations in which key objectives, such as weight, height, and body mass index ,will be assessed for the growth profile; waist circumference, middle-upper arm circumference, hand-grip strength, body fat percentage, and food intake will be evaluated in a nutritional assessment; psychosocial and mental issues will be evaluated according to behavioral problems, symptoms of depression, quality of life, sleep patterns, anxiety disorders, and parenting style through the use of specific questionnaires; and pubertal stage will be assessed using a self-report questionnaire. Some cross-sectional data, such as cognitive performance, hair zinc levels, vitamin D levels, bone mineral density, and bone age, will also be included. All the outcomes will be analyzed in accordance with the variable types. Discussion: This study provides a thorough dataset of Indonesian adolescents encompassing several elements, such as growth, nutrition, psychosocial wellbeing, mental health, and pubertal development, for both stunted and non-stunted individuals. The data acquired from this study can be used to formulate policies to prevent stunting through targeted interventions for adolescents. Finally, a better understanding of adolescent health could lead to improved strategies to decrease the number of stunted individuals in the next Indonesian generation.

Persistence and Variation of the Indirect Effects of COVID-19 Restrictions on the Spectrum of Notifiable Infectious Diseases in China: Analysis of National Surveillance Among Children and Adolescents From 2018 to 2021.

BACKGROUND: Beyond the direct effect of COVID-19 infection on young people, the wider impact of the pandemic on other infectious diseases remains unknown. OBJECTIVE: This study aims to assess changes in the incidence and mortality of 42 notifiable infectious diseases during the pandemic among children and adolescents in China, compared with prepandemic levels. METHODS: The Notifiable Infectious Disease Surveillance System of China was used to detect new cases and fatalities among individuals aged 5-22 years across 42 notifiable infectious diseases spanning from 2018 to 2021. These infectious diseases were categorized into 5 groups: respiratory, gastrointestinal and enterovirus, sexually transmitted and blood-borne, zoonotic, and vector-borne diseases. Each year (2018-2021) was segmented into 4 phases: phase 1 (January 1-22), phase 2 (January 23-April 7), phase 3 (April 8-August 31), and phase 4 (September 1-December 31) according to the varying intensities of pandemic restrictive measures in 2020. Generalized linear models were applied to assess the change in the incidence and mortality within each disease category, using 2018 and 2019 as the reference. RESULTS: A total of 4,898,260 incident cases and 3701 deaths were included. The overall incidence of notifiable infectious diseases decreased sharply during the first year of the COVID-19 pandemic (2020) compared with prepandemic levels (2018 and 2019), and then rebounded in 2021, particularly in South China. Across the past 4 years, the number of deaths steadily decreased. The incidence of diseases rebounded differentially by the pandemic phase. For instance, although seasonal influenza dominated respiratory diseases in 2019, it showed a substantial decline during the pandemic (percent change in phase 2 2020: 0.21, 95% CI 0.09-0.50), which persisted until 2021 (percent change in phase 4 2021: 1.02, 95% CI 0.74-1.41). The incidence of gastrointestinal and enterovirus diseases decreased by 33.6% during 2020 but rebounded by 56.9% in 2021, mainly driven by hand, foot, and mouth disease (percent change in phase 3 2021: 1.28, 95% CI 1.17-1.41) and infectious diarrhea (percent change in phase 3 2020: 1.22, 95% CI 1.17-1.28). Sexually transmitted and blood-borne diseases were restrained during the first year of 2021 but rebounded quickly in 2021, mainly driven by syphilis (percent change in phase 3 2020: 1.31, 95% CI 1.23-1.40) and gonorrhea (percent change in phase 3 2020: 1.10, 95% CI 1.05-1.16). Zoonotic diseases were not dampened by the pandemic but continued to increase across the study period, mainly due to brucellosis (percent change in phase 2 2020: 0.94, 95% CI 0.75-1.16). Vector-borne diseases showed a continuous decline during 2020, dominated by hemorrhagic fever (percent change in phase 2 2020: 0.68, 95% CI 0.53-0.87), but rebounded in 2021. CONCLUSIONS: The COVID-19 pandemic was associated with a marked decline in notifiable infectious diseases in Chinese children and adolescents. These effects were not sustained, with evidence of a rebound to prepandemic levels by late 2021. To effectively address the postpandemic resurgence of infectious diseases in children and adolescents, it will be essential to maintain disease surveillance and strengthen the implementation of various initiatives. These include extending immunization programs, prioritizing the management of sexually transmitted infections, continuing feasible nonpharmaceutical intervention projects, and effectively managing imported infections.

The Burden of Type 1 and Type 2 Diabetes Among Adolescents and Young Adults in 24 Western European Countries, 1990-2019: Results From the Global Burden of Disease Study 2019.

Objectives: As little is known about the burden of type 1 (T1DM) and type 2 diabetes (T2DM) in adolescents in Western Europe (WE), we aimed to explore their epidemiology among 10-24 year-olds. Methods: Estimates were retrieved from the Global Burden of Diseases Study (GBD) 2019. We reported counts, rates per 100,000 population, and percentage changes from 1990 to 2019 for prevalence, incidence and years lived with disability (YLDs) of T1DM and T2DM, and the burden of T2DM in YLDs attributable to high body mass index (HBMI), for 24 WE countries. Results: In 2019, prevalence and disability estimates were higher for T1DM than T2DM among 10-24 years old adolescents in WE. However, T2DM showed a greater increase in prevalence and disability than T1DM in the 30 years observation period in all WE countries. Prevalence increased with age, while only minor differences were observed between sexes. Conclusion: Our findings highlight the substantial burden posed by DM in WE among adolescents. Health system responses are needed for transition services, data collection systems, education, and obesity prevention.