Mental Health Admissions to Paediatric Wards Study (MAPS): protocol of a prospective study of mental health admissions to paediatric wards in England using surveillance and qualitative methods.

INTRODUCTION: Children and young people (CYP) presenting with a mental health (MH) crisis are frequently admitted to general acute paediatric wards as a place of safety. Prior to the pandemic, a survey in England showed that CYP occupied 6% of general paediatric inpatient beds due to an MH crisis, and there have been longstanding concerns about the quality of care to support these patients in this setting. MAPS aims to generate a Theory of Change (ToC) model to improve the quality of care for CYP admitted to acute paediatric services after presenting with an MH crisis. Here, we describe work packages (WPs) 2 and 3 of the study, which have been granted ethics approval. METHODS AND ANALYSIS: We will undertake a national (England), sequential, mixed-methods study to inform a ToC framework alongside a stakeholder group consisting of patients, families/carers and healthcare professionals (HCPs). Our study consists of four WPs undertaken over 30 months. WP2 is limited to working with stakeholders to develop a data collection instrument and then use this in a prospective study of MH admissions over 6 months in 15 purposively recruited acute paediatric wards across England. WP3 consists of gathering the views of CYP, their families/carers and HCPs during admissions using semistructured interviews. ETHICS AND DISSEMINATION: WP2 and WP3 received ethical approval (ref: 23/LO/0349). We will publish the overall synthesis of data and the final ToC to improve care of CYP with MH crisis admitted to general acute paediatric settings. As co-producers of the ToC, we will work with our stakeholder group to ensure wide dissemination of findings. Potential impacts will be upon service development, new models of care, training and workforce planning. PROSPERO REGISTRATION NUMBER: CRD42022350655.

Mental Health Admissions to Paediatric Wards Study (MAPS): a protocol for the analysis of Hospital Episode Statistics (HES) data.

INTRODUCTION: Children and young people (CYP) presenting with a mental health (MH) crisis are frequently admitted to general acute paediatric wards as a place of safety. Prior to the pandemic, a survey in England showed that CYP occupied 6% of general paediatric inpatient beds due to an MH crisis, and there have been longstanding concerns about the quality of care to support these patients in this setting. Mental Health Admissions to Paediatric Wards Study aims to generate a theory of change (ToC) model to improve the quality of care for CYP admitted to acute paediatric services after presenting in a MH crisis. METHODS AND ANALYSIS: We will undertake a national (England), sequential, mixed methods study to inform a ToC framework alongside a stakeholder group consisting of patients, families/carers and healthcare professionals (HCPs). Our study consists of four work packages (WP) undertaken over 30 months. WP1 is limited to using national routine administrative data to identify and characterise trends in MH admissions in acute paediatric wards in England between 2015- 2022. ETHICS AND DISSEMINATION: WP1 received ethical approval (Ref 23/NW/0192). We will publish the overall synthesis of data and the final ToC to improve care of CYP with MH crisis admitted to general acute paediatric settings. As coproducers of the ToC, we will work with our stakeholder group to ensure wide dissemination of findings. Potential impacts will be on service development, new models of care, training and workforce planning.

Risk factors for post-COVID-19 condition in previously hospitalised children using the ISARIC Global follow-up protocol: a prospective cohort study.

BACKGROUND: The long-term sequelae of coronavirus disease 2019 (COVID-19) in children remain poorly characterised. This study aimed to assess long-term outcomes in children previously hospitalised with COVID-19 and associated risk factors. METHODS: This is a prospective cohort study of children (≤18 years old) admitted to hospital with confirmed COVID-19. Children admitted between 2 April 2020 and 26 August 2020 were included. Telephone interviews used the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 Health and Wellbeing Follow-up Survey for Children. Persistent symptoms (>5 months) were further categorised by system(s) involved. RESULTS: 518 out of 853 (61%) eligible children were available for the follow-up assessment and included in the study. Median (interquartile range (IQR)) age was 10.4 (3-15.2) years and 270 (52.1%) were girls. Median (IQR) follow-up since hospital discharge was 256 (223-271) days. At the time of the follow-up interview 126 (24.3%) participants reported persistent symptoms, among which fatigue (53, 10.7%), sleep disturbance (36, 6.9%) and sensory problems (29, 5.6%) were the most common. Multiple symptoms were experienced by 44 (8.4%) participants. Risk factors for persistent symptoms were: older age "6-11 years" (OR 2.74, 95% CI 1.37-5.75) and "12-18 years" (OR 2.68, 95% CI 1.41-5.4), and a history of allergic diseases (OR 1.67, 95% CI 1.04-2.67). CONCLUSIONS: A quarter of children experienced persistent symptoms months after hospitalisation with acute COVID-19 infection, with almost one in 10 experiencing multisystem involvement. Older age and allergic diseases were associated with higher risk of persistent symptoms at follow-up.

Study Protocol for "Psilocybin as a Treatment for Anorexia Nervosa: A Pilot Study".

Background: Anorexia nervosa (AN) is a serious and life-threatening psychiatric condition. With a paucity of approved treatments, there is a desperate need for novel treatment avenues to be explored. Here, we present (1) an overview of the ways through which Public Patient Involvement (PPI) has informed a trial of psilocybin-assisted therapy for AN and (2) a protocol for a pilot study of psilocybin-assisted therapy in AN currently underway at Imperial College London. The study aims to assess the feasibility, brain mechanisms and preliminary outcomes of treating anorexia nervosa with psilocybin. Methods: (1) PPI: Across two online focus groups, eleven individuals with lived experience of AN were presented with an overview of the protocol. Their feedback not only identified solutions to possible barriers for future participants, but also helped the research team to better understand the concept of "recovery" from the perspective of those with lived experience. (2) Protocol: Twenty female participants [21-65 years old, body mass index (BMI) 15 kg/m2 or above] will receive three oral doses of psilocybin (up to 25 mg) over a 6-week period delivered in a therapeutic environment and enveloped by psychological preparation and integration. We will work with participant support networks (care teams and an identified support person) throughout and there will be an extended remote follow-up period of 12 months. Our two-fold primary outcomes are (1) psychopathology (Eating Disorder Examination) across the 6-month follow-up and (2) readiness and motivation to engage in recovery (Readiness and Motivation Questionnaire) across the 6-week trial period. Neurophysiological outcome measures will be: (1) functional magnetic resonance imaging (fMRI) brain changes from baseline to 6-week endpoint and (2) post-acute changes in electroencephalography (EEG) activity, including an electrophysiological marker of neuronal plasticity. Discussion: The results of this pilot study will not only shed light on the acceptability, brain mechanisms, and impression of the potential efficacy of psilocybin as an adjunct treatment for AN but will be essential in shaping a subsequent Randomised Control Trial (RCT) that would test this treatment against a suitable control condition. Clinical Trial Registration: identifier: NCT04505189.

Roles of cyberbullying, sleep, and physical activity in mediating the effects of social media use on mental health and wellbeing among young people in England: a secondary analysis of longitudinal data.

BACKGROUND: There is growing concern about the potential associations between social media use and mental health and wellbeing in young people. We explored associations between the frequency of social media use and later mental health and wellbeing in adolescents, and how these effects might be mediated. METHODS: We did secondary analyses of publicly available data from the Our Futures study, a nationally representative, longitudinal study of 12 866 young people from age 13 years to 16 years in England. The exposure considered was the frequency of social media use (from weekly or less to very frequent [multiple times daily]) at wave 1 (participants aged 13-14 years) through wave 3 of the study (participants aged 15-16 years). Outcomes were mental health at wave 2 (with high 12-item General Health Questionnaire [GHQ12] scores [≥3] indicating psychological distress), and wellbeing at wave 3 (life satisfaction, feeling life is worthwhile, happiness, and anxiety, rated from 1 to 10 by participants). Analyses were adjusted for a minimal sufficient confounding structure, and were done separately for boys and girls. Cyberbullying, sleep adequacy, and physical activity were assessed as potential mediators of the effects. FINDINGS: Very frequent use of social media increased from wave 1 to wave 3: from 34·4% (95% CI 32·4-36·4) to 61·9% (60·3-63·6) in boys, and 51·4% (49·5-53·3) to 75·4% (73·8-76·9) in girls. Very frequent social media use in wave 1 predicted a high GHQ12 score at wave 2 among girls (adjusted odds ratio [OR] 1·31 [95% CI 1·06-1·63], p=0·014; N=4429) and boys (1·67 [1·24-2·26], p=0·0009; N=4379). Persistent very frequent social media use across waves 1 and 2 predicted lower wellbeing among girls only (adjusted ORs 0·86 [0·74-0·99], N=3753, p=0·039 for life satisfaction; 0·80 [0·70-0·92], N=3831, p=0·0013 for happiness; 1·28 [1·11-1·48], N=3745, p=0·0007 for anxiety). Adjustment for cyberbullying, sleep, and physical activity attenuated the associations of social media use with GHQ12 high score (proportion mediated 58·2%), life satisfaction (80·1%), happiness (47·7%), and anxiety (32·4%) in girls, such that these associations (except for anxiety) were no longer significant; however, the association with GHQ12 high score among boys remained significant, being mediated only 12·1% by these factors. INTERPRETATION: Mental health harms related to very frequent social media use in girls might be due to a combination of exposure to cyberbullying or displacement of sleep or physical activity, whereas other mechanisms appear to be operative in boys. Interventions to promote mental health should include efforts to prevent or increase resilience to cyberbullying and ensure adequate sleep and physical activity in young people. FUNDING: None.

Low levels of knowledge on the assessment of underweight in children and adolescents among middle-grade doctors in England and Wales.

BACKGROUND: Safe assessment of severe underweight in children is important but experience suggests a frequent lack of understanding. Here we sought evidence from a wide spectrum of trainees. METHODS: Cross-sectional telephone survey of an on-call middle-grade paediatric doctor in hospitals providing acute inpatient general paediatric care in England and Wales. RESULTS: Response rate was 100%. Only 50% identified BMI as the appropriate measure for underweight in children. Most did not identify any clinical cardiovascular complications of severe underweight. Only 13% identified corrected QT time (QTc) as an important ECG finding. Knowledge of the refeeding syndrome was poor with 20% unable to define it at all, 21% able to identify some clinical features and 57% aware of potential phosphate abnormalities. CONCLUSIONS: Knowledge base among middle-grades doctors in England and Wales on this topic is worryingly poor, particularly in relation to several life-threatening features. Existing and new training approaches should recognise this.

Early intervention in eating disorders: a parent group approach.

AIM: Early intervention in eating disorders (EDs) has been a neglected area. Peak onset is in adolescence, suggesting that early intervention should include parents. We synthesize findings from five key theoretical domains, and present pilot data from a phase-specific early intervention for new onset EDs in young people. METHODS: From literature searches, we reviewed current knowledge on risk factors for EDs; ED prevention in young people; the evidence base for treatment for young people with EDs; early intervention in other mental health fields; and parenting interventions. Based on these findings, we devised and piloted a parent group intervention. RESULTS: Presenting features are typically parental concern about changes in eating behaviour and/or weight loss. There is a delay between symptom onset and help seeking, by which time the illness is well established. Early intervention should therefore target parents and be delivered at secondary rather than primary care. Effective treatments favour family-focused interventions with parental responsibility for symptom management. We hypothesized that a parents' group might be effective for addressing the specific emotional experience of parents in the early stages and their relative lack of knowledge and understanding. Pilot data show significant improvements in knowledge, skills, confidence, understanding and their child's adherence to meal plans as a result of a 6-week parent group intervention. CONCLUSION: A parent group intervention addressing themes identified from risk factor, prevention and treatment research is a potentially promising approach to early intervention for EDs. The impact of the intervention on patient outcome needs evaluation.

Medical instability and growth of children and adolescents with early onset eating disorders.

OBJECTIVE: Little is known about the physical burden of early onset eating disorders (EOEDs). Most published data on physical instability and growth in malnutrition come from specialist centres, or from the developing world where aetiology differs. The authors present data on physical status at presentation from population-based surveillance systems in the UK and Ireland. DESIGN: Prospective surveillance study. PARTICIPANTS: All suspected cases of EOED in children under 13 years of age reported by paediatricians and psychiatrists via the British Paediatric Surveillance System (BPSU) and Child and Adolescent Psychiatric Surveillance System (CAPSS) in the UK and Ireland from March 2005 to May 2006 (15 months). RESULTS: 208 cases were identified (24% reported by paediatricians). Median age was 11.8 years (IQR 1.74). 171 (82%) were female (78% premenarcheal and 60% prepubertal). 74% of males were prepubertal. 35% of cases had medical instability at presentation (60% bradycardia, 54% hypotension, 34% dehydration, 26% hypothermia). 52% of cases required admission at diagnosis (73% to a paediatric ward). 41% of cases with medical instability were not underweight, that is, they had body mass index (BMI) z-scores above -2.0 (2nd centile). Sensitivities for identifying medical instability with BMI z-score <-3 or 70% median BMI were 31% and 15%, respectively. Menarcheal status did not predict risk of medical instability. CONCLUSIONS: EOEDs present with severe levels of physical instability and frequently to paediatricians. As anthropological indices alone are poor markers for medical instability, clinical assessment is essential. Doctors providing care for children have a central role in both the recognition and management of EOEDs.

Childhood eating disorders: British national surveillance study.

BACKGROUND: The incidence of eating disorders appears stable overall, but may be increasing in younger age groups. Data on incidence, clinical features and outcome of early-onset eating disorders are sparse. AIMS: To identify new cases of early-onset eating disorders (<13 years) presenting to secondary care over 1 year and to describe clinical features, management and 1-year outcomes. METHOD: Surveillance over 14 months through the established British Paediatric Surveillance System, and a novel child and adolescent psychiatry surveillance system set up for this purpose. RESULTS: Overall incidence was 3.01/100,000 (208 individuals). In total, 37% met criteria for anorexia nervosa; 1.4% for bulimia nervosa; and 43% for eating disorder not otherwise specified. Nineteen per cent showed determined food avoidance and underweight without weight/shape concerns. Rates of comorbidity were 41%; family history of psychiatric disorder 44%; and early feeding difficulties 21%. Time to presentation was >8 months. A total of 50% were admitted to hospital, typically soon after diagnosis. Outcome data were available for 76% of individuals. At 1 year, 73% were reported improved, 6% worse and 10% unchanged (11% unknown). Most were still in treatment, and seven were hospital in-patients for most of the year. CONCLUSIONS: Childhood eating disorders represent a significant clinical burden to paediatric and mental health services. Efforts to improve early detection are needed. These data provide a baseline to monitor changing trends in incidence.

Childhood risk factors for lifetime anorexia nervosa by age 30 years in a national birth cohort.

OBJECTIVE: To examine whether previously identified childhood risk factors for anorexia nervosa (AN) predict self-reported lifetime AN by age 30 years in a prospective birth cohort. METHOD: Using data from the 1970 British Cohort Study, at birth, 5, 10, and 30 years, we examined associations between suggested childhood risk factors and self-reported lifetime AN at 30 years, adjusted for sex and socioeconomic status. RESULTS: Anorexia nervosa was independently predicted by female sex (odds ratio [OR] 22.1), infant feeding problems (OR 2.6), maternal depressive symptoms (OR 1.8), and a history of undereating (OR 2.7). High self-esteem (OR 0.3) and higher maternal body mass index (OR 0.91) were protective. CONCLUSIONS: Of 22 suggested risk factors for AN, only four risk and two protective factors were confirmed in this prospective cohort study. We did not identify a role for perinatal factors, parenting, childhood body mass index, childhood emotional or sleep problems, academic ability, or exercise.