Anxiety symptoms and disorders during the COVID-19 pandemic in children and adolescents: Systematic review and meta-analysis

Background and Objectives The COVID-19 pandemic and its associated factors have been shown to affect anxiety levels of young people. We meta-analytically assessed the prevalence of anxiety symptoms and anxiety disorders in children and adolescents during the pandemic, and the predictors and moderating factors influencing anxiety. Methods Multiple databases and registers were searched in this PRISMA and MOOSE-compliant systematic review and meta-analysis (PROSPERO:CRD42021266695) until 27/06/2021. We included individual studies evaluating the prevalence and characteristics of anxiety symptoms or anxiety disorders in children and adolescents (mean age ≤18 years), during the COVID-19 pandemic. Data extraction and quality assessment were carried out by independent authors. Random-effects meta-analyses of the prevalence of anxiety symptoms and anxiety disorders were conducted using Comprehensive Meta-Analysis (CMA) V3. Results 74 articles (total participant sample=478,882) were included (mean age=13.4 years, 52.3% female). The pooled rate of children and adolescents fulfilling diagnostic criteria for anxiety disorders was 13.0% (95%CI=4.9–30.1); the pooled prevalence of anxiety symptoms was 26.5% (95%CI=20.3–33.9). Anxiety symptoms were significantly more prevalent in females than males (B = 0.103, p<.001), significantly higher during the second wave of COVID-19, following July 2020, than during the first wave, prior to June 2020, (Q= 8.136, p=.017), and during school closure (Q= 8.100, p=.014). Quality of included studies was overall moderate. Conclusions There is a high prevalence of anxiety symptoms in children and adolescents during the COVID-19 pandemic, especially amongst females. This study identifies vulnerable groups, risk, and protective factors, which is crucial to developing clinical practice to prevent further mental health deterioration in young people. (AU)

Emotional status of children aged 7 to 17 of health workers and in the general population during the COVID-19 pandemic: A cross-sectional comparative study in Belgium.

Background: We assessed the mental health of children and adolescents aged 7 to 17 and their parents immediately after the first wave of the COVID-19 pandemic. Method: A survey online was conducted in Belgium between May 29th and August 31st 2020. Results: (1) Anxious and depressive symptoms were self-reported by one out of four children and hetero-reported by parents for one out of five children; (2) Anxiety scores were higher in children compared to adolescents; (3) Social introversion scores were significantly higher in adolescents compared to children; (4) No significant differences for anxio-depressive symptoms were found between healthcare worker parents and the other parents. Children's self- or hetero-reported symptoms were not found to be connected to parents' professional activities. Conclusions: This cross-sectional survey adds evidence to the impact the COVID-19 pandemic has had on children's and adolescents' emotional state, in particular on their levels of anxiety and depression.

Objectif: Nous avons évalué la santé mentale d'enfants et d'adolescents âgés de 7 à 17 ans et de leurs parents immédiatement après la première vague de la pandémie de COVID-19. Méthodologie: Une enquête en ligne a été réalisée en Belgique entre le 29 mai et le 31 août 2020. Résultats: (1) Les symptômes anxieux et dépressifs étaient auto-déclarés par un enfant sur quatre et hétéro-déclarés par les parents pour un enfant sur cinq ; (2) Les scores d'anxiété étaient plus élevés chez les enfants par rapport aux adolescents ; (3) Les scores d'introversion sociale étaient significativement plus élevés chez les adolescents par rapport aux enfants ; (4) Aucune différence significative pour les symptômes anxio-dépressifs n'a été trouvée entre les parents travailleurs de la santé et les autres parents. Les symptômes auto- ou hétéro-déclarés par les enfants ne se sont pas avérés être liés aux activités professionnelles des parents. Conclusions: Cette enquête transversale ajoute des preuves de l'impact de la pandémie de COVID-19 sur l'état émotionnel des enfants et des adolescents, en particulier sur leurs niveaux d'anxiété et de dépression.

Coping with the mental health impact of COVID-19: A study protocol for a multinational longitudinal study on coping and resilience during the COVID-19 pandemic.

BACKGROUND: Mental health is challenged due to serious life events such as the COVID-19 pandemic and can differ by the level of resilience. National studies on mental health and resilience of individuals and communities during the pandemic provide heterogeneous results and more data on mental health outcomes and resilience trajectories are needed to better understand the impact of the pandemic on mental health in Europe. METHODS: COPERS (Coping with COVID-19 with Resilience Study) is an observational multinational longitudinal study conducted in eight European countries (Albania, Belgium, Germany, Italy, Lithuania, Romania, Serbia, and Slovenia). Recruitment of participants is based on convenience sampling and data are gathered through an online questionnaire. gathering data on depression, anxiety, stress-related symptoms suicidal ideation and resilience. Resilience is measured with the Brief Resilience Scale and with the Connor-Davidson Resilience Scale. Depression is measured with the Patient Health Questionnaire, Anxiety with the Generalized Anxiety Disorder Scale and stress-related symptoms with the Impact of Event Scale Revised- Suicidal ideation is assessed using item 9 of the PHQ-9. We also consider potential determinants and moderating factors for mental health conditions, including sociodemographic characteristics (e.g., age, gender), social environmental factors (e.g., loneliness, social capital) and coping strategies (e.g., Self-efficacy Belief). DISCUSSION: To the best of our knowledge, this is the first study to multi-nationally and longitudinally determine mental health outcomes and resilience trajectories in Europe during the COVID-19 pandemic. The results of this study will help to determine mental health conditions during the COVID-19 pandemic across Europe. The findings may benefit pandemic preparedness planning and future evidence-based mental health policies.

Dimensional model on how familial vulnerability and environmental factors impact transitional age youth psychopathology: The Transition_psy study.

Background: Understanding psychopathology in transitional age youth (TAY) requires a complex model, incorporating familial vulnerability and environmental factors. A trans-diagnostic and dimensional approach seems the most appropriate. Transition_psy study aims to assess factors playing a role in TAY psychopathology and to define predictors. Materials and methods: This article presents part of the Transition_psy study results, a case-control observational study. Youth aged 17 years old were recruited between June 2020 and December 2021, from both clinical [clinical population (CP) group] and non-clinical settings [non-clinical population (NCP) group]. Participants completed self-report questionnaires. The primary outcome to assess TAY psychopathology was the Youth-Self Report (YSR). We evaluated care needs with the Health of The Nation Outcome Scales For Children And Adolescents (HoNOSCA-SR) and quality of life with the World Health Organization Quality of Life - BREF (WHOQoL-BREF). Exposure factors included familial vulnerability, childhood, and present environmental factors, such as first-degree family history of psychopathology, the Childhood Trauma Questionnaire (CTQ) and the Family Assessment Device (FAD). YSR scores were compared, between groups, according to exposure factors with ANOVA and linear regression. We performed best subsets selection of multivariable analyses based on the Akaike Information Criterion. This study was registered with ClinicalTrials.gov (Identifier: NCT04333797). Results: A total of 220 TAY (CP = 106, NCP = 114) were included in the study. Participants were aged 17 years old. The majority were female (69.1%), single (96.8%), and born in Belgium (82.3%). Clinical data were all significantly different between CP and NCP groups. YSR scores were found statistically different according to group (p < 0.001), first-degree family history of psychopathology (p < 0.001), CTQ (p < 0.001), and FAD (p < 0.001). Predictive dimensional model suggested that TAY psychopathology can be predicted by group, CTQ and FAD. Significant positive correlation was found between YSR and HoNOSCA (rho = 0.81) and negative correlation between YSR and physical and psychological health (rho = -0.69 and -0.71, respectively). Conclusion: This study findings allowed to present a predictive dimensional model on TAY psychopathology, including belonging to a clinical population at transitional age, childhood trauma, and family dysfunction. Further research is needed to replicate Transition_psy study results in other samples. The proposed model could be used in clinical practice to improve assessment of TAY psychopathology.

Case report: From anxiety disorders to psychosis, a continuum in transitional age youth?

Introduction: To date, among individuals meeting ultra-high risk criteria for psychosis, the relationship between the presence of anxiety disorders and the risk of psychotic transition raises several unanswered questions. Case description: This case report describes the clinical progression of a 17-year-old male initially presenting anxious symptoms meeting the DSM-V criteria for panic disorder. The patient also reported social withdraw, mild depressive symptoms, insomnia and fatigue. Over a 6 month period, a gradual onset of subthreshold psychotic symptoms suggested a prodromal phase of a psychotic disorder. Diagnostic assessment and therapeutic intervention: A detailed assessment of UHR criteria for psychosis was performed. The overall level of social and occupational functioning was assessed by the SOFAS, which showed a 35% drop over a 12 months period. The CAARMS, has also been administered. The patient met the diagnostic criteria for UHR, APS group. The care plan included psychiatric follow-up, pharmacologic treatment, individual psychological follow-up and individual and familial psychoeducation. Over a 6 months period, the patient did not experienced a first psychotic episode and presented a partial improvement of psychotic symptoms. Conclusion: The DSM-V categorical approach does not seem to adapt well to early clinical presentations in transitional age youth. A transdiagnostic and dimensional approach allows to better identify at-risk patients of psychiatric disorders and implement early intervention strategies.

Child, adolescent, and parent mental health in general population during a year of COVID-19 pandemic in belgium: a cross-sectional study.

BACKGROUND: This study aims to evaluate the mental health status of children, adolescents and their parents during the first year of COVID-19 pandemic in Belgium. METHOD: Analysis compared results before and during the second national lockdown, which started on November 2nd 2020. A cross-sectional online survey was conducted between May 2020 and April 2021. RESULTS: Two hundred and eighteen adults and 273 children fully completed the survey. Almost one in five children (17.9%) presented moderate-to-severe scores of depression. Adolescents presented a higher level of depression than children (p = 0.007). The rate of moderate-to-severe depression scores (10.8% to 21%, p = 0.007) and internalized symptoms increased during the second lockdown (p < 0.001). Parents' depression (p < 0.001) and anxiety (p = 0.027) levels also increased during the second lockdown. Logistic regression showed that the use of psychotropic medication in parents and parents' depression scores were risk factors for children to have worse depression scores. CONCLUSION: The second lockdown appears to worsen the effects of the pandemic on children's and parents' mental health. There is a need to implement specific interventions targeting both children/adolescents and their parents to support them during lockdown periods and improve mental health outcomes.

The Transition from Child and Adolescent Mental Health Services (CAMHS) To Adult Mental Health Services (AMHS): What about Autism Spectrum Disorder?

BACKGROUND: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder and a long-term condition that may require psychiatric life-long care. Transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) possibly concerns a great portion of patients with ASD. This study focuses on transitional age youth (TAY) with ASD and proposes specific innovative tools to manage the transition process. SUBJECTS AND METHODS: This explorative study focuses on TAY with ASD. Data on socio-demographic characteristics and personal medical history was collected. Three self-rated questionnaires were used: the Health of The Nation Outcome Scales For Children And Adolescents (HoNOSCA-SR), to assess care need, the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale and the Transition Readiness and Appropriateness Measure (TRAM), to evaluate barriers to functioning. RESULTS: The sample was composed of 10 patients with ASD aged from 17 to 18. The majority of them were male (70%) and born in Belgium (60%). The median (interquartile range) age of ASD diagnosis was 16 (13-17). The comorbidity rate was 60% for psychiatric disorders and 30% for somatic diseases; 80% of the participants were under psychotropic drugs. The average questionnaires scores were respectively: HoNOSCA-SR = 21.63 (±9.90), WHOQOL-BREF physical health = 50.88 (±19.14), psychological health = 36.13 (±13.97), social relationships = 48.50 (±18.23) and environment = 59.38 (±14.08); TRAM's number of barriers to functioning were 4.25 (±1.39). CONCLUSIONS: These preliminary data, accompanied by current recommendations, allow to clarify the strategies to an optimal transition in ASD. Special insight is given to strategies to reach a well-managed transition from CAMHS to AMHS, such as the assessment of psychiatric and somatic comorbidities, the care need continuity, the elaboration, in advance, of a transition plan, the assessment of the barriers to functioning, and the involvement of young patients and their families.

Outpatient Care in Psychiatry for Transitional Age Youth (16 to 24 Years Old): Which Trajectories of Psychiatric Care in French-Speaking Belgium?

BACKGROUND: Transitional age youth (TAY) are a particularly at-risk population in mental health. They have specific needs, not currently covered between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS), mainly because of existing barriers. This retrospective study was carried out to describe sociodemographic and clinical characteristics of patients who attended a new outpatient program specifically conceived for TAY in Brussels, Belgium. Outcomes related to trajectories of psychiatric care were analysed, such as leading symptom, consultation's referral and requester, and final orientation. SUBJECTS AND METHODS: The total sample included 243 patients aged from 16 to 24 years old who presented for care in this outpatient program between October 2019 and May 2021. Data were retrospectively extracted from each patient's electronic medical records. RESULTS: The sample was mainly composed by female participants; the average age was 18.7 (±2.0) years. General practitioner (18.9%), child and adolescent psychiatrist (18.1%), psychologist (11.5%) and adult psychiatrist (7.4%) referred patients. Leading symptoms were divided into three dimensions: internalizing (67.5%), externalizing (21.8%) and psychotic (10.7%) ones. After first assessment, 81.5% of youth were followed-up in our specific outpatient program. Overall, at the end of data collection, youth were orientated towards ongoing follow-up in this program (37%), AMHS care (21.8%), end of psychiatric care (17.3%) and CAMHS care (4.1%). 19.8% patients discontinued the proposed care. CONCLUSIONS: This psychiatric outpatient program for TAY represents an innovative contribution to reinforce CAMHS-AMHS interface in French-speaking Belgium. The analysis of trajectories in psychiatric care suggests positive outcomes of this TAY-tailored clinical program to achieve high quality standard of care in youth mental health. Future research and clinical implementation programs should further explore which factors influence decision-making process in TAY psychiatric assessment and care.

Study Protocol: Transition_psy a Multicenter Prospective Longitudinal Cohort Study Assessing Risk and Protective Factors to Develop Psychopathology in Transitional Age Youth in Belgium.

Introduction: Emerging adults are a particularly at-risk population in mental health. The primary aim of the Transition_psy study is to evaluate changes in mental health care need and quality of life during transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS). The relationship between these changes and genetic or environmental vulnerabilities and clinical dimensions representing risk and protective factors to the development of psychopathology will be analyzed. We also aim to explore how each factor plays, specifically, a role in developing internalizing and externalizing symptoms, in order to predict the most common paths of psychopathology in transitional age youth (TAY). Methods and Analysis: Transition_psy is a multicenter prospective longitudinal cohort study. The transversal and trans-diagnostic approach consists of a dimensional evaluation: 300 youth at the age of 17 will be included in a cohort of in-patients, out-patients and control group. Participants will be assessed at baseline (T0) and 24 months later (T1). The primary objective to determine changes in self-rated Health Of The Nation Outcome Scales For Children And Adolescents (HONOSCA-SR) and WHO Quality of Life-BREF (WHOQOL-BREF) scores between T0 and T1. Pearson correlation and mediation analysis will be performed. A secondary objective analysis using mediation and moderation models with several dimensional aspects, including self-reported and cognitive measures, will be conducted to disentangle the potential relationships between the two scores. Discussion: Transition from CAMHS to AMHS occurs at a crucial age in terms of the continuum between adolescent and adulthood psychopathology. This collaborative and cohesive protocol between CAMHS and AMHS represents the first national cohort study about Transition Psychiatry in French-speaking Belgium. Ethics and Dissemination: The study protocol was approved by the Institutional Review Boards (IRB) of the three participating sites. Results will be published in peer-reviewed journals and disseminated at national and international conferences. This trial was registered in ClinicalTrials.gov (Identifier: NCT04333797) on 3 April 2020.

Study of resilience and loneliness in youth (18-25 years old) during the COVID-19 pandemic lockdown measures.

This study evaluated the risks and protective factors in mental health in 825 emerging adults aged from 18 to 25 years old in Belgium and in Italy. Resilience, loneliness and social, and family context were explored to determine their specific role in coping with the emotional distress that spread worldwide during the coronavirus disease 2019 (COVID-19) pandemic. We conducted an online survey on the secured platform Research Electronic Data Capture©. Data were collected between April 7th and May 4th, 2020. The primary outcomes were the resilience scale for adults (RSA) and the University of California Los Angeles Loneliness Scale. The secondary outcomes included mental health status in terms of professional help seeking, use of psychotropic drugs, admission to a psychiatric department before and during lockdown measures. Responders were divided into three groups following the mental healthcare needs (MHCN) before and after the lockdown measures. The group who experienced an increase in MHCN represented almost 5% of the assessed youth. Statistically significant differences were found in means of RSA total score and RSA perception of self. This study enlightens the possibly traumatic impact of the COVID-19 pandemic on at-risk youth's mental health. Early detection and intervention should be structured in large-scale disasters.