Attachment theory: survival, trauma, and war through the eyes of Bowlby.

Children are no strangers to war and conflict, and for as long as history has been documented, so too has the negative impact of war on children. Attachment theory, which has shone a light upon the ways in which early life experiences can impact individuals across the lifespan, is a helpful lens through which we can view the consequences of war. Similar to the aftermath of war leading to lifelong and transgenerational suffering due to deaths and physical health issues, attachment difficulties created during war further compound long-term damage. Yet, despite our theoretical understanding of the detrimental impact of war on children and on humankind, humanity has failed to find ways to avert, or at least minimise, this unfortunate risk. Instead in this century, we see a growing number of conflicts globally with increasing asylum seekers. In this editorial, we argue that the large-scale disruption to attachment relationships caused by conflict and war is an important consideration for global policy, and that the healthcare community must show leadership in highlighting this serious impact of war.

Functional impairment and quality of life in newly diagnosed adults attending a tertiary ADHD clinic in Ireland.

BACKGROUND: Attention Deficit-Hyperactive Disorder (ADHD) is a neurodevelopmental disorder, often persisting into adulthood. AIMS: To investigate the levels of functionality and quality of life (QoL) in adult patients newly diagnosed with ADHD and to compare with those without an ADHD diagnosis. METHODS: Consecutive patients who were referred to and assessed in a tertiary adult ADHD clinic enrolled in the study. Diagnosis of ADHD was based on DSM-5 criteria. Functionality was measured using the Weiss Functional Impairment Rating Scale (WFIRS) and the Global Assessment of Functioning Scale (GAF). QoL was assessed with the Adult ADHD Quality of Life Questionnaire (AAQoL). RESULTS: Three-hundred and forty participants were recruited, 177 (52.1%) females. Of them 293 (86.2%) were newly diagnosed with ADHD. Those with ADHD had significant lower functionality as it was measured with the WFIRS and GAF, and worse QoL (AAQoL) compared to those without. In addition, a significant correlation between GAF and WFIRS was found. CONCLUSIONS: The results show that adults with ADHD have decreased functionality and worse QoL when compared against those presenting with a similar symptomatology, but no ADHD diagnosis. ADHD is not just a behavioural disorder in childhood, but a lifelong condition with accumulating problems that can lead to lower QoL and impaired functioning throughout adulthood.

The use of telehealth in attention-deficit/hyperactivity disorder: a survey of parents and caregivers.

The use of telehealth became widespread during the COVID-19 pandemic, including in child and adolescent attention-deficit/hyperactivity disorder (ADHD) services. Telehealth is defined as live, synchronous phone and video appointments between a healthcare provider and a parent and/or child with ADHD. There is a dearth of research on the use of telehealth within this population. The aim of this study was to examine parents' and caregivers' perceptions of telehealth for children and adolescents with ADHD. A cross-sectional survey design was employed. Recruitment of parents and caregivers of children and adolescents with ADHD was conducted online. The survey asked participants about their views of telehealth, previous experience, and willingness to use telehealth. Quantitative data were analysed using STATA. Qualitative data were analysed using content analysis. One hundred and twelve respondents participated in the survey. Participants were mostly female (n = 97, 86.6%) and aged between 45 and 54 (n = 64, 57.1%). Of the 61 (54.5%) participants with experience of telehealth, the majority reported that that they were at least satisfied with telehealth visits (n = 36, 59%), whilst approximately half rated their quality more poorly than in-person visits (n = 31, 50.8%). The majority of respondents (n = 91, 81.3%) reported that they would be willing to use telehealth for their child's future appointments. Most common reasons selected for wanting to use telehealth included saving time, improvements to the family routine, and reducing costs. Reasons selected for not wanting to use telehealth included not being able to receive hands-on care, belief that the quality of care is poorer than in-person consultations, and distraction of the child during telehealth visits. The study demonstrates that parents recognise deficits and benefits of telehealth, suggesting a need to build their trust and confidence in remote ADHD care.

Turning 18 in mental health services: a multicountry qualitative study of service user experiences and views.

BACKGROUND: Worldwide, the division between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) has frequently resulted in fragmented care with an unprepared, non-gradual transition. To improve continuity of care and other service transition experiences, service user input is essential. However, such previous qualitative studies are from a decade ago or focused on one mental disorder or country. The aim of the present study was to learn from service users' transition experiences and suggested improvements. METHODS: Semi-structured interviews were held with young people aged 18-24 and/or parents/caregivers in the United Kingdom, Ireland, the Netherlands and Croatia. Inclusion was based on the experience of specialist mental health care before and after turning 18. Thematic analysis of transcribed and translated interview transcripts was performed using ATLAS.ti 9. RESULTS: Main themes of service user experiences included abrupt changes in responsibilities, various barriers and a lack of preparation, communication and ongoing care. Young people expressed a great need for continuity of care. Their suggestions to improve transitional care included early and adequate preparation, joint working, improved communication from and between services, overlapping services, staying at CAMHS for longer and designated youth mental health teams. CONCLUSIONS: Young people who experienced care before and after turning 18 suggested either altering the age limits of services or ensuring early preparation and communication regarding the transition and finding AHMS. This communication should include general changes when turning 18. Further considerations include increasing collaboration and overlap between CAMHS and AMHS.

Eating disorders and COVID-19 - different or just more?

BACKGROUND: COVID-19 saw an increase in child mental health presentations internationally. Clinicians analogised the exponential increase in anorexia nervosa to a 'tsunami' or 'outbreak', raising parallel concerns regarding medical and psychological risks (Marsh in The Guardian, 2021; Leask in NZ Herald, 2021; Monteleone et al. in Eat Weight Disord 26(8):2443-2452, 2021) . It is unclear whether Ireland emulated this picture of increased referrals with increased medical compromise. AIMS: This paper examines both rates and clinical profiles of child eating disorder presentations in the Republic of Ireland (ROI), across different clinical settings. METHODS: Following ethical approval, retrospective chart reviews were conducted in a community eating disorder service and in two paediatric hospital settings. The time frame of the different studies ranged from January 2016 to December 2022. RESULTS: Community eating disorder services saw significantly higher referral rates post COVID-19 (3.78/month vs. 2.31/month, p = 0.02), with a shorter duration of illness (4.8 months vs. 7.4 months, p = 0.001), but no significant difference in ideal body weight % (IBW%) at referral (85.32% vs. 83.7%, p = 0.1). Both paediatric hospitals witnessed significantly increased referrals post-COVID-19 (hospital 1; 4.38/month vs. 1.93/month, p = 0.0001; hospital 2; 2.8/month vs. 0.92/month, p < 0.0001), but no significant difference in IBW% at assessment (hospital 1; 82.7% vs. 81.39%, p = 0.673; hospital 2; 81.5% vs. 83%, p = 0.563). There was no significant difference in clinical profile, management, or duration of hospital stay. CONCLUSIONS: This study supports the growing consensus of a pandemic specific increase in eating disorder referrals to both medical and psychiatry services. However, there was little to indicate a change in clinical profile or severity. Ongoing monitoring of referrals is necessary to ensure adequate service availability and expertise.

A systematic review of COVID-19 and the presentation of avoidant/restrictive food intake disorder and avoidant/restrictive food intake disorder-like symptoms.

BACKGROUND: The adverse effects of COVID-19 and the associated restrictions on eating disorder populations have been discussed in recent literature. However, little is known about the presentation of cases with avoidant/restrictive food intake disorder (ARFID) during this period. AIMS: To explore the extent of the literature on the presentation of ARFID, and ARFID-like cases, during the COVID-19 pandemic. METHOD: Cochrane Library, CINAHL (EBSCO), PsycINFO (EBSCO), EMBASE (Ovid) and Medline (Ovid) were searched for publications between March 2020 and May 2023. Google Scholar and reference lists were hand searched. At least two reviewers independently screened each paper. Narrative synthesis was used. RESULTS: Seven papers were included: four case reports and three cohort studies (total ARFID sample of 46). Included papers were assessed as having high (n = 3) or moderate (n = 4) quality. Findings did not suggest an increase in ARFID cases during the COVID-19 pandemic, although it is unclear if this is because of a lack of impact or underrecognition of ARFID. A need for a multidisciplinary approach to differentiate between ARFID and organic causes of ARFID-like presentations (e.g. gastrointestinal effects of COVID-19) was highlighted. CONCLUSIONS: Publications specifically pertaining to ARFID presentations during the COVID-19 pandemic have been few. Papers found have been of small sample sizes and lack subanalyses for ARFID within broader eating disorder samples. Continued surveillance is needed to evaluate any COVID-19-specific effects on the development, identification, treatment and outcomes of ARFID.

"We're seen as part of the supply chain of medicines rather than as the professionals that we are": The wellbeing of community pharmacists during the COVID response.

INTRODUCTION: Challenges facing community pharmacists in delivering and adapting services during the COVID-19 response have been reported. However, few qualitative studies have examined the impact of these experiences on their wellbeing, and what supports the profession requires in the future. AIM(S): To examine the work-related experiences and psychosocial needs of community pharmacists situated in the Republic of Ireland arising from the COVID-19 response. METHOD: 11 pharmacists and 1 representative were interviewed and data analysed through inductive thematic analysis. RESULTS: Work experiences were characterised by increased workload linked to multiple roles pharmacists played during the pandemic. Remaining open, meeting the social and medical needs of patients unable to easily access other primary services exerted its toll on pharmacists while at the same time providing a sense of professional fulfilment. Participants felt contributions made to the community during COVID-19 went largely unrecognised by the wider healthcare structure. This added to a prior sense of professional disenchantment arising from long-standing under-resourcing, lack of clinical autonomy and high administrative burden eroding their sense of purpose and meaning. Informal, peer-support networks were preferred over formal psychological support initiatives. CONCLUSIONS: The post-pandemic environment is an opportune time for policy makers to reconsider the role of community pharmacists. Greater clinical autonomy beyond dispensing of medicines, for example, for example, would also serve to enhance the sense of purpose and meaning of pharmacists as healthcare professionals. The longer-term well-being of community pharmacists is contingent on recognition of the value that community pharmacy bring both to the healthcare system and wider society as a whole.

A Qualitative Exploration of Prominent Factors Contributing to the Aetiology of Child and Adolescent Eating Disorder Presentations during the COVID-19 Pandemic: The Perspectives of Patients, Parents and Clinicians.

AIM: The aim of this study was to explore the prominent factors that contributed to the development of child and adolescent eating disorder presentations during the COVID-19 pandemic. METHODS: This was achieved through a qualitative analysis of interviews gathered from (1) adolescent patients diagnosed with an eating disorder (ED) during the COVID-19 pandemic (aged 13-18) (n = 4), (2) parents of patients attending an ED service (n = 7) and (3) clinicians working within a specialist child and adolescent ED support service (n = 7). Reflexive thematic analysis was used to analyse the data and establish the most prominent aetiological factors reported. RESULTS: The most prominent aetiological factors reported were (1) the accumulation of risk factors; (2) seeking control amid increased anxiety, stress and uncertainty; (3) social isolation; (4) an increased focus on exercise and "healthy eating"; (5) increased social media use promoting unhelpful attention towards ED triggers; and (6) a lack of both awareness and support services. CONCLUSION: During the COVID-19 pandemic, the quantity and severity of ED presentations increased. The current study uncovered six themes perceived by patients, parents and clinical staff that contributed to the aetiology of ED presentations during the COVID-19 pandemic. It is hoped that the insight gained through this research study into ED aetiology may act as a basis for further research and support ED awareness, prevention and intervention in the future.

A scoping review of physical activity interventions in youth attending child and adolescent mental health services.

BACKGROUND: There has been an international effort to improve physical health in general and in those with mental illness. Physical activity (PA) may be beneficial as an adjunctive treatment for mental health disorders and to improve physical well-being. AIMS: The objective of this scoping review is to understand the extent and type of evidence in relation to PA interventions offered in child and adolescent mental health services (CAMHS). Eligibility was determined using the Population, Concept, Context framework. Studies were included if the participants were under 18 years old, attending CAMHS and where PA interventions were offered. METHODS: PubMed, MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO and SportDiscus were searched without language or date restrictions. Titles and abstracts, followed by full texts, were screened by two independent reviewers. Two reviewers carried out data extraction, and discrepancies in any of these processes were resolved in consultation with a third reviewer. RESULTS: After 2213 non-duplicate titles and abstracts were screened, 2090 were excluded and 123 full texts were screened. Seventeen studies met inclusion criteria. Included studies demonstrated PA interventions to be effective in reducing depressive symptoms and improving psychosocial functioning. While no study reported significant changes in anthropometric measurements, 2 studies demonstrated increased aerobic fitness. CONCLUSION: Evidence that PA interventions are being offered in CAMHS worldwide is limited. Included studies demonstrate potential benefits in depressive symptoms, psychosocial functioning, self-esteem and aerobic fitness in youth attending CAMHS. Future research should identify effective ways to incorporate exercise interventions in CAMHS and evaluate long-term benefits.

The end of COVID-19: not with a bang but a whimper.

The formal announcement of the end of the COVID-19 pandemic by the WHO came on the 5th of May 2023; however, unlike the pandemic onset, the pandemic end date was not met with any significant media coverage or news reporting in Ireland. Additionally, there were no series of contemplations either in newspapers or other media about the impact of the decision to formally end the pandemic despite having financial and legislative impacts on a wide number of people. Given the potential impact of the removal of government subsidies on health and occupations, government and media coverage of the decisions and potential implications would have been helpful. The opportunity for a significant debriefing of the pandemic outlining what we have learned from the COVID-19 pandemic response may have been missed.

The ethicality of the COVID-19 response in children and adolescents.

Childhood and adolescence are critical periods of physiological growth as well as development in biological, emotional, and social domains. During the COVID-19 pandemic, children and adolescent's lives were drastically changed. Many countries including the United Kingdom and Ireland imposed strict universal lockdowns, which included the closing of creches, schools and universities as well as restricting peer interactions, social activities, and recreational pursuits. Evidence is emerging of a catastrophic impact on the younger generation, which leads the authors to explore the ethicality of the COVID-19 response in this population in relation to the four pillars of medical ethics: beneficence, nomaleficence, autonomy, and justice.

Age of first self-harm act in childhood and adolescence: A scoping review protocol.

Background: Self-harm in youth is associated with adverse outcomes for many. The age of first self-harm is not often reported in the literature and there is considerable heterogeneity in how it is reported and in the methods used to estimate it. The objective of this study will be to examine the age of first self-harm act in childhood and adolescence and to identify the research methods used to assess this. Methods: This scoping review will follow JBI guidance. Five electronic databases, Medline, PsycInfo, CINAHL Plus, Embase, and Web of Science will be searched from inception. Grey literature will be searched via Google Scholar. Studies reporting the age of first act of self-harm in young people aged 17 years and younger are of interest. Any study design and methodology will be eligible for inclusion. Included studies may use any self-harm definition, any measures used to assess self-harm and the age of the first act. The focus can be in any context, including health services presenting or community samples. Title and abstract screening and full text screening will be carried out by two reviewers independently. The data extraction tool will be piloted by two reviewers independently, included studies will undergo data extraction by one reviewer and this will be checked by a second, independent reviewer. Results: The resulting data will be presented using descriptive statistics, in tabular format, and accompanied with a narrative presentation of results. The results of this study will be distributed by publication in an academic journal.

Predictors of transitioning to adult mental health services and associated costs: a cross-country comparison.

BACKGROUND: Young people are at risk of falling through the care gap after leaving child and adolescent mental health services (CAMHS) despite an ongoing need for mental health support. Currently, little is known about the predictors of transitioning to adult mental health services (AMHS), and associated healthcare and societal costs as young people cross the transition boundary. OBJECTIVE: To conduct a secondary data analysis exploring predictors of transitioning or falling through the gap and associated costs. METHODS: Data were used from a longitudinal study, which followed young people from seven European countries for 2 years after reaching their CAMHS boundary. Predictors of transitioning (including sociodemographic and clinical variables) and longitudinal resource use were compared for 488 young people who transitioned to AMHS versus those who fell through the gap. FINDINGS: Young people were more likely to transition to AMHS if they were severely ill. Those from Italy, the Netherlands and the UK were more likely to fall through the gap than transition to AMHS. Healthcare costs fell for all young people over the study, with a sharper decrease for those who fell through the gap. CONCLUSIONS: Total healthcare costs fell for all participants, indicating that the intensity of mental health support reduces for all young people as they cross the CAMHS boundary, regardless of clinical need. CLINICAL IMPLICATIONS: It is important that alternative forms of mental health support are available for young people who do not meet the AMHS care threshold but still have mental health needs after leaving CAMHS.

Burnout in mental health services in Ireland during the COVID-19 pandemic.

BACKGROUND: Burnout is a consequence of chronic occupational stress. Specific work-related factors may contribute to burnout experienced by those working in mental health services (MHS), many of which have increased since the COVID-19 pandemic. AIMS: To examine personal, work- and patient-related burnout among MHS staff in Ireland during the COVID-19 pandemic, and explore the impact of work-related conditions on burnout. METHOD: We conducted a cross-sectional survey of three MHS across Ireland utilising a study-specific questionnaire, the Copenhagen Burnout Inventory and the Effort-Reward Imbalance scale. RESULTS: Of 396 participants, 270 (70.6%) were female. Moderate and high personal burnout was experienced by 244 (64.1%) participants; work-related burnout by 231 (58.5%) participants and patient-related burnout by 83 (21.5%) participants. Risk factors for both personal and work-related burnout were female gender, urban service, time spent outside main responsibilities, overcommitment, high score on the Effort-Reward Imbalance scale and intention to change job. Being younger, with high workload and deterioration of personal mental health during the pandemic was associated with higher personal burnout, whereas a lack of opportunity to talk about work-related stress contributed to work-related burnout. Fewer factors were associated with patient-related burnout, namely overcommitment, working in urban services and poorer physical and mental health during the COVID-19 pandemic. CONCLUSIONS: High levels of personal and work-related burnout were found among mental health workers. The weak association with COVID-19-related factors suggest levels of burnout predated the pandemic. This has implications for MHS given the recognised additional work burden created by COVID-19.

Healthcare costs for young people transitioning the boundary between child/adolescent and adult mental health services in seven European countries: results from the MILESTONE study.

BACKGROUND: The boundary between services for children and adolescents and adults has been identified as problematic for young people with mental health problems. AIMS: To examine the use and cost of healthcare for young people engaged in mental healthcare before and after the child/adolescent and adult service boundary. METHOD: Data from 772 young people in seven European countries participating in the MILESTONE trial were analysed. We analysed and costed healthcare resources used in the 6-month period before and after the service boundary. RESULTS: The proportion of young people engaging with healthcare services fell substantially after crossing the service boundary (associated costs €7761 pre-boundary v. €3376 post-boundary). Pre-boundary, the main cost driver was in-patient care (approximately 50%), whereas post-boundary costs were more evenly spread between services; cost reductions were correlated with pre-boundary in-patient care. Severity was associated with substantially higher costs pre- and post-boundary, and those who were engaged specifically with mental health services after the service boundary accrued the greatest healthcare costs post-service boundary. CONCLUSIONS: Costs of healthcare are large in this population, but fall considerably after transition, particularly for those who were most severely ill. In part, this is likely to reflect improvement in the mental health of young people. However, qualitative evidence from the MILESTONE study suggests that lack of capacity in adult services and young people's disengagement with formal mental health services post-transition are contributing factors. Long-term data are needed to assess the adverse long-term effects on costs and health of this unmet need and disengagement.

Stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Remote mental health consultations were swiftly implemented across mental health services during the COVID-19 pandemic. Research has begun to inform future design and delivery of telemental health services. Exploring the in-depth experiences of those involved is important to understand the complex, multi-level factors that influence the implementation of remote mental health consultations. The aim of this study was to explore stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic in Ireland. METHODS: A qualitative study was conducted whereby semi-structured, individual interviews were undertaken with mental health providers, service users, and managers (n = 19) to acquire rich information. Interviews were conducted between November 2021 and July 2022. The interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Data were analysed thematically using a deductive and inductive approach. RESULTS: Six themes were identified. The advantages of remote mental health consultations were described, including convenience and increased accessibility to care. Providers and managers described varying levels of success with implementation, citing complexity and incompatibility with existing workflows as barriers to adoption. Providers' access to resources, guidance, and training were notable facilitators. Participants perceived remote mental health consultations to be satisfactory but not equivalent to in-person care in terms of quality. Views about the inferior quality of remote consultations stemmed from beliefs about the inhibited therapeutic relationship and a possible reduction in effectiveness compared to in-person care. Whilst a return to in-person services was mostly preferred, participants acknowledged a potential adjunct role for remote consultations in certain circumstances. CONCLUSIONS: Remote mental health consultations were welcomed as a means to continue care during the COVID-19 pandemic. Their swift and necessary adoption placed pressure on providers and organisations to adapt quickly, navigating challenges and adjusting to a new way of working. This implementation created changes to workflows and dynamics that disrupted the traditional method of mental health care delivery. Further consideration of the importance of the therapeutic relationship and fostering positive provider beliefs and feelings of competence are needed to ensure satisfactory and effective implementation of remote mental health consultations going forward.