The role of social support in reducing the impact of violence on adolescents' mental health in São Paulo, Brazil.

OBJECTIVES: We investigated whether perceived social support among adolescent students moderated the association between violence exposure and internalising symptoms in São Paulo city, Brazil. METHODS: We tested the stress-buffering model using data from the cross-sectional school-based, survey São Paulo Project on the Social Development of Children and Adolescents. Internalising symptoms were measured using an adapted version of the Social Behaviour Questionnaire; serious victimisation, being bullied once/week, school violence and community violence, friend and teacher support were scales adapted by the research team; the Alabama Parenting Questionnaire measured parenting style. Linear mixed-effects models were used to quantify moderation effects of (i) social support between violence exposure and internalising symptoms and (ii) gender between violence exposure and internalising symptoms across schools. RESULTS: Across schools, being bullied once/week, school violence, and community violence were associated with a significant (p<0.001) increase in internalising symptoms (e.g., bullied b = 5.76, 95% CI 2.26, 9.26; school violence b = 0.48, 95% CI 0.30, 0.67; community violence b = 0.36; 95% CI 0.22, 0.50). Males exposed to all types of violence had significantly lower (p<0.01) internalising symptoms compared to females (e.g., serious victimisation: b = -1.45; 95% CI -2.60, -0.29; school violence b = -0.27; 95% CI -0.30, -0.24; community violence b = -0.23; 95% CI -0.25, -0.20). As a main effect, social support was associated with a significant (p<0.01) decrease in internalising symptoms across schools (e.g., positive parenting b = -2.42; 95% CI -3.12, -1.72; parent involvement b = -2.75; 95% CI -3.32, -2.17; friend support b = -1.05; 95% CI -1.74, -0.34; teacher support b = -0.90; 95% CI -1.58, -0.22). Social support did not moderate the association between violence exposure and internalising symptoms. CONCLUSIONS: Adolescent students in São Paulo exposed to violence have a higher likelihood of internalising symptoms, compared to those who are not. Support from parents, friends, and teachers, independent of violence, appear to be protective against internalising symptoms, pointing to potential programmes that could improve adolescent mental health

Male and LGBT survivors of sexual violence in conflict situations: a realist review of health interventions in low-and middle-income countries

Conflict-related sexual violence (CRSV) against women and girls has been the subject of increasing research and scholarship. Less is known about the health of men, boys and lesbian, gay, bisexual, transgender (LGBT) and other gender non-binary persons who survive CRSV. This paper is the first systematic realist review on medical, mental health and psychosocial support (MHPSS) interventions that focusses on male and LGBT survivors of CRSV. The review explores the gender differences in context, mechanisms and outcomes that underpin interventions addressing the health and psychosocial wellbeing of male and LGBT survivors. The aim is to contribute to the design and delivery of gender-sensitive and, when needed, gender-specific approaches for interventions that respond to specific needs of different groups of all survivors. We conducted a systematic search of academic and grey literature to identify medical and MHPSS interventions that included men, boys and LGBT survivors. We identified interventions specifically targeting women and girls that we used as comparators. We then purposively sampled studies from the fields of gender and health, and sexual abuse against men and LGBT people for theory building and testing. We identified 26 evaluations of interventions for survivors of CRSV. Nine studies included male survivors, twelve studies focussed exclusively on female survivors and one study targeted children and adolescents. No intervention evaluation focussed on LGBT survivors of CRSV. The interventions that included male survivors did not describe specific components for this population. Results of intervention evaluations that included male survivors were not disaggregated by gender, and some studies did not report the gender composition. Although some mental health and psychosocial consequences of sexual violence against men and boys may be similar among male and female survivors, the way each process trauma, display symptoms, seek help, adhere to treatment and improve their mental health differ by gender. Initiatives targeting male and LGBT survivors of CRSV need to be designed to actively address specific gender differences in access, adherence and response to MHPSS interventions. Models of care that are gender-sensitive and integrated to local resources are promising avenues to promote the health of male and LGBT survivors of CRSV

Local understandings of PTSD and complex PTSD among health professionals working with adolescents in violent neighbourhoods of São Paulo city, Brazil

BACKGROUND: Adolescents in low-resource urban settings in Brazil are often exposed to high levels of trauma that can result in post-traumatic stress disorder (PTSD). However, preliminary evidence indicates that PTSD tends to be under-reported in Brazilian health services, despite the high prevalence of trauma. Additionally, little is known about the perceived applicability among clinicians of the new ICD-11 diagnosis of complex PTSD (CPTSD), despite its potential relevance for contexts of chronic trauma. The current study investigated local understandings of PTSD and CPTSD among health professionals working with adolescents in violent neighbourhoods of São Paulo city. METHODS: Semi-structured interviews were conducted with 58 health professionals working at both the primary care and specialized mental health levels in two areas of São Paulo city with high levels of community violence. RESULTS: Most participants knew about PTSD, but most did not know about CPTSD. There were mixed views concerning the commonality of PTSD among adolescents exposed to community violence. Many participants reported having no experience working with patients with the PTSD diagnosis. According to some, community violence was normalized by adolescents and health professionals, and did not result in PTSD. Others highlighted how they did not use psychiatric diagnoses in their practice, had critical perspectives towards psychiatric diagnoses and/or PTSD, or simply knew little about PTSD. Furthermore, many highlighted how the chronic nature of multiple traumas experienced by adolescents often resulted in complex clinical presentations characterised by many symptoms beyond PTSD. The diagnosis of CPTSD was considered appropriate to the context by many participants as it captured the complex traumatic histories and symptom presentations of adolescents exposed to community violence in Brazil. CONCLUSIONS: These findings have important implications for the assessment and treatment of mental health among adolescents exposed to community violence in Brazil

Adolescent Mental Health and Mental Health Services: A Mixed Methods Investigation

Mental health symptoms largely emerge during childhood, adolescence, and young adulthood, with estimates suggesting that by 25 years of age, 62% of all mental health disorders have appeared. These conditions are the largest contributors to the burden of disease during adolescence (10-19 years), and are exacerbated in resource-limited environments where the majority of the world’s adolescents live. Adolescent mental health is influenced by (i) their needs (mental health problems; risk and protective factors; and social determinants); and (ii) actions through mental health services; structural (policies) and the community (multisectoral strategies). In São Paulo city, Brazil, the site of this thesis, the prevalence of common mental disorders among adolescents (15-19 years) was estimated at 13.2% in 2015. Meanwhile, levels of social inequality, violence and poverty are high. No study to date has been conducted in São Paulo investigating adolescent mental health needs and how health services are responding to these needs, particularly in limited resource and violent neighbourhoods. This mixed methods thesis bridges this gap and aims to provide an opportunity to better understand how adolescent mental health services are delivered and responding to adolescents’ mental health needs within this context. The study involved a systematic review of the global literature on quality in adolescent mental health services, identifying aspects and challenges to quality in adolescent mental health service provision. It also involved a secondary data analysis of adolescents (n=2,702) in secondary schools across São Paulo to investigate mental health needs among adolescents and how these needs relate to the local contexts within which quality in mental health service is provided. Finally, semi-structured interviews among health care providers (n=45) were conducted in limited-resource and violent settings in south west São Paulo city to explore providers’ perception of quality, barriers and facilitators to the provision of adolescent mental health services in primary and secondary facilities. The analysis and interpretation of findings led to the evaluation of potential interventions, including the standardisation of quality and methods to measure quality; the conceptualisation of a navigation pathway to quality adolescent mental health services; policy implications that promote social support; and recommendations on better integration of primary health services in adolescent mental health care

Evaluating quality in adolescent mental health services: a systematic review

Objectives To evaluate the quality of adolescent mental health service provision globally, according to the WHO Global Standards of adolescent mental health literacy, appropriate package of services and provider competencies.Design and data sources Systematic review of 5 databases, and screening of eligible articles, from 1 January 2008 to 31 December 2020.Study eligibility criteria We focused on quantitative and mixed-method studies that evaluated adolescent mental health literacy, appropriate package of services and provider competencies in mental health services, and that targeted depression, anxiety and post-traumatic stress disorder among adolescents (10–19 years). This included adolescents exposed to interventions or strategies within mental health services.Study appraisal and synthesis methods Study quality was assessed using the National Institutes for Health Study Quality Assessment Tools. Data were extracted and grouped based on WHO quality Standards.Results Of the 20 104 studies identified, 20 articles were included. The majority of studies came from high-income countries, with one from a low-income country. Most of the studies did not conceptualise quality. Results found that an online decision aid was evaluated to increase adolescent mental health literacy. Studies that targeted an appropriate package of services evaluated the quality of engagement between the therapist and adolescent, patient-centred communication, mental health service use, linkages to mental health services, health facility culture and intensive community treatment. Provider competencies focused on studies that evaluated confidence in managing and referring adolescents, collaboration between health facility levels, evidence-based practices and technology use.Conclusions and implications There is limited evidence on quality measures in adolescent mental health services (as conforms to the WHO Global Standards), pointing to a global evidence gap for adolescent mental health services. There are several challenges to overcome, including a need to develop consensus on quality and methods to measure quality in mental health settings.PROSPERO registration number CRD42020161318

Associations over the COVID-19 pandemic period and the mental health and substance use of youth not in employment, education or training in Ontario, Canada : a longitudinal, cohort study

Background: The economic shutdown and school closures associated with the COVID-19 pandemic have negatively influenced many young people’s educational and training opportunities, leading to an increase in youth not in education, employment, or training (NEET) globally and in Canada. NEET youth have a greater vulnerability to mental health and substance use problems, compared to their counterparts who are in school and/or employed. There is limited evidence on the association between COVID-19 and NEET youth. The objectives of this exploratory study included investigating: longitudinal associations between the COVID-19 pandemic and the mental health and substance use (MHSU) of NEET youth; and MHSU among subgroups of NEET and non-NEET youth. Methods: 618 youth (14–28 years old) participated in this longitudinal, cohort study. Youth were recruited from four pre-existing studies at the Centre for Addiction and Mental Health. Data on MHSU were collected across 11 time points during the COVID-19 pandemic (April 2020-August 2022). MHSU were measured using the CoRonavIruS Health Impact Survey Youth Self-Report, the Global Appraisal of Individual Needs Short Screener, and the PTSD Checklist for DSM-5. Linear Mixed Models and Generalized Estimating Equations were used to analyze associations of NEET status and time on mental health and substance use. Exploratory analyses were conducted to investigate interactions between sociodemographic characteristics and NEET status and time. Results: At baseline, NEET youth were significantly more likely to screen positive for an internalizing disorder compared to non-NEET youth (OR = 1.92; 95%CI=[1.26–2.91] p = 0.002). No significant differences were found between youth with, and without, NEET in MHSU symptoms across the study time frame. Youth who had significantly higher odds of screening positive for an internalizing disorder included younger youth (OR = 1.06, 95%CI=[1.00-1.11]); youth who identify as Trans, non-binary or gender diverse (OR = 8.33, 95%CI=[4.17–16.17]); and those living in urban areas (OR = 1.35, 95%CI=[1.03–1.76]), compared to their counterparts. Youth who identify as White had significantly higher odds of screening positive for substance use problems (OR = 2.38, 95%CI=[1.72–3.23]) compared to racialized youth. Conclusions: Our findings indicate that sociodemographic factors such as age, gender identity, ethnicity and area of residence impacted youth MHSU symptoms over the course of the study and during the pandemic. Overall, NEET status was not consistently associated with MHSU symptoms over and above these factors. The study contributes to evidence on MHSU symptoms of NEET youth.Medicine, Faculty ofNon UBCOccupational Science and Occupational Therapy, Department ofReviewedFacultyResearche