Anxiety disorders in children and young people are common and impairing. Cognitive behavioural therapy (CBT) is the recommended first-line treatment and the past two decades have seen numerous digital CBT interventions emerge. Digital CBT has the potential to improve access, reduce waiting times and scale services. However, guidance on how digital CBT should be integrated into routine care pathways remains limited. This article summarises current clinical guidelines for children and young people with anxiety disorders from different parts of the world, with a specific focus on recommendations for digital CBT and its integration into broader care models. Finally, it discusses the role of digital CBT in stepped-care and stratified-care approaches, including ongoing research integrating and sequencing digital CBT differently.
Ambient voice technology has been proposed as a promising approach to reduce documentation burden in child and adolescent mental health services and neurodevelopmental settings. In response to Dineley and colleagues' discussion of responsible implementation and evidence gaps, this letter argues that ambient voice technology should be evaluated as a care-pathway intervention rather than merely as a note-generation tool. We emphasize the importance of outcome-accountable implementation, including measurement of documentation time, clinician cognitive load, note correction burden, error severity, therapeutic alliance, patient and carer experience, equity, and downstream care decisions. Particular attention is needed in multilingual, family-based, and neurodevelopmental consultations, where multispeaker attribution, atypical speech, and culturally specific expressions of distress may challenge automated systems. Ambient voice technology should protect clinical reasoning, preserve uncertainty, and remain subject to auditable human oversight. Its value in CAMHS should be judged by safety, equity, experience, and meaningful clinical improvement.
BACKGROUND:In England, 18% of children and young people (CYP) experience clinical levels of mental health difficulties. CYP who are involved in children's social care, either receiving in-home care (i.e. child protection plans; CPP) or out-of-home care (i.e. children looked after; CLA), may experience higher prevlance than peers. Less is known about actual contacts with mental health services. This study aimed to provide an account of the contacts with mental health services for children with and without CPP and CLA, and reasons for referral. METHODS:Data were extracted from NHS Digital for all CYP in England in contact (e.g. through referral, appointment, support) with mental health services between April 2016 and March 2021, and included sociodemographic information, CPP or CLA status and referral reason. RESULTS:In total, 1,984,827 CYP were in contact with mental health services. The most common referral reasons were anxiety (13%), 'in crisis' (10%) and depression (7%). Contacts tended to increase each year for all groups. Overall, CPP and CLA were between 2 and 3 times more likely to be in contact with mental health services compared to peers. However, this represented between 9% and 18% of CPP and CLA. CONCLUSION:The findings suggest that there are wide discrepancies between mental health needs and contacts with services. CPP and CLA have particularly high levels of unmet need. While these data indicate escalating demand, service contacts have not increased significantly, suggesting an increased threshold for access in a stretched clinical service.
BACKGROUND:Mental-health-disorders in children/young adults increased post-pandemic; however, the absence of linkage to COVID-19 registries made direct attribution of psychological sequelae to acute infection challenging. METHODS:Healthcare-claims databases in Singapore were utilised to evaluate rates of new-incident mental-health-disorders in children/young adults aged 6-25 years from January 1st, 2012 to 29th February, 2024. Influence on monthly observed new-incident mental-health-disorders across various pandemic phases was modelled using negative binomial regression, accounting for seasonality and overall increasing trend (year). Separate linkage with the national COVID-19 database allowed construction of contemporaneous SARS-CoV-2-infected/test-negative cohorts. Cox regression, with overlap weights applied, was utilised to estimate risks of new-incident medically-diagnosed mental-health-disorders 31-300 days post-infection versus test-negatives. RESULTS:Overall, there was no significant increase in risk for any new-incident medically-diagnosed mental-health-disorders (adjusted-hazards-ratio, aHR = 1.01 [95% CI = 0.90-1.12]) amongst SARS-CoV-2-infected children/young adults (N = 456,034) versus test-negatives (N = 482,588); with the sole exception that of stress/anxiety disorders (aHR = 1.20 [95% CI = 1.02-1.40]). Only infections during the pandemic-containment-phase were associated with significantly increased risk of stress/anxiety, but not during the pandemic-resiliency-phase when restrictions were lifted (pandemic-containment: aHR = 1.25 [95% CI = 1.02-1.54]; pandemic-resiliency: aHR = 1.15 [95% CI = 0.89-1.48]). Risk of stress/anxiety was elevated amongst COVID-19 cases with a concurrently-infected adult household contact. A 10% increase in new-incident mental-health-disorders was observed amongst Singaporean children/young adults during the pandemic-containment-phase, but this subsequently normalised in the pandemic-resiliency-phase. CONCLUSIONS:Increase in medically-diagnosed mental-health-disorders amongst Singaporean children/young adults at the height of pandemic restrictions did not persist into endemicity. Increased incidence of medically-diagnosed stress/anxiety post-COVID-19 in children/young adults at the pandemic height may be mediated by initial infection severity and concurrent household infection.
BACKGROUND:Memory bias, the tendency to retrieve specific memories, is an established phenomenon in adults with depression. However, evidence on the link between depression and memory bias in children is mixed. This systematic review aimed to synthesize current knowledge examining memory bias and depression in children and adolescents. METHODS:Systematic searches were conducted in February 2025 in six databases (MEDLINE, Embase, APA PsycINFO, CINAHL Plus, Child Development & Adolescent Studies, Scopus). Studies measuring memory bias for autobiographical memory, emotional faces, words, and pictures in children and adolescents (≤18 years) with depression were included. Included studies were peer-reviewed and of cross-sectional or longitudinal design. Random effects meta-analyses of study outcomes were performed. The Joanna Briggs Institute Critical Appraisal Tools assessed study quality. RESULTS:Thirty-six studies, comprising 4293 adolescents (mean age 14.5 ± 1.3 years, age range: 12-17 years; 65% female), were included. Compared with controls, participants with depression exhibited better recall of overgeneral memories (g = 0.86; 95% CI: 0.42, 1.30) and poorer recognition of sad faces (g = -0.43; 95% CI: -0.79, -0.06) and neutral pictures (g = -0.48; 95% CI: -0.93, -0.03). No differences in recognition of happy, fearful, angry, or neutral faces, as well as emotional words or pictures, were observed. CONCLUSION:Associations between memory bias and depression in adolescents were observed, but were fewer compared to the more established literature association of memory bias and depression in adults. Increased recall of overgeneral memories may represent an isolated therapeutic target for adolescents with depression.
This editorial explores young people's experiences with technology (AI, chatbots, social media, wearable devices and medical technology) using Ecological Systems Theory. The framework describes the bidirectional relationships between young people, organizations, symbols and key individuals in a variety of environments. The editorial argues that theory must evolve to integrate technologies into existing models to remain relevant to contemporary child and adolescent development.
Conversational AI is increasingly being used by young people for emotional support, advice and conversations about personal concerns. Emerging evidence suggests that these systems may offer mental health benefits, particularly for depressive symptoms, while also raising concerns about dependency, relational dynamics, safety and therapeutic precision. This debate article argues that the central question is not whether conversational AI should be viewed as beneficial or harmful, or as therapeutic or nontherapeutic. Rather, its impact on young people's mental health may depend substantially on how these systems are designed. As the boundaries between clinically oriented and general-purpose conversational agents become increasingly blurred, design decisions concerning relational style, responses to distress, risk management, transparency and human oversight take on growing importance. These decisions are clinical and developmental as much as technical. The article argues that mental health expertise has an important role to play in shaping, evaluating and governing conversational AI systems, particularly as they become more embedded in the everyday lives of young people.
BACKGROUND:School absence is associated with mental health problems in adolescents, but most studies are cross-sectional. Longitudinal studies where school absence precedes mental health problems are needed to infer whether school absence is associated with later mental health problems. We aimed to investigate the association between school absence among 14- to 15-year-olds and later mental health problems at ages 16-17 in England. METHODS:A retrospective cohort study using an existing linkage between the Millennium Cohort Study (MCS) and the National Pupil Database (NPD), representing 8438 adolescents. We explored different absence thresholds and used logistic regression to examine associations between school absence and later mental health problems. RESULTS:A threshold of >10% of half-day school sessions missed identified 18% of adolescents who reported mental health problems at follow-up. At this threshold, high school absence was associated with increased odds of later mental health problems after adjusting for covariates (girls = 1.44, 95% CI 1.05-1.98; boys OR = 1.49, 95% CI 1.04-2.13). The strength of associations between absence and later mental health problems increased with longer durations of absence. CONCLUSION:We found a longitudinal association between high levels of school absence (>10% of sessions) and later mental health problems in a nationally representative sample of adolescents in England. High levels of school absence can be used as an early marker of increased risk of mental health problems in the general population. School absence may contribute to the development of later mental health problems in adolescents.
Children and young people's mental health appears to be worsening, despite marked declines in many forms of severe adversity over recent decades. This article argues that young people's distress and withdrawal from society are understandable responses to an environment that is simultaneously over-protective in some respects and chronically threatening in others. It calls for more systemic thinking in how we support children, expanding opportunities for face and overcome manageable challenges, while acknowledging the very real structural stressors shaping their lives.
In institutional settings, adolescents are often asked to perform identity rather than explore it. Poetry - particularly brief, metaphor-rich forms - can function as a developmental bridge, creating conditions in which identity can be explored gradually, relationally, and on their own terms. This paper reflects on a six-session, school-based poetry curriculum for adolescents at elevated risk for behavioural and emotional concerns, organised around specific poetic forms as narrative tools for adolescent identity formation. We consider how six-word stories, sentence stems, persona-based writing, unsent letters, and group poems shape what can be said and how identity can be held, shared, and revised. In doing so, the paper suggests that poetic forms offer adolescents a safer, more agentic pathway into identity exploration with meaningful implications for school-based mental health practice.
BACKGROUND:Anxiety disorders are highly prevalent in childhood and adolescence, but access to treatment is limited. Internet-based cognitive behavioral therapy (ICBT) has been proposed as an effective treatment to increase accessibility to evidence-based treatment. OBJECTIVE:This systematic review and meta-analysis aimed to investigate the efficacy of ICBT for children and adolescents with anxiety disorders and explore moderating effects of control conditions, age, parental involvement, and therapist support on treatment outcomes. METHODS:Systematic searches were conducted in PsycInfo, PubMed, SCOPUS, Embase, and Web of Science to identify randomized controlled trials comparing ICBT with control conditions controlling for the effects of time or nonspecific effects of treatment. Studies should include children and adolescents aged 6-18 years with anxiety disorders. RESULTS:The searches identified 1241 papers, of which 11 studies met the inclusion criteria. The adjusted pooled effect size estimate for the random-effects meta-analysis demonstrated a medium statistically significant effect in favor of ICBT over control conditions (g = 0.740, 95% CI 0.555-0.925). The overall quality of evidence (GRADE) was rated as low due to risk of bias and inconsistencies in reporting. No significant moderators of treatment effects were identified. CONCLUSION:This meta-analysis supports the use of ICBT as a treatment option for children and adolescents with anxiety disorders. Additionally, the results suggest that therapist support format may be a relevant treatment component to explore in future studies. However, all findings must be subjected to additional testing, and more high-quality studies including long-term follow-ups are needed to assess the effects of ICBT and clarify the impact of moderators.
The rapid adoption of conversational AI among adolescents has sparked growing debate about its implications for development and well-being. This article applies a Self-Determination Theory lens to explore how and under which conditions adolescents' conversational AI usage supports or frustrates their basic psychological needs for competence, relatedness, and autonomy. Conversational AI may enhance competence through learning assistance, relatedness through emotional and relational support, and autonomy through increased independence. At the same time, it may also promote the risk of superficial competence, displace human relationships, and constrain authentic autonomy. Overall, the role conversational AI plays in adolescents' development is unlikely to be universally positive or negative for all adolescents, but instead depends on how, why, and in which context these technologies are used, highlighting the need for nuanced research and developmentally sensitive design.
Conversational AI is now deeply embedded in adolescents' mental health help-seeking and emotional lives, creating both risks and a rare population health opportunity. This debate piece argues that the key question for researchers and implementers to consider is no longer whether adolescents should use general-purpose chatbots for mental health support, but rather how scientists, regulators, and technology companies should shape these systems to reduce harm and promote constructive action. At present, built-in chatbot responses to user expressions of distress often emphasize detection, refusal, or crisis referral, strategies that may protect developers but can fail to meet adolescents' immediate needs. At the same time, open-ended, pseudo-therapeutic interactions with untested agents can reinforce risk, dependency, and inaccurate or harmful beliefs about mental health and help-seeking. We propose that general-purpose conversational AI platforms are well-positioned to function as bridges to evidence-based support, rather than as replacements for formal therapy or treatment. Brief, bounded interventions, including digital single-session interventions, offer a promising model for responding to moments of need while preserving adolescent agency. Ethical AI design should prioritize safeguards, empirical testing, and pathways to evidence-based care.
Background Child and Adolescent Mental Health Services (CAMHS) are currently marked by a paradox: growing public recognition of youth mental health difficulties coincides with increasingly fragile and underresourced services. Beyond organisational strain, the field is shaped by competing narratives about its mission and limits (hopeful progressivism which emphasises innovation, early intervention and developmental plasticity; on the other, defensive pessimism which foregrounds chronicity, clinical realism and institutional constraint.Aims To examine how these competing narratives operate within CAMHS and to articulate an alternative orientation capable of supporting ethical clinical practice.Materials & Methods A conceptual and narrative analysis drawing on medical humanities and social sciences perspectives, in particular the concept of moral economy, illustrated by a clinical vignette.Results Hopeful progressivism and defensive pessimism function as moral postures that distribute responsibility, legitimacy and emotional labour within institutions, with hope and cynicism operating as institutional currencies. Although seemingly opposed, both positions risk obscuring the structural determinants of care and relocating difficulties onto clinicians or families.Discussion Rather than choosing between optimism and cynicism, CAMHS may benefit from holding these narratives in productive tension through a dialogical, reflexive approach that re-centres families and re-politicizes the conditions of care.Conslusion A form of realistic hope, grounded in developmental temporality and attentive to material conditions is essential to ethical and clinically meaningful care.
BACKGROUND:Schools provide critical support for students exposed to traumatic experiences, with school-based trauma interventions demonstrating reductions in posttraumatic stress symptoms. However, heterogeneity in design, implementation, and efficacy of existing interventions makes it challenging to select suitable interventions and to understand which components of programs are effective. This review and meta-analysis identified school-based trauma interventions and evaluated the common and effective practice, process, and implementation elements of these programs. METHODS:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guideline recommendations, a literature search was conducted using keywords of interest. Studies included controlled trials that described school-based interventions designed to reduce post-traumatic stress disorder (PTSD) symptoms in students. A frequency analysis of emerging elements was executed. A meta-analysis calculated the effect size of individual elements in reducing PTSD symptoms. This review was registered with PROSPERO (CRD42022337818). RESULTS:Forty-five studies were included, with 46 datasets used for analysis. The pooled effect size was g = -0.97 (CI: -1.29, -0.65) for all studies, or g = -0.62 (CI: -0.87, -0.38) when removing outliers, indicating a medium-large effect of school-based programs in reducing PTSD symptoms. Common practice elements included psychoeducation, cognitive behavioural therapy, and coping skills. Common process elements included group therapy, 10-12 sessions, 30-60 min in length, 4-6 weeks duration, homework assignments, run by mental health professionals. Common implementation elements included supervision of facilitators, 3-5 days facilitator training, parental involvement, and the use of a manual. CONCLUSION:The identification of common and effective elements in reducing PTSD among students is critical for the implementation of existing interventions and the development of new interventions.
Zaidman-Zait et al. (Child and Adolescent Mental Health, 2025, 30, 327) present a rigorous network analysis of autism characteristics and anxiety symptoms in 623 autistic children across four countries, identifying preference for predictability and sensory hypersensitivity rather than social communication difficulties as the primary bridge nodes linking autistic features to anxiety. We offer three methodological and conceptual extensions. First, the unexpected weakness of the social communication-social anxiety connection may reflect the absence of theory of mind (ToM) and affective social cognition as network nodes: impaired affective ToM independently contributes to social anxiety in clinical adolescent samples and may mediate the social communication-anxiety pathway in ways that parent-reported social communication items cannot capture. Second, while preference for predictability and sensory hypersensitivity are identified as bridge nodes, their underlying mechanisms, intolerance of uncertainty and arousal dysregulation, are not explicitly modelled; including these as network variables would enable direct testing of their bridging function and identify specific intervention targets. Third, the exclusive reliance on parent-report data in a population in which anxiety masking is well documented introduces a systematic informant asymmetry that may distort the network structure. Multi-informant designs incorporating child self-report are essential for accurately mapping autism-anxiety co-occurrence.
This Response addresses methodological and conceptual issues raised in a Letter to the Editor concerning our recently published network analysis of autism characteristics and anxiety symptoms in autistic children and youth. We clarify concerns related to potential conceptual overlap between autistic characteristics and anxiety-related symptoms and address questions concerning the multinational nature of the dataset. We also summarize sensitivity and stability analyses showing that the identified bridge nodes are robust to variation in regularization parameters and operational definitions. Together, these clarifications support the interpretation of the reported network findings.
BACKGROUND:Death of a caregiver during childhood can have profound influences on child wellbeing and later trajectories. Globally, child and adolescent mental health is an increasing area of concern with widespread negative implications. These data provide the first comprehensive exploration of the mental health of children experiencing COVID-19-associated orphanhood over time, as well as risk and protective factors for their mental health. METHODS:Data are drawn from a longitudinal cohort study of children and adolescents (9-18 years) residing in South Africa who had experienced COVID-19-associated parent or caregiver death (n = 211), and a control group (no loss; n = 210). Mental health data were gathered at two timepoints utilising validated instruments. Data are stratified according to orphanhood status and biological sex. Mixed-effect regression modelling is undertaken-identifying associations between sociodemographic predictors and mental health status. RESULTS:Among those experiencing orphanhood, prevalence of poor mental health increased between baseline and follow-up, indicating greater mental health burden over time compared to the control group. Females experiencing orphanhood reported a higher prevalence of poor mental health, a finding that persisted over time. Identified probable risk factors for likely mental disorder include older age (OR: 1.15 [95% CI: 1.03-1.28]), food insecurity (OR: 2.91 [95% CI: 1.07-7.92]) and exposure to domestic violence (OR: 1.74 [95% CI: 1.03-2.93]). Increased access to necessities (OR: 0.83 [95% CI: 0.71-0.97]) was identified as a protective factor for mental health. CONCLUSION:This is the first longitudinal investigation of mental health in the context of COVID-related orphanhood. In measuring both prevalence and intensity of mental health symptoms, we identified multiple factors relating to poor mental health including living in poverty and experiencing early adversities alongside loss. Females experiencing orphanhood were at an increased risk of poor mental health. Tailoring existing mental health provision for children and adolescents within low- and middle-income countries may be required. Policy and programming focusing on poverty and violence alleviation may be of benefit.
The growing concern about the impact of smartphone use on adolescent mental health has led to increasing policy interest in school-based smartphone bans. A recent cross-sectional study by Sullivan and colleagues, examining digital safeguarding incidents in schools with and without smartphone restriction policies, contributes to this debate. However, caution is needed when interpreting these findings as evidence of mental health benefits. Cross-sectional designs inherently limit causal inference, as schools adopting smartphone restrictions may differ systematically in institutional resources, monitoring practices, and student populations. Higher reported safeguarding incidents in schools with restrictions may therefore reflect greater detection sensitivity rather than increased underlying harm. Furthermore, digital safeguarding incidents are not direct indicators of psychological well-being, but are shaped by reporting practices and institutional thresholds. Population-level research suggests that associations between smartphone use and mental health are modest and context-dependent. While school-based restrictions may reduce in-school phone use, there is little evidence that they reduce overall screen time or improve mental health outcomes. Future longitudinal and quasi-experimental studies directly assessing psychological outcomes are needed. Until such evidence is available, caution is warranted in promoting smartphone restriction policies as effective mental health interventions.
