Publications

Purpose
China’s rapid urbanization has been associated with increased mental health challenges, especially in rural-to-urban migrant children. This study evaluates the effects of mindfulness and life-skills (LS) training on emotional regulation and anxiety symptoms from a randomized controlled trial aimed at improving the mental health of Chinese migrant children.

Methods
Two intervention arms—mindfulness training (MT) and MT plus LS mentorship (MT + LS)—were compared to a waitlist control group of 368 migrant children aged 9–17 years. Volunteers were trained to deliver interventions to 285 migrant children in small groups of 15 for eight weeks weekly. Social integration varied: migrant children mixed with local children at public schools were considered highly integrated, those in migrant-only classrooms at public schools had intermediate levels of integration, and children in private migrant schools had low integration. Emotion regulation and anxiety symptoms were assessed preintervention, postintervention, and three months postintervention.

Results
Postintervention and compared to the control group, children with high social integration in the MT arm showed increased cognitive reappraisal ability (p < .05) but higher physical anxiety (p < .01). Children with high social integration in the MT + LS arm had lower anxiety symptoms of harm avoidance (p < .01) and physical anxiety (p < .05). Children with low social integration in the MT + LS arm showed lower cognitive reappraisal (p < .01) and poorer overall emotion regulation abilities (p < .01). Three months later, children with intermediate integration in the MT + LS arm had lower separation anxiety (p < .05) and harm avoidance anxiety (p < .05). No other groups showed significant improvements in emotion regulation or reducing in anxiety symptoms three months postintervention.

Discussion
Mindfulness and LS training may benefit Chinese migrant children who have higher levels of social integration but increase anxiety in those with lower social integration. Future research should consider the sociocultural context in which a treatment is implemented.

Background
Comorbidity in mental disorders is prevalent among adolescents, with evidence suggesting a general psychopathology factor (“p” factor) that reflects shared mechanisms across different disorders. However, the association between the “p” factor and protective factors remains understudied. The current study aimed to explore the “p” factor, and its associations with psycho-social functioning, in Chinese adolescents.

Methods
2052 students, aged 9–17, were recruited from primary and secondary schools in Shanghai, China. Multiple rating scales were used to assess psychological symptoms and psycho-social functioning. Confirmatory factor analysis was conducted to verify the fit of models involving different psychopathology domains such as externalizing, internalizing, and the “p” factor. Subsequently, structural equation models were used to explore associations between the extracted factors and psycho-social functioning, including emotion regulation, mindful attention awareness, self-esteem, self-efficacy, resilience, and perceived support.

Results
The bi-factor model demonstrated a good fit, with a “p” factor accounting for 46 % of symptom variation, indicating that the psychological symptoms of Chinese adolescents could be explained by internalizing, externalizing, and the “p” factor. Psychologically, a higher “p” was positively correlated with emotion suppression and negatively correlated with mindful attention awareness, emotion reappraisal, self-esteem, and resilience. Socially, a higher “p” was associated with decreased perceived support.

Limitations
Only common symptoms were included as this study was conducted at school. Furthermore, the cross-sectional design limited our ability to investigate causal relationships.

Conclusions
A “p” factor exists among Chinese adolescents. Individuals with higher “p” factor levels were prone to experience lower levels of psycho-social functions.

Background: To explore the associations between anxiety and depression symptoms and academic burnout among children and adolescents in China, and to examine the role of resilience and self-efficacy in addressing academic burnout.

Methods: A total of 2,070 students in grades 4–8 were recruited from two primary and three middle schools in Shanghai, completed the Elementary School Student Burnout Scale (ESSBS), the Multidimensional Anxiety Scale for Children-Chinese (MASC-C), the Center for Epidemiological Studies Depression Scale (CES-D), the Connor-Davidson Resilience Scale (CD-RISC), and the General Self-Efficacy Scale (GSES), with 95.04% effective response rate. Multivariable regression analyses examining the associations between anxiety / depression symptoms and academic burnout (as well as the associations between resilience / self-efficacy and academic burnout) were performed using STATA 16.0 and SmartPLS 3.0.

Results: Anxiety symptoms (β = 0.124, p < 0.01) and depression symptoms (β = 0.477, p < 0.01) were positively correlated with academic burnout. Resilience partially mediated the association between depression symptoms and academic burnout (β = 0.059, p < 0.01), with a mediation rate of 12.37%. Self-efficacy partially mediated the associations between anxiety symptoms and academic burnout (β = 0.022, p < 0.01) and between depression symptoms and academic burnout (β = 0.017, p < 0.01), with mediation rates of 17.74% and 3.56%, respectively. Resilience and self-efficacy together (β = 0.041, p < 0.01) formed a mediating chain between depression symptoms and academic burnout, with a mediation rate of 8.6%.

Conclusions: Anxiety and depression symptoms were positively associated with academic burnout. Resilience and self-efficacy were found to mediate the associations partially.

Background: Comorbidity in mental disorders is prevalent among adolescents, with evidence suggesting a general psychopathology factor (“p” factor) that reflects shared mechanisms across different disorders. However, the association between the “p” factor and protective factors remains understudied. The current study aimed to explore the “p” factor, and its associations with psycho-social functioning, in Chinese adolescents.

Methods: 2052 students, aged 9–17, were recruited from primary and secondary schools in Shanghai, China. Multiple rating scales were used to assess psychological symptoms and psycho-social functioning. Confirmatory factor analysis was conducted to verify the fit of models involving different psychopathology domains such as externalizing, internalizing, and the “p” factor. Subsequently, structural equation models were used to explore associations between the extracted factors and psycho-social functioning, including emotion regulation, mindful attention awareness, self-esteem, self-efficacy, resilience, and perceived support.

Results: The bi-factor model demonstrated a good fit, with a “p” factor accounting for 46 % of symptom variation, indicating that the psychological symptoms of Chinese adolescents could be explained by internalizing, externalizing, and the “p” factor. Psychologically, a higher “p” was positively correlated with emotion suppression and negatively correlated with mindful attention awareness, emotion reappraisal, self-esteem, and resilience. Socially, a higher “p” was associated with decreased perceived support.

Limitations: Only common symptoms were included as this study was conducted at school. Furthermore, the cross-sectional design limited our ability to investigate causal relationships.

Conclusions: A “p” factor exists among Chinese adolescents. Individuals with higher “p” factor levels were prone to experience lower levels of psycho-social functions.

Objective: The measures implemented to control the spread of Coronavirus disease 2019 (COVID-19) could affect children’s mental and vision health. Youth particularly from minority and socioeconomically disadvantaged backgrounds were more likely to be impacted by these measures. This study aimed to examine the mental health of children with vision impairment and associated factors in North-western China during the COVID-19 pandemic.

Methods: A cross-sectional study was conducted among 2,036 secondary school children living in Ningxia Hui Autonomous Region. Participants completed a survey on sociodemographic and lifestyle information and answered the Chinese version of the 21-item Depression Anxiety Stress Scales (DASS-21) questionnaire. Presenting visual acuity was measured by a trained enumerator. Multivariate logistic regression analysis was used to identify potential risk factors for mental health problems.

Results: Responses from 1,992 (97.8%) children were included in the analysis after excluding those with incomplete mental health outcome data. The prevalence of depression, anxiety and stress symptoms within the dataset were 28.9, 46.4, and 22.3%, respectively. The distribution of children with different stress levels differed significantly between those with and without vision impairment (p = 0.03). Multivariable logistic regression analyses revealed that depression symptoms decreased with higher parental education (OR, 0.76, 95% confidence intervals (CI):0.63–0.96), longer sleep duration (OR, 0.90, 95% CI: 0.81–0.97) and longer study time (OR, 0.82, 95% CI: 0.74–0.91), whereas they increased with higher recreational screen time (OR, 1.19, 95% CI: 1.08–1.32). Anxiety symptoms decreased with higher parental education (OR, 0.80, 95% CI: 0.66–0.96) and increased with higher recreational screen time (OR, 1.15, 95% CI: 1.04–1.27) and being a left-behind child (OR, 1.26, 95% CI: 1.04–1.54). In addition, stress symptoms decreased with longer sleep duration (OR, 0.92, 95%CI: 0.85–0.99) and increased with higher number of siblings (OR, 1.10, 95% CI: 1.01–1.19), higher recreational screen time (OR, 1.15, 95% CI: 1.04–1.28) and older age (OR,1.12, 95% CI: 1.004–1.24).

Conclusion: A considerable proportion of our sample experienced mental health problems during the pandemic. Healthcare planners in China should consider interventions such as reducing recreational screen time, ensuring sufficient sleep, and timely detection of mental health symptoms among socioeconomically disadvantaged groups.

Objective
To test the feasibility and effectiveness of a mindfulness-based intervention in rural-to-urban migrant Chinese children using trained community volunteers.

Method
Migrant students ages 9 to 16 from 5 schools in Shanghai (N = 653) were randomly assigned to a mindfulness only group (n = 167), a mindfulness plus life skills group (n = 118), or a waitlist control group (n = 368). The first 2 groups received an 8-week mindfulness intervention delivered 1 hour weekly by trained community volunteers. The mindfulness plus life skills group received 8 additional hours of skills-based mentorship. Measurements on mindfulness, resilience, and anxiety and depression symptoms were collected before and after intervention. Multivariable regression analyses compared the intervention vs control groups.

Results
Before intervention, there were no significant demographic or outcome measure differences between groups except that students in the intervention groups were slightly older. Students had relatively low levels of mindfulness and prosociality difficulties and similar degrees of depression and anxiety symptoms compared with prior studies. After intervention, no statistically significant differences were found in mean scores for mindfulness, resilience, anxiety, or depression in the intervention vs control groups.

Conclusion
A volunteer-led mindfulness intervention did not significantly benefit migrant Chinese children after 8 weeks. More implementation research is needed for low-cost, scalable, and contextually effective mental health prevention programs.

This study investigated the association between household characteristics, perceived family support (PFS), and the developmental outcomes (resilience, academic performance, and prosociality) among at-risk students. Our large sample included 1564 primary and secondary school students from poor rural China (M = 11.55 years old). Having a caregiver whose resilience score was in the top 50% of the sample was associated with a 0.48-point increase (or 0.31 d effect size), while having a migrant mother was correlated with a 0.26-point decrease (or 0.17 d effect size). PFS was a significant (p < 0.0001) mediator between household characteristics and developmental outcomes. Our study highlights the link between caregiver resilience and PFS, and the healthy functioning of disadvantaged students in a developing context.

This study conducts an exploratory analysis of the impacts of a center-based early childhood development intervention on the mental health of caregivers, using data from a cluster-randomized controlled trial of 1664 caregivers (Mage = 36.87 years old) of 6- to 24-month-old children in 100 villages in rural China. Caregivers and children in 50 villages received individual parenting training, group activities and open play space in village parenting centers. The results show no significant overall change in caregiver-reported mental health symptoms after 1 year of intervention. Subgroup analyses reveal heterogeneous effects by caregiver socioeconomic status and identity (mother vs. grandmother). Findings suggest that early childhood development interventions without targeted mental health components may not provide sufficient support to improve caregiver mental health.

Resilience can play an important role in enabling disadvantaged students to succeed academically. However, few studies in low-resource contexts have evaluated resilience as a process (including a child’s internal capabilities and external resources, like the internal capabilities of a child’s caregiver) and as an outcome (e.g., academic achievement). In the current study, we examined the associations among students’ self-reported internal capabilities, their external resources (e.g., caregivers’ internal capabilities), and their academic resilience (operationalized as performance on a math test). The study was conducted among 1609 primary and secondary school students in rural China using the Connor–Davidson Resilience Scale (CD-RISC) to measure internal capabilities. Student CD-RISC scores were positively associated with external resources including caregiver CD-RISC scores, maternal education level, high levels of perceived social support, recreational reading, and involvement in group-based activities at school. A one-point increase in students’ CD-RISC scores was associated with a 0.01 SD increase in math score (p < 0.001), and the math scores of students whose CD-RISC scores were in the bottom quartile were 0.18 SD lower than those of their peers (p < 0.01). High levels of perceived social support and recreational reading were also associated with academic resilience in the adjusted equation. Directions for future research and policy implications are discussed.

Topic
This systematic review and meta-analysis summarizes existing evidence to establish whether vision impairment, ocular morbidity and their treatment are associated with depression and anxiety in children.

Clinical Relevance
Understanding and quantifying these associations support early detection and management of mental health symptoms in children with vision impairment and ocular morbidity. Additionally, this review provides evidence in favour of insurance coverage for timely strabismus surgery.

Methods
We searched nine electronic databases from inception to February 18, 2021, including observational and interventional studies assessing whether vision impairment and/or ocular morbidity and their treatment are associated with depression and/or anxiety in children. We used narrative synthesis and meta-analysis with the residual maximum likelihood method. A protocol was registered and published on The International Prospective Register of Systematic Reviews (PROSPERO, CRD42021233323).

Results
Among 28,992 studies, 28,956 (99.9%) were excluded as duplicates or unrelated content. Among 36 remaining studies, 21 (58.3%) were observational studies concerning vision impairment, eight (22.2%) were observational studies concerning strabismus, and seven (19.4%) were interventional studies. Vision-impaired children experienced significantly higher scores of depression (Standard Mean Difference [SMD] 0.57, 95% Confidence Interval (CI) 0.26-0.89, 11 studies) and anxiety (SMD 0.61, 95% CI 0.40-0.821, 14 studies) than normally-sighted children. In particular, myopic children experienced higher scores of depression (SMD 0.59, 95% CI 0.36-0.81, six studies) than normally-sighted children. Strabismus surgery significantly improved symptoms of depression (SMD: 0.59 95% CI 0.12-1.06, three studies) and anxiety (SMD: 0.69 95% CI 0.24-1.14, four studies) in children.

Discussion
Among children, vision impairment is associated with greater symptoms of depression and anxiety. Surgical treatment of strabismus improved these symptoms. Further randomized controlled trials exploring the impact of public health measures for myopia correction on mental health in children are needed. Scaling up access to strabismus surgery could improve the mental health of affected children.

Although children living in low- and middle-income countries (LMICs) account for 90% of the global population of children, depression, and anxiety among children in LMICs have been understudied. This study examines the prevalence of depression and anxiety and their associations with biological and psychosocial factors among children across China, with a focus on rural areas. We conducted a large-scale epidemiological study of depression and anxiety among 53,421 elementary and junior high school-aged children across China. The results show that 20% are at risk for depression, 6% are at risk for generalized anxiety, and 68% are at risk for at least one type of anxiety. Girls and junior high school students show a higher risk for both depression and anxiety symptoms, while socioeconomic status has varying associations to depression and anxiety symptoms. Our results also show consistent correlations between depression and anxiety symptoms and standard math test scores. These findings underscore the importance of identification, prevention, and treatment of youth depression and anxiety in underdeveloped areas. As China constitutes 15% of the global population of children under age 18, this study offers valuable information to the field of global mental health.

Assessing the mental health problems encountered by school children and understanding the contributing factors are crucial to inform strategies aimed at improving mental health in low-resource contexts. However, few studies have investigated the mental health problems among disadvantaged children in poorer countries. This study examines the prevalence of mental health problems in rural China and their association with child and family characteristics. The study uses survey data from 9696 children in 120 rural primary schools and measures child mental health using the Strengths and Difficulties Questionnaire (SDQ). Overall, 17.9% of the sample children were found to be in the abnormal range of the SDQ total difficulties scores. The mean score was 12.93 (SD = 4.94). Abnormal scores were associated with child and family characteristics, including older child age (Odds Ratio, OR = 0.704, 95% CI: 0.611, 0.810; p < 0.001), gender (OR = 1.235, 95% CI: 1.112, 1.371; p < 0.001), and academic performance (OR = 0.421, 95% CI: 0.369, 0.480; p < 0.001). Reading time was found to be protective for mental health. Risk factors include excessive screen time (OR = 1.685, 95% CI: 1.409, 2.016; p < 0.001) and being bullied (OR = 3.695, 95% CI: 3.301, 4.136; p < 0.001). Our study suggests that future mental health illness prevention programs in rural China should consider targeting different aspects of children’s social contexts.