Cost-utility analysis of Social Stories™ for children with autism spectrum disorder in mainstream primary schools: results from a randomised controlled trial.

BACKGROUND: One in 57 children are diagnosed with autism in the UK, and the estimated cost for supporting these children in education is substantial. Social Stories™ is a promising and widely used intervention for supporting children with autism in schools and families. It is believed that Social Stories™ can provide meaningful social information to children that can improve social understanding and may reduce anxiety. However, no economic evaluation of Social Stories has been conducted. AIMS: To assess the cost-effectiveness of Social Stories through Autism Spectrum Social Stories in Schools Trial 2, a multi-site, pragmatic, cluster-randomised controlled trial. METHOD: Children with autism who were aged 4-11 years were recruited and randomised (N = 249). Costs measured from the societal perspective and quality-adjusted life-years (QALYs) measured by the EQ-5D-Y-3L proxy were collected at baseline and at 6-month follow-up for primary analysis. The incremental cost-effectiveness ratio was calculated, and the uncertainty around incremental cost-effectiveness ratios was captured by non-parametric bootstrapping. Sensitivity analyses were performed to evaluate the robustness of the primary findings. RESULTS: Social Stories is likely to result in a small cost savings (-£191 per child, 95% CI -767.7 to 337.7) and maintain similar QALY improvements compared with usual care. The probability of Social Stories being a preferred option is 75% if society is willing to pay £20 000 per QALY gained. The sensitivity analysis results aligned with the main study outcomes. CONCLUSIONS: Compared with usual care, Social Stories did not lead to an increase in costs and maintained similar QALY improvements for primary-aged children with autism.

Play brick therapy to aid the social skills of children and young people with autism spectrum disorder: the I-SOCIALISE cluster RCT.

Background: Social skills interventions are commonly recommended to help children and young people with autism spectrum disorder develop social skills, but some struggle to engage in these interventions. LEGO® (LEGO System A/S, Billund, Denmark) based therapy, a group social skills intervention, aims to be more interesting and engaging. Objective: To evaluate the clinical effectiveness of LEGO® based therapy on the social and emotional skills of children and young people with autism spectrum disorder in school settings compared with usual support. Secondary objectives included evaluations of cost-effectiveness, acceptability and treatment fidelity. Design: A cluster randomised controlled trial randomly allocating participating schools to either LEGO® based therapy and usual support or usual support only. Setting: Mainstream schools in the north of England. Participants: Children and young people (aged 7-15 years) with autism spectrum disorder, their parent/guardian, an associated teacher/teaching assistant and a facilitator teacher/teaching assistant (intervention schools only). Intervention: Schools randomised to the intervention arm delivered 12 weekly sessions of LEGO® based therapy, which promotes collaborative play and encourages social problem-solving in groups of three children and young people with a facilitator (trained teacher or teaching assistant). Participants received usual support from school and community services. Participants in the control arm received usual support only. Research assistants and statisticians were blind to treatment allocation. Main outcome measure: The social skills subscale of the Social Skills Improvement System (SSIS), completed by the children and young people's unblinded teacher pre randomisation and 20 weeks post randomisation. The SSIS social skills subscale measures social skills including social communication, co-operation, empathy, assertion, responsibility and self-control. Participants completed a number of other pre- and post-randomisation measures of emotional health, quality of life, loneliness, problem behaviours, academic competence, service resource utilisation and adverse events. Results: A total of 250 children and young people from 98 schools were randomised: 127 to the intervention arm and 123 to the control arm. Intention-to-treat analysis of the main outcome measure showed a modest positive difference of 3.74 points (95% confidence interval -0.16 to 7.63 points, standardised effect size 0.18; p = 0.06) in favour of the intervention arm. Statistical significance increased in per-protocol analysis, with a modest positive difference (standardised effect size 0.21; p = 0.036). Cost-effectiveness of the intervention was found in reduced service use costs and a small increase in quality-adjusted life-years. Intervention fidelity and acceptability were positive. No intervention-related adverse events or effects were reported. Conclusions: The primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes of between 0.15 and 0.21. There were positive health economics and qualitative findings, corroborated by the difference between arms for the majority of secondary outcomes, which were not statistically significant but favoured the intervention arm. Post hoc additional analysis was exploratory and was not used in drawing this conclusion. Given the small positive change, LEGO® based therapy for children and young people with autism spectrum disorder in schools should be considered. Limitations: The primary outcome measure was completed by an unblinded teacher (rather than by the facilitator). Future work: The study team recommends future research into LEGO® based therapy, particularly in school environments. Trial registration: This trial is registered as ISRCTN64852382. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information.

Autism spectrum disorder is characterised by difficulties with social relationships and communication, which can make it difficult to make friends. Social skills training is commonly used to help children and young people learn different social skills, but some children and young people do not enjoy these therapies. LEGO^® (LEGO System A/S, Billund, Denmark) based therapy takes a new approach by focusing on making the process interesting and fun. This research investigated the effect of LEGO^® based therapy groups in schools on the social and emotional abilities of children and young people with autism spectrum disorder. It was a randomised controlled trial, so each school that was taking part was randomly chosen to provide either usual support (from the school or NHS services) or 12 sessions of LEGO^® based therapy with a trained school staff member as well as usual support. Children and young people played one of three roles ­ the 'engineer' (gives instructions), the 'supplier' (finds the pieces) or the 'builder' (builds the model) ­ and worked together. Questionnaires completed by children and young people, their parents/guardians and teachers were used to look at the intervention's effects. The main objective was to see if there was a change in social skills measured by a teacher-completed questionnaire. Results showed that the social skills of children and young people in the LEGO^® based therapy groups did improve a little. We found that the intervention is not very costly for schools to run. Many parents/guardians and teachers thought that the intervention was beneficial and that the children and young people enjoyed it.

A systematic review of non-coding RNA genes with differential expression profiles associated with autism spectrum disorders.

AIMS: To identify differential expression of shorter non-coding RNA (ncRNA) genes associated with autism spectrum disorders (ASD). BACKGROUND: ncRNA are functional molecules that derive from non-translated DNA sequence. The HUGO Gene Nomenclature Committee (HGNC) have approved ncRNA gene classes with alignment to the reference human genome. One subset is microRNA (miRNA), which are highly conserved, short RNA molecules that regulate gene expression by direct post-transcriptional repression of messenger RNA. Several miRNA genes are implicated in the development and regulation of the nervous system. Expression of miRNA genes in ASD cohorts have been examined by multiple research groups. Other shorter classes of ncRNA have been examined less. A comprehensive systematic review examining expression of shorter ncRNA gene classes in ASD is timely to inform the direction of research. METHODS: We extracted data from studies examining ncRNA gene expression in ASD compared with non-ASD controls. We included studies on miRNA, piwi-interacting RNA (piRNA), small NF90 (ILF3) associated RNA (snaR), small nuclear RNA (snRNA), small nucleolar RNA (snoRNA), transfer RNA (tRNA), vault RNA (vtRNA) and Y RNA. The following electronic databases were searched: Cochrane Library, EMBASE, PubMed, Web of Science, PsycINFO, ERIC, AMED and CINAHL for papers published from January 2000 to May 2022. Studies were screened by two independent investigators with a third resolving discrepancies. Data was extracted from eligible papers. RESULTS: Forty-eight eligible studies were included in our systematic review with the majority examining miRNA gene expression alone. Sixty-four miRNA genes had differential expression in ASD compared to controls as reported in two or more studies, but often in opposing directions. Four miRNA genes had differential expression in the same direction in the same tissue type in at least 3 separate studies. Increased expression was reported in miR-106b-5p, miR-155-5p and miR-146a-5p in blood, post-mortem brain, and across several tissue types, respectively. Decreased expression was reported in miR-328-3p in bloods samples. Seven studies examined differential expression from other classes of ncRNA, including piRNA, snRNA, snoRNA and Y RNA. No individual ncRNA genes were reported in more than one study. Six studies reported differentially expressed snoRNA genes in ASD. A meta-analysis was not possible because of inconsistent methodologies, disparate tissue types examined, and varying forms of data presented. CONCLUSION: There is limited but promising evidence associating the expression of certain miRNA genes and ASD, although the studies are of variable methodological quality and the results are largely inconsistent. There is emerging evidence associating differential expression of snoRNA genes in ASD. It is not currently possible to say whether the reports of differential expression in ncRNA may relate to ASD aetiology, a response to shared environmental factors linked to ASD such as sleep and nutrition, other molecular functions, human diversity, or chance findings. To improve our understanding of any potential association, we recommend improved and standardised methodologies and reporting of raw data. Further high-quality research is required to shine a light on possible associations, which may yet yield important information.

Improving the Scope of Child Mental Health Interventions in Our Modern World.

Twenty years ago, an important systematic review showed that the empirical research evidence for interventions available for children and young people with mental health problems were rarely developed with their specific developmental needs in mind [...].

I-SOCIALISE: Results from a cluster randomised controlled trial investigating the social competence and isolation of children with autism taking part in LEGO® based therapy ('Play Brick Therapy') clubs in school environments.

LAY ABSTRACT: Autism is characterised by keen interests and differences in social interactions and communication. Activities that help autistic children and young people with social skills are commonly used in UK schools. LEGO® based therapy is a new activity that provides interesting and fun social opportunities for children and young people and involves building LEGO® models together. This study looked at LEGO® based therapy for the social skills of autistic children and young people in schools. It was a randomised controlled trial, meaning each school was randomly chosen (like flipping a coin) to either run LEGO® based therapy groups in school over 12 weeks and have usual support from school or other professionals, or only have usual support from school or other professionals. The effect of the LEGO® based therapy groups was measured by asking children and young people, their parents/guardians, and a teacher at school in both arms of the study to complete some questionnaires. The main objective was to see if the teacher's questionnaire answers about the children and young people's social skills changed between their first and second completions. The social skills of participants in the LEGO® based therapy groups were found to have improved in a small way when compared to usual support only. The study also found that LEGO® based therapy was not very costly for schools to run and parents/guardians and teachers said they thought it was good for their children and young people. We suggest further research into different potential benefits of LEGO® based therapy.

Routinely used interventions to improve attachment in infants and young children: a national survey and two systematic reviews.

BACKGROUND: Attachment refers to an infant's innate tendency to seek comfort from their caregiver. Research shows that attachment is important in promoting healthy social and emotional development. Many parenting interventions have been developed to improve attachment outcomes for children. However, numerous interventions used in routine practice have a limited evidence base, meaning that we cannot be sure if they are helpful or harmful. OBJECTIVES: This research aimed to conduct a large-scale survey to identify what interventions are being used in UK services to improve child attachment; conduct a systematic review to evaluate the evidence for parenting attachment interventions; and develop recommendations for future research and practice. DESIGN AND METHODS: We worked closely with our Expert Reference Group to plan a large-scale survey focused on relevant UK services. We then conducted two systematic reviews. One searched for all randomised controlled trial evidence for any attachment parenting intervention. The second searched for all research for the top 10 routinely used interventions identified from the survey. RESULTS: The survey collected 625 responses covering 734 UK services. The results identified the 10 most commonly used interventions. The responses showed a limited use of validated measures and a wide variety of definitions of attachment. For the first review, seven studies were included from 2516 identified records. These were combined with results from previous reviews conducted by the team. Meta-analyses showed that, overall, parenting interventions are effective in reducing disorganised attachment (pooled odds ratio 0.54, 95% confidence interval 0.39 to 0.77) and increasing secure attachment (pooled odds ratio 1.85, 95% confidence interval 1.36 to 2.52). The second review searched the literature for the top 10 routinely used interventions identified by the survey; 61 studies were included from 1198 identified records. The results showed that many of the most commonly used interventions in UK services have a weak evidence base and those with the strongest evidence base are not as widely used. CONCLUSIONS: There is a need for better links between research and practice to ensure that interventions offered to families are safe and effective. Possible reasons for the disparity include the cost and accessibility of training. There is also a need for improved understanding by professionals regarding the meaning of attachment. LIMITATIONS: Although the survey had good geographical spread, most respondents were based in England. For review 2 we were unable to access a large number of papers; however, we conducted extensive reference checking to account for this. FUTURE WORK: There is a need for robust research to test the efficacy of routinely used attachment interventions. Research could also explore why routinely used interventions are not consistently subject to thorough evaluation; how to embed dissemination, cost-effectiveness, fidelity and sustainability into research; and how to keep clinical practice up to date with research developments. STUDY REGISTRATION: This study is registered as PROSPERO CRD42019137362. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 2. See the NIHR Journals Library website for further project information.

Attachment refers to an infant's natural instinct to seek comfort from their main carers. There are four ways in which infants show attachment ('attachment patterns'). These are known as secure, insecure-avoidant, insecure-resistant and disorganised. Secure attachment usually occurs with consistent and responsive parenting/caregiving and is linked with positive social and emotional child development. Inconsistent, neglectful or abusive parenting/caregiving can lead to problems with attachment, including disorganised attachment, and is linked to poorer outcomes. Parenting support, education and therapies help parents improve infant attachment and their child's outcomes. We surveyed UK services to see what they offered families with attachment problems. A total of 734 UK services responded. This identified 10 therapies or support packages most commonly offered to parents. We checked what research had been done on these. We found very little. We found 61 studies of support packages with quite good evidence, but these were generally not ones offered by UK services. We also looked in detail at research for all types of support/therapies to improve attachment. We looked for the best research (called 'randomised controlled trials'); 26 studies had tested therapies to see if they improved secure attachment and 20 had tested whether or not they improved (i.e. reduced) disorganised attachment. We found that these therapies or support packages are good at increasing secure attachment and improving disorganised attachment. Mostly they did this by helping parents/caregivers improve caregiving and particularly how sensitive and responsive they are to their child and their needs. Currently, practice is not following research, and research is not being done to properly evaluate current practice. We need to improve the evidence and the way it links to practice, including how those organising and paying for services are made aware of up-to-date research to make sure that the best treatments are available. High-quality training for staff is also important.

Comparison of Diagnostic Profiles of Deaf and Hearing Children with a Diagnosis of Autism.

There is limited research comparing the presentation of autism in deaf and hearing children and young people. These comparisons are important to facilitate accurate diagnosis, as rates of misdiagnosis and delay in diagnosis amongst deaf children and young people are high. The aim of this study was to compare diagnostic assessment profiles of a UK cohort of autistic deaf and hearing children and young people. The Autism Diagnostic Interview-Revised-Deaf adaptation was completed with the parents of 106 children and young people (deaf children = 65; hearing children = 41). The majority of items explored showed no significant differences between deaf and hearing children and young people. Differences were found in peer relationships, where autistic deaf participants were less likely to respond to the approaches of other children or play imaginatively with peers. These findings need to be taken into consideration by clinicians in the assessment process.

One session treatment (OST) is equivalent to multi-session cognitive behavioral therapy (CBT) in children with specific phobias (ASPECT): results from a national non-inferiority randomized controlled trial.

BACKGROUND: 5%-10% children and young people (CYP) experience specific phobias that impact daily functioning. Cognitive Behaviour Therapy (CBT) is recommended but has limitations. One Session Treatment (OST), a briefer alternative incorporating CBT principles, has demonstrated efficacy. The Alleviating Specific Phobias Experienced by Children Trial (ASPECT) investigated the non-inferiority of OST compared to multi-session CBT for treating specific phobias in CYP. METHODS: ASPECT was a pragmatic, multi-center, non-inferiority randomized controlled trial in 26 CAMHS sites, three voluntary agency services, and one university-based CYP well-being service. CYP aged 7-16 years with specific phobia were randomized to receive OST or CBT. Clinical non-inferiority and a nested cost-effectiveness evaluation was assessed 6-months post-randomization using the Behavioural Avoidance Task (BAT). Secondary outcome measures included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children's Anxiety Depression Scale, goal-based outcome measure, and EQ-5DY and CHU-9D, collected blind at baseline and six-months. RESULTS: 268 CYPs were randomized to OST (n = 134) or CBT (n = 134). Mean BAT scores at 6 months were similar across groups in both intention-to-treat (ITT) and per-protocol (PP) populations (CBT: 7.1 (ITT, n = 76), 7.4 (PP, n = 57), OST: 7.4 (ITT, n = 73), 7.6 (PP, n = 56), on the standardized scale-adjusted mean difference for CBT compared to OST -0.123, 95% CI -0.449 to 0.202 (ITT), mean difference -0.204, 95% CI -0.579 to 0.171 (PP)). These findings were wholly below the standardized non-inferiority limit of 0.4, suggesting that OST is non-inferior to CBT. No between-group differences were found on secondary outcomes. OST marginally decreased mean service use costs and maintained similar mean Quality Adjusted Life Years compared to CBT. CONCLUSIONS: One Session Treatment has similar clinical effectiveness to CBT for specific phobias in CYP and may be a cost-saving alternative.

Does Father Christmas Have a Distinctive Facial Phenotype?

We investigated whether Father Christmas has a distinguishable facial phenotype by performing a cross-sectional cohort study examining the facial feature vectors of all publicly available photographs obtained from a google image search of individuals meeting our eligibility criteria presenting as Father Christmas compared with other adult and elderly bearded men. Facial feature vectors were determined using the open-source OpenFace facial recognition system and assessed by support vector machines (SVM). SVM classifiers were trained to distinguish between the facial feature vectors from our groups. Accuracy, precision, and recall results were calculated and the area under the curve (AUC) of the receiver operating characteristic (ROC) were reported for each classifier. SVM classifiers were able to distinguish the face of Father Christmas from other adult men with a high degree of accuracy and could discriminate Father Christmas from elderly bearded men but with lower accuracy. Father Christmas appears to have a distinct facial phenotype when compared to adult men and elderly bearded men. This will be reassuring to children who may be keen to recognise him but raises some interesting questions about the careful use of two-dimensional facial analysis, particularly when employed to explore the relationships between genotype and facial phenotype in a clinical dysmorphology setting.

Parental death: a systematic review of support experiences and needs of children and parent survivors.

BACKGROUND: Bereaved people need a supportive response from those around them. Knowing children's and surviving parents' needs following parental death is the first step to ensuring a supportive response. However, no systematic review has reported on this phenomenon. AIM: To systematically identify and synthesise qualitative literature exploring support experiences of parentally bereaved children and surviving parents. METHODS: Systematic review with thematic synthesis, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. MEDLINE, Embase, PsycINFO, CINAHL and the British Nursing Database were searched for relevant papers to September 2021. Included studies were appraised for quality and thematically synthesised using Thomas and Harden's thematic synthesis framework. RESULTS: Fifteen qualitative studies from nine countries were included. There were four analytical themes from the children's perspectives (1) Openness of communication with children about death and dying, (2) Children's challenges of managing change, (3) Navigating emotions, and (4) Children's acceptability, access and engagement with support. There were three analytical themes from the parents' perspectives: (1) Adjusting as a parent, (2) Supporting their children, and (3) Parent's acceptability, access and engagement with support. CONCLUSIONS: Following a parental death, open and honest communication and involvement in what is happening within the family will help children cope. Both children and parents suppress emotions and avoid conversations to protect each other and those around them. A taboo around death exists and constrains the support some families receive. Childhood bereavement is a public health issue, with a need for professionals and communities to better understand and respond to the needs of bereaved families.CRD42020166179.

One-session treatment compared with multisession CBT in children aged 7-16 years with specific phobias: the ASPECT non-inferiority RCT.

BACKGROUND: Up to 10% of children and young people have a specific phobia that can significantly affect their mental health, development and daily functioning. Cognitive-behavioural therapy-based interventions remain the dominant treatment, but limitations to their provision warrant investigation into low-intensity alternatives. One-session treatment is one such alternative that shares cognitive-behavioural therapy principles but has a shorter treatment period. OBJECTIVE: This research investigated the non-inferiority of one-session treatment to cognitive-behavioural therapy for treating specific phobias in children and young people. The acceptability and cost-effectiveness of one-session treatment were examined. DESIGN: A pragmatic, multicentre, non-inferiority randomised controlled trial, with embedded economic and qualitative evaluations. SETTINGS: There were 26 sites, including 12 NHS trusts. PARTICIPANTS: Participants were aged 7-16 years and had a specific phobia defined in accordance with established international clinical criteria. INTERVENTIONS: Participants were randomised 1 : 1 to receive one-session treatment or usual-care cognitive-behavioural therapy, and were stratified according to age and phobia severity. Outcome assessors remained blind to treatment allocation. MAIN OUTCOME MEASURES: The primary outcome measure was the Behavioural Avoidance Task at 6 months' follow-up. Secondary outcomes included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children's Anxiety and Depression Scale, a goal-based outcome measure, Child Health Utility 9D, EuroQol-5 Dimensions Youth version and resource usage. Treatment fidelity was assessed using the Cognitive Behaviour Therapy Scale for Children and Young People and the One-Session Treatment Rating Scale. RESULTS: A total of 274 participants were recruited, with 268 participants randomised to one-session treatment (n = 134) or cognitive-behavioural therapy (n = 134). A total of 197 participants contributed some data, with 149 participants in the intention-to-treat analysis and 113 in the per-protocol analysis. Mean Behavioural Avoidance Task scores at 6 months were similar across treatment groups when both intention-to-treat and per-protocol analyses were applied [cognitive-behavioural therapy: 7.1 (intention to treat), 7.4 (per protocol); one-session treatment: 7.4 (intention to treat), 7.6 (per protocol); on the standardised scale adjusted mean difference for cognitive-behavioural therapy compared with one-session treatment -0.123, 95% confidence interval -0.449 to 0.202 (intention to treat), mean difference -0.204, 95% confidence interval -0.579 to 0.171 (per protocol)]. These findings were wholly below the standardised non-inferiority limit of 0.4, which suggests that one-session treatment is non-inferior to cognitive-behavioural therapy. No between-group differences in secondary outcome measures were found. The health economics evaluation suggested that, compared with cognitive-behavioural therapy, one-session treatment marginally decreased the mean service use costs and maintained similar mean quality-adjusted life-year improvement. Nested qualitative evaluation found one-session treatment to be considered acceptable by those who received it, their parents/guardians and clinicians. No adverse events occurred as a result of phobia treatment. LIMITATIONS: The COVID-19 pandemic meant that 48 children and young people could not complete the primary outcome measure. Service waiting times resulted in some participants not starting therapy before follow-up. CONCLUSIONS: One-session treatment for specific phobia in UK-based child mental health treatment centres is as clinically effective as multisession cognitive-behavioural therapy and highly likely to be cost-saving. Future work could involve improving the implementation of one-session treatment through training and commissioning of improved care pathways. TRIAL REGISTRATION: This trial is registered as ISRCTN19883421. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 42. See the NIHR Journals Library website for further project information.

A phobia is an intense, ongoing fear of an everyday object or situation. The phobia causes distress and the person with the phobia avoids that object or situation. Many children and young people have phobias that affect their daily lives. Cognitive­behavioural therapy helps by changing what people do or think when they have a phobia and is the most common treatment approach. However, cognitive­behavioural therapy is expensive, takes time and is not always easy to get. Different treatments are needed to help children and young people with specific phobias. One such therapy is one-session treatment, which works in similar ways to cognitive­behavioural therapy but takes place over one main 3-hour session. Our study, called ASPECT (Alleviating Specific Phobias Experienced by Children Trial), compared these two treatments to examine whether or not one-session treatment is as effective as cognitive­behavioural therapy. Overall, 274 children and young people aged 7­16 years from 26 sites nationally helped with our research, of whom 268 received either cognitive­behavioural therapy or one-session treatment. The results at 6 months found that one-session treatment and cognitive­behavioural therapy worked as well as each other for treating phobias in children and young people. We also found evidence that one-session treatment is cheaper than cognitive­behavioural therapy. We spoke with children and young people, their parents/guardians and the therapists of the single-session treatment, and we found one-session treatment to be acceptable for their needs. Future research could explore how to make one-session treatment more easily available for children and young people with specific phobias because it can save time and money, and works just as well as cognitive­behavioural therapy.

One-session treatment for specific phobias: Barriers, facilitators and acceptability as perceived by children & young people, parents, and clinicians.

Between 2015 and 2020 the Alleviating Specific Phobias Experienced by Children Trial (ASPECT) was conducted in the UK to examine the non-inferiority of One-Session Treatment in comparison to Cognitive Behavioural Therapy based interventions for children and young people with specific phobias. A nested qualitative evaluation was conducted as part of this trial to examine the acceptability of One-Session Treatment. Qualitative interviews were conducted with children and young people taking part in the trial, their parents/guardians, and clinicians delivering the intervention, about their experiences and the acceptability of One Session Treatment. Interviews were digitally recorded and transcribed verbatim. Analysis followed a qualitative framework approach, a widely used method of analysing primary qualitative data pertaining to healthcare practices with policy relevance. Stakeholder groups found One Session Treatment to be an acceptable intervention and barriers and facilitators for its implementation into services were also identified. Potential barriers included challenges to patient flow and treatment scepticism, whilst facilitators included adopting a child-centred approach, child readiness and suitability, opportunity for increased momentum, parental support and involvement, and proximal and distal gains. For One Session Treatment's successful implementation into services, consideration of these barriers is needed and suitability guidance for its use in this population should be developed. Further research exploring children and young people's experiences of receiving Cognitive Behavioural Therapy and its acceptability in comparison to One Session Treatment would be welcomed.

A modified video-feedback intervention for carers of foster children aged 6 years and under with reactive attachment disorder: a feasibility study and pilot RCT.

BACKGROUND: Looked-after children are at risk of suboptimal attachment patterns and reactive attachment disorder. However, access to interventions varies widely and there are no evidence-based interventions for this disorder. OBJECTIVES: (1) To adapt an existing video-feedback intervention to meet the specific needs of foster children in the UK with reactive attachment symptoms, (2) to conduct a case series to road-test the treatment manual and study procedures, (3) to conduct a scoping study of the key hurdles in a pilot trial and (4) to conduct a pilot randomised controlled trial of the adapted intervention to determine the feasibility of a future full-scale trial. DESIGN: This was a mixed-methods study. The adapted treatment manual was developed with expert input and tested on a small case series. Qualitative interviews with key stakeholders were used in the scoping study in preparation for the trial and later with foster carers who received the new intervention. The final stage was a feasibility and pilot randomised controlled trial of the new intervention, compared with usual care. Researchers assessing the outcomes were blinded to group assignment. SETTING: The study was set in outpatient child and adolescent mental health services and partner social services departments. Sites included urban and rural/semirural areas. PARTICIPANTS: Participants were foster carers with children aged ≤ 6 years presenting with difficulties in the domain of reactive attachment disorder. Key stakeholders included children's services managers and mental health service practitioners in the scoping study. Foster carers who received the modified intervention participated in qualitative interviews. INTERVENTION: The video-feedback intervention to promote positive parenting and sensitive discipline is an extensively evaluated and effective treatment approach. This intervention was modified (based on the adapted version for foster care in the Netherlands) to suit the needs of young children with reactive attachment symptoms in foster care in the UK and was delivered to improve the sensitive responding of foster carers, foster carer-child relationships and child outcomes. The modified intervention was delivered in-home by trained mental health professionals over a period of 4-6 months. MAIN OUTCOME MEASURE: The main outcome was reactive attachment symptom scores on the Disturbances of Attachment Interview. RESULTS: A series of minor changes to the intervention programme were introduced, which focused on improving its suitability for the UK foster care context. Challenges in recruitment meant that, despite numerous modifications to the protocol and the inclusion of additional sites, only 30 families (target, n = 40) were recruited to the randomised controlled trial (15 allocated to each group). However, most other trial parameters were deemed feasible and acceptable, particularly the high levels of data and treatment completeness. All randomised families were available for baseline analyses, but two in the treatment arm were not available for post-treatment analyses. The revised intervention was positively received by practitioners and foster carers. LIMITATIONS: Only three-quarters of the target sample size was recruited. Furthermore, the sites' own exclusion of potential participants and the low return rates of screening questionnaires raise the possibility of non-randomness of non-responses. CONCLUSION: A larger-scale trial may be feasible, but only if recruitment barriers can be overcome. Dedicated resources to support recruitment within local authorities and wider inclusion criteria are recommended. Central resourcing of intervention capacity to supplement NHS staff is also recommended. TRIAL REGISTRATION: This trial is registered as ISRCTN18374094. FUNDING: This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 35. See the NIHR Journals Library website for further project information.

Children in foster care typically have had a very difficult start in life, often as a result of abuse or neglect within their family of origin, and separation from caregivers. These children can find it difficult to trust new adults, and in some cases difficulties in attachment may justify a diagnosis of reactive attachment disorder. This disorder is a pattern of behaviour among young children who have received extremely insufficient early care, whereby they fail to seek or respond to comfort from carers when hurt or distressed, and they can be very withdrawn. There are currently no evidence-based treatments for reactive attachment disorder. The Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline is a treatment programme that was developed to promote secure attachments in young children and to help parents deal with difficult behaviour. A practitioner films the child and parent interacting at home and provides feedback in the following session. This treatment was previously adapted for use in foster care in the Netherlands. In this study, we modified the treatment further to ensure that it appropriately addressed the needs of young children in foster care in the UK who present with reactive attachment disorder symptoms. We then worked with local authorities and linked mental health services to develop a system for identifying young children in foster care in need of this treatment. Finally, we conducted a small (pilot) study to gather information about the best way to provide the modified treatment in this context. The revised treatment was positively received by practitioners and foster carers. The majority of the processes involved in running a trial also worked well (e.g. good levels of attendance at assessments and at the treatment sessions). However, we encountered significant difficulties in recruiting foster carers to the study. We concluded that a full-scale trial would be very valuable, and could potentially be undertaken if difficulties with recruitment are overcome. We recommend that greater resources be provided to local authorities to help them engage and recruit foster carers.

Cost and effectiveness of one session treatment (OST) for children and young people with specific phobias compared to multi-session cognitive behavioural therapy (CBT): results from a randomised controlled trial.

BACKGROUND: In the UK, around 93,000 (0.8%) children and young people (CYP) are experiencing specific phobias that have a substantial impact on daily life. The current gold-standard treatment-multi-session cognitive behavioural therapy (CBT) - is effective at reducing specific phobia severity; however, CBT is time consuming, requires specialist CBT therapists, and is often at great cost and limited availability. A briefer variant of CBT called one session treatment (OST) has been found to offer similar clinical effectiveness for specific phobia as multi-session CBT. The aim of this study was to assess the cost-effectiveness of OST compared to multi-session CBT for CYP with specific phobias through the Alleviating Specific Phobias Experienced by Children Trial (ASPECT), a two-arm, pragmatic, multi-centre, non-inferiority randomised controlled trial. METHODS: CYP aged seven to 16 years with specific phobias were recruited nationally via Health and Social Care pathways, remotely randomised to the intervention group (OST) or the control group (CBT-based therapies) and analysed (n = 267). Resource use based on NHS and personal social services perspective and quality adjusted life years (QALYs) measured by EQ-5D-Y were collected at baseline and at six-month follow-up. Incremental cost-effectiveness ratio (ICER) was calculated, and non-parametric bootstrapping was conducted to capture the uncertainty around the ICER estimates. The results were presented on a cost-effectiveness acceptability curve (CEAC). A set of sensitivity analyses (including taking a societal perspective) were conducted to assess the robustness of the primary findings. RESULTS: After adjustment and bootstrapping, on average CYP in the OST group incurred less costs (incremental cost was -£302.96 (95% CI -£598.86 to -£28.61)) and maintained similar improvement in QALYs (QALYs gained 0.002 (95% CI - 0.004 to 0.008)). The CEAC shows that the probability of OST being cost-effective was over 95% across all the WTP thresholds. Results of a set of sensitivity analyses were consistent with the primary outcomes. CONCLUSION: Compared to CBT, OST produced a reduction in costs and maintained similar improvement in QALYs. Results from both primary and sensitivity analyses suggested that OST was highly likely to be cost saving. TRIAL REGISTRATION: ISRCTN19883421 (30/11/2016).

Children in foster care with symptoms of reactive attachment disorder: feasibility randomised controlled trial of a modified video-feedback parenting intervention.

BACKGROUND: Looked-after children are at risk of suboptimal attachment patterns and reactive attachment disorder (RAD). However, access to interventions varies widely, and there are no evidence-based interventions for RAD. AIMS: To modify an existing parenting intervention for children with RAD in the UK foster care setting, and test the feasibility of conducting a randomised controlled trial (RCT) of the modified intervention. METHOD: The intervention was modified with expert input and tested on a case series. A feasibility and pilot RCT compared the new intervention with usual care. Foster carers and children in their care aged ≤6 years were recruited across nine local authorities, with 1:1 allocation and blind post-treatment assessments. The modified intervention was delivered in-home by trained mental health professionals over 4-6 months. Children were assessed for RAD symptoms, attachment quality and emotional/behavioural difficulties, and foster carers were assessed for sensitivity and stress. RESULTS: Minimal changes to the intervention programme were necessary, and focused on improving its suitability for the UK foster care context. Recruitment was challenging, and remained below target despite modifications to the protocol and the inclusion of additional sites. Thirty families were recruited to the RCT; 15 were allocated to each group. Most other feasibility outcomes were favourable, particularly high numbers of data and treatment completeness. The revised intervention was positively received by practitioners and foster carers. CONCLUSIONS: A large-scale trial may be feasible, but only if recruitment barriers can be overcome. Dedicated resources to support recruitment within local authorities and wider inclusion criteria are recommended.

A mixed methods evaluation of the acceptability of therapy using LEGO® bricks (LEGO® based therapy) in mainstream primary and secondary education.

Many autistic children and young people need extra support with social skills. Social skills programmes, such as LEGO® based therapy (LBT), are commonly used to help with these difficulties. The aim of this study was to examine the acceptability of LBT using qualitative interviews and questionnaires with facilitators and parents/guardians on behalf of autistic children and young people. Acceptability was measured in line with constructs of the Theoretical Framework of Acceptability. Questionnaires were analyzed descriptively and between group comparisons were undertaken using the Mann-Whitney U Test. Telephone interviews were undertaken with a sub-sample of facilitators. All interviews were recorded, transcribed verbatim, and framework analysis was performed by two researchers supported by NVivo. The questionnaire response rate was 80% for facilitators and 77% for parents/guardians. Overall acceptability, measured on a 1-5 (minimum-maximum) scale, was high for both facilitators and parents/guardians with a median (range) of 5 (4-5) and 4 (3-5), respectively. Facilitators rated the acceptability of the programme significantly higher overall than parents (p < 0.001). Facilitators reported that participants and wider school staff viewed the programme positively. They observed improvements in communication and social skills during the sessions. Potential barriers to programme delivery, such as resources and staff schedules, were identified but facilitators reported that these challenges did not outweigh the benefits. There is increasing emphasis on the role of schools in seeking to improve social outcomes for autistic children therefore this high degree of acceptability makes this an attractive school-based programme for schools, autistic children and their families. LAY SUMMARY: Social skills programmes, such as LEGO® based therapy (LBT), are often used to help autistic children and young people with their social skills. The acceptability of LBT with school staff and parents/guardians on behalf of children and young people was explored using interviews and questionnaires. Our results show that LBT is viewed as a highly acceptable programme that can help autistic children and young people improve their communication and social skills.

Cost-utility analysis of LEGO based therapy for school children and young people with autism spectrum disorder: results from a randomised controlled trial.

OBJECTIVES: To assess the cost-effectiveness of LEGO-based therapy compared with usual support. DESIGN: Cost-utility analysis alongside randomised control trial. SETTING: Mainstream primary and secondary schools in the UK. PARTICIPANTS: 248 children and young people (CYP) with autism spectrum disorder (ASD) aged 7-15 years. INTERVENTION: LEGO-based therapy is a group social skills intervention designed specifically for CYP with ASD. Through play, CYP learn to use the skills such as joint attention, sharing, communication and group problem-solving. CYP randomised to the intervention arm received 12 weekly sessions of LEGO-based therapy and usual support, while CYP allocated to control arm received usual support only. MAIN OUTCOME MEASURES: Average costs based on National Health Service (NHS) and personal social services perspective and quality-adjusted life years (QALYs) measured by EQ-5D-Y over time horizon of 1 year were collected during the trial. Incremental cost-effectiveness ratio (ICER) was calculated, and non-parametric bootstrapping was conducted. The uncertainty around the ICER estimates was presented using cost-effectiveness acceptability curve (CEAC). A set of sensitivity analyses were conducted to assess the robustness of the primary findings. RESULTS: After adjustment and bootstrapping, on average, CYP in LEGO-based therapy group incurred less costs (incremental cost was -£251 (95% CI -£752 to £268)) and gained marginal improvement in QALYs (QALYs gained 0.009 (95% CI -0.008 to 0.028)). The CEAC shows that the probability of LEGO-based therapy being cost-effective was 94% at the willingness-to-pay threshold of £20 000 per QALY gained. Results of sensitivity analyses were consistent with the primary outcomes. CONCLUSION: Compared with usual support, LEGO-based therapy produced marginal reduction in costs and improvement in QALYs. Results from both primary and sensitivity analyses suggested that LEGO-based therapy was likely to be cost-effective. TRIAL REGISTRATION NUMBER: ISRCTN64852382.

Adapting and validating the Autism Diagnostic Observation Schedule Version 2 for use with deaf children and young people.

We report a Delphi Consensus modification and first validation study of the Autism Diagnostic Observation Schedule - 2 with deaf children and young people (ADOS-2 Deaf adaptation). Validation included 122 deaf participants (aged 2-18 years), 63 with an Autism Spectrum Disorder (ASD). This was compared to a National Institute for Health and Clinical Excellence (NICE) guideline standard clinical assessment by blinded independent specialist clinicians. Results showed overall sensitivity 73% (95%CI 60%, 83%); specificity 71% (95%CI 58%, 82%), and for the more common modules 1-3 (combined as in previous studies) sensitivity 79% (95% CI 65-89%); specificity 79% (95% CI 66-89%) suggesting this instrument will be a helpful addition for use with deaf children and young people.

Adapting and validating the Autism Diagnostic Interview - Revised for use with deaf children and young people.

LAY ABSTRACT: Autism assessment processes need to improve for deaf children as they are currently being diagnosed later than their hearing counterparts and misdiagnosis can occur. We took one of the most commonly used parent developmental interviews for autism spectrum disorder the Autism Diagnostic Interview-Revised and adapted it using international expert advice. Modifications were proposed and agreed by the expert panel for 45% of items; the remaining 55% of items were unchanged. We then tested the revised version, adapted for deaf children (Autism Diagnostic Interview-Revised Deaf Adaptation), in a UK sample of 78 parents/carers of deaf children with autism spectrum disorder and 126 parents/carers with deaf children without autism spectrum disorder. When compared to National Institute for Health and Care Excellence guideline standard clinical assessments, the Autism Diagnostic Interview-Revised Deaf Adaptation diagnostic algorithm threshold scores could identify those deaf children with a definite diagnosis (true autism spectrum disorder positives) well (sensitivity of 89% (79%-96%)) and those deaf children who did not have autism spectrum disorder (true autism spectrum disorder negatives) well (specificity of 81% (70%-89%)). Our findings indicate that the Autism Diagnostic Interview-Revised Deaf Adaptation is likely to prove a useful measure for the assessment of deaf children with suspected autism spectrum disorder and that further research would be helpful.

Mental Health Provision in UK Secondary Schools.

Research reports high levels of mental health problems faced by young people in the UK. Schools provide a range of mental health support services, although these are often not robustly evaluated. This paper aims to explore the mental health provision of secondary schools across two large regions in the North of England and provide comparisons to the mental health questionnaire scores of their pupils. Results are part of a wider study providing an overview of the mental health of secondary school pupils. Measures include the Strengths and Difficulties Questionnaire, distributed to year 8, 9, and 11 pupils attending secondary schools and a bespoke mental health service provision questionnaire for school staff at the same schools. A total of 6328 pupil questionnaires and 36 staff questionnaires were returned from 21 schools. Results showed a non-significant correlation between provision and young people's mental health scores and highlight a range of factors to take into consideration. There is a need to improve the evaluation and recording of school-based mental health provision. Mental health difficulties in young people are prevalent in schools. Future research is needed to elucidate which types of services are most helpful in preventing, supporting, and signposting those with mental health problems.