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BACKGROUND: Non-suicidal self-injury (NSSI) is of high clinical relevance due to its high prevalence and negative long-term implications. In 2016, the German consensus-based clinical guidelines for diagnostic, assessment and treatment of NSSI in childhood and adolescence were published. However, research indicates that clinical guidelines are often poorly implemented in clinical practice. One crucial part of this process is the training of healthcare professionals to transfer knowledge and capacities to bring guideline recommendations into clinical practice. METHODS: The effect of three different dissemination strategies (printed educational material, e-learning, and blended-learning) on the NSSI guidelines´ recommendations was examined among 671 physicians and psychotherapists via an online-survey. The quasi-experimental study included three measurement points (before the training, after the training, 3-month follow-up) and mixed effects models were used to test for changes in knowledge, competences and attitudes toward NSSI and treatment. Moreover, the transfer of gained competences to practical work and user satisfaction were reviewed. RESULTS: With all three training formats, the intended changes of the outcome variables could be observed. Hereby, the printed educational material condition showed the lowest improvement in the scores for the 'negative attitudes toward NSSI and those who self-injure'. The training effect remained stable throughout the follow-up measurement. The highest application rate of acquired intervention techniques in clinical practice was reported for the blended-learning condition. For all three training strategies, user satisfaction was high and evaluation of training quality was positive, with printed educational material receiving the lowest and blended-learning the highest evaluations. CONCLUSIONS: In summary, all three training formats were perceived to be of high quality and seem to be suited to cover the needs of a heterogeneous group of physicians and psychotherapists. The choice of training method could be driven by considering which training goals are desired to be achieved and by the benefit-cost ratio allowing for tailored training approaches.
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Comportamento Autodestrutivo , Prevenção do Suicídio , Humanos , Comportamento Autodestrutivo/psicologia , Comportamento Autodestrutivo/terapia , Adolescente , Suicídio/estatística & dados numéricos , Suicídio/psicologia , Medição de Risco , Adulto Jovem , Fatores de Risco , Feminino , MasculinoRESUMO
Background: Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions is lacking. An individual patient data meta-analysis has the potential to provide more reliable estimates of the effects of therapeutic interventions for self-harm than conventional meta-analyses, to explore which treatments are best suited to certain groups. Method: A systematic review and individual patient data meta-analysis of randomised controlled trials of therapeutic interventions to reduce repeat self-harm in adolescents who had a history of self-harm and presented to clinical services. Primary outcome was repetition of self-harm. The methods employed for searches, study screening and selection, and risk of bias assessment are described, with an overview of the outputs of the searching, selection and quality assessment processes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance is followed. Results: We identified a total 39 eligible studies, from 10 countries, where we sought Individual Patient Data (IPD), of which the full sample of participants were eligible in 18 studies and a partial sample of participants were eligible in 21 studies. We obtained IPD from 26 studies of 3448 eligible participants. For our primary outcome, repetition of self-harm, only 6 studies were rated as low risk of bias with 10 rated as high risk (although 2 of these were for secondary outcomes only). Conclusions: Obtaining individual patient data for meta-analyses is possible but very time-consuming, despite clear guidance from funding bodies that researchers should share their data appropriately. More attention needs to be paid to seeking appropriate consent from study participants for (pseudo) anonymised data-sharing and institutions need to collaborate on agreeing template data-sharing agreements. Researchers and funders need to consider issues of research design more carefully. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/117/11. A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/GTNT6331.
Self-harm is very common in young people and leads to an increased risk of death by suicide. Research so far has not provided clear evidence about which interventions can help to prevent self-harm repetition when young people present to services having harmed themselves. One way to understand what might help is to pool the results from lots of different clinical trials this is known as a meta-analysis. This has already been done using the data published in research articles but has not led to clearer conclusions. In part this is because the information available in published articles is patchy and inconsistent which makes pooling the information and analysing it, difficult. A more useful approach is to ask researchers who led the clinical trials for their original 'raw' data and then pool and analyse all that data this is known as an individual patient data meta-analysis. This has the added benefit that it is possible to include studies where only some of the participants are young people. We did this, and were able to identify many more study participants along with their data, compared to earlier meta-analyses. In this article, we describe how we searched for relevant research studies and the methods we used to obtain individual patient data from other researchers. We also describe our rating of the research quality of the studies we identified. We identified more studies, with many more participants in total, than in previous pooled study research. Gathering the data from other researchers was very time-consuming and not everyone was willing or able to share their data. When we rated the quality of the studies that we found, many were not of high quality. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people.
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OBJECTIVE: More than 200 million children and adolescents live in countries affected by violent conflict, are likely to have complex mental health needs, and struggle to access traditional mental health services. Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support. We performed a scoping review to map existing digital mental health interventions relevant for children and adolescents affected by war, to examine the strength of the evidence base, and to inform the development of future interventions. METHOD: Based on a pre-registered strategy, we systematically searched MEDLINE, Embase, Global Health, APA PsychInfo, and Google Scholar from the creation of each database to September 30, 2022, identifying k = 6,843 studies. Our systematic search was complemented by extensive consultation with experts from the GROW Network. RESULTS: The systematic search identified 6 relevant studies: 1 study evaluating digital mental health interventions for children and adolescents affected by war, and 5 studies for those affected by disasters. Experts identified 35 interventions of possible relevance. The interventions spanned from universal prevention to specialist-guided treatment. Most interventions directly targeted young people and parents or carers/caregivers and were self-guided. A quarter of the interventions were tested through randomized controlled trials. Because most interventions were not culturally or linguistically adapted to relevant contexts, their implementation potential was unclear. CONCLUSION: There is very limited evidence for the use of digital mental health interventions for children and adolescents affected by war at present. The review provides a framework to inform the development of new interventions. DIVERSITY & INCLUSION STATEMENT: We actively worked to promote sex and gender balance in our author group. STUDY PREREGISTRATION INFORMATION: Digital mental health interventions for children and young people affected by war: a scoping review; https://osf.io/; hrny9.
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Establishing effective treatments for youth at risk of suicide is one of the most pressing and important tasks within child and adolescent psychiatry. Self-harm, which includes suicide attempt (SA), nonsuicidal self-injury (NSSI), and nonsuicidal self-poisoning, is one of the strongest predictors of suicide.1 Youth who engage in self-harm or experience mental health crisis are becoming more and more common, at increasingly younger ages, and so confidence in treatments to successfully reduce self-harm and prevent relapse and recurrence is crucial.2 However, the evidence base for such treatments is severely lacking despite some progress in the field.3-5 Dialectical behavior therapy (DBT) is the most established treatment option, but even so, the evidence comes from just a handful of studies and primarily focuses on the ability of DBT to reduce the repetition of self-harm. Whether DBT is successful in supporting young people along their recovery journey and is equally effective at treating different forms of self-harm are yet to be properly explored.
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Adverse childhood experiences can have a significant impact on adult psychosocial outcomes. However, negative outcomes are not inevitable, and protective factors can interrupt the realisation of negative developmental trajectories and result in positive adaptation in spite of childhood adversity. Interventions that promote social support, encourage education and academic achievement, and address specific personality and dispositional factors are likely to beneficial for those with experience of childhood adversity. Holistic assessment that considers both neurodevelopmental conditions and trauma symptoms is also important for promoting resilience and avoiding assumptions that mental and behavioural problems in children with cumulative adversity are purely 'social'.
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The number of accident and emergency (A&E) hospital attendances by young people aged 18 or under with a recorded diagnosis of a psychiatric condition more than tripled between 2010 and 2022. After discharge from the hospital, attendance at follow-up appointments in the community is critical to ensure the safety of young people and optimise the use of clinical resources. A retrospective cohort study was conducted to evaluate the association between follow-up attendance and the continuity of clinicians and clinical teams, using electronic clinical record data from East London NHS Foundation Trust (ELFT), between April 2019 and March 2022. Multi-level mixed effects logistic regression was performed to model the follow-up attendance odds based on whether the same or different clinician and clinical team offered the initial A&E and the community follow-up appointment or whether a crisis team was involved. 3134 A&E presentations by 2368 young people were identified within the study period. Following these presentations, 2091 follow-up appointments in the community were offered. The attendance rate increased by more than three times if the follow-up appointment was offered by the same clinician who saw the young person in A&E (odds ratio (OR) = 3.66; 95% CI 1.65-8.13). Whether the same clinical team provided the community follow-up appointment, or whether a crisis team was involved before discharge made no difference to the likelihood of follow-up attendance. The findings support the importance of the continuity of clinicians in the care of young people in crisis.
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BACKGROUND: Over 3000 young people under the age of 18 are admitted to Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient units across the UK each year. The average length of hospital stay for young people across all psychiatric units in the UK is 120 days. Research is needed to identify the most effective and efficient ways to care for young people (YP) with psychiatric emergencies. This study aims to evaluate the clinical effectiveness and cost-effectiveness of intensive community care service (ICCS) compared to treatment as usual (TAU) for young people with psychiatric emergencies. METHODS: This is a multicentre two-arm randomized controlled trial (RCT) with an internal pilot phase. Young people aged 12 to < 18 considered for admission at participating NHS organizations across the UK will be randomized 1:1 to either TAU or ICCS. The primary outcome is the time to return to or start education, employment, or training (EET) at 6 months post-randomization. Secondary outcomes will include evaluations of mental health and overall well-being and patient satisfaction. Service use and costs and cost-effectiveness will also be explored. Intention-to-treat analysis will be adopted. The trial is expected to be completed within 42 months, with an internal pilot phase in the first 12 months to assess the recruitment feasibility. A process evaluation using visual semi-structured interviews will be conducted with 42 young people and 42 healthcare workers. DISCUSSION: This trial is the first well-powered randomized controlled trial evaluating the clinical and cost-effectiveness of ICCS compared to TAU for young people with psychiatric emergencies in Great Britain. TRIAL REGISTRATION: ISRCTN ISRCTN42999542, Registration on April 29, 2020.
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Emergências , Saúde Mental , Criança , Adolescente , Humanos , Resultado do Tratamento , Satisfação do Paciente , Reino Unido , Análise Custo-Benefício , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
The worldwide pooled prevalence of psychiatric disorders in children is 13.4%. Studying the prevalence of childhood psychiatric disorders across radically different economic systems and social structures could indicate universal factors leading to their development. The prevalence of childhood psychiatric disorders in a mixed-subsistence foraging society has not been studied. The Strengths and Difficulties Questionnaire and the Development and Well-Being Assessment were used to compare the prevalence of behavioural symptoms and psychiatric disorders in Hadza children aged 5-16 years (n = 113) to a nationally representative sample from England (n = 18,029) using a cross-sectional study design. Emotional problems, conduct problems and hyperactivity were lower in the Hadza children. Prosocial behaviour and peer problems were higher in Hadza children. 3.6% of Hadza children met the criteria for a psychiatric disorder compared to 11.8% of English children. All psychiatric disorders in Hadza children were co-morbid with autism spectrum disorder. No child from the Hadza group met the criteria for an emotional, behaviour or eating disorder. Further work should study the factors which lead to the different prevalence of psychiatric disorders in Hadza children.
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Transtorno do Espectro Autista , Transtornos da Alimentação e da Ingestão de Alimentos , Humanos , Transtorno do Espectro Autista/psicologia , Prevalência , Estudos Transversais , Sintomas Afetivos/psicologia , Sintomas Comportamentais , Inquéritos e QuestionáriosRESUMO
Background: Dramatherapy, a creative form of psychotherapy, may be a useful treatment for child and adolescent mental health. As there is a growing evidence base, this systematic review sought to identify, describe and evaluate dramatherapy with children and adolescents who were experiencing emotional distress (anxiety, depression and trauma) in order to inform future research in this area. Methods: Seven databases (PsychInfo, PubMed, Scopus, Web of Science, CINAHL, EMBASE and Cochrane) were searched for peer-reviewed articles exploring dramatherapy as a treatment for child and adolescent emotional distress. Hand searches of relevant journals were also conducted. Two reviewers coded articles for eligibility and independently appraised papers using the Joanna Briggs Institute Critical Appraisal Tools. Details relating to intervention and participant characteristics were extracted and, where data were available, effect sizes on measures relating to emotional distress were calculated. Results: Fifteen papers were included. Studies showed that dramatherapy was often delivered in schools (46%) and clinical settings (20%) and was more frequently delivered to adolescents (53%) (>11 years) than children (26%) (8-11 years). Dramatherapy was used as a treatment for diagnostically heterogeneous groups (40%), for emotional and behavioural difficulties (33%) and following a shared, traumatic, experience (20%). Seven papers reported relevant quantitative data however, just three of these studies were controlled and none were blinded. Pre-to-post intervention effect sizes ranged from d = 0.17 to d > 2 yet samples were small and participant response to treatment was not always consistent. The largest effects were seen in dramatherapy employed following trauma and in clinical settings. Medium to large effects were also seen in early intervention school-based dramatherapy. Conclusion: Despite promising results with regards to the treatment of child and adolescent emotional distress, the evidence base for dramatherapy is small and methodologically flawed. Larger, methodologically robust trials should test the efficacy of dramatherapy in future research.
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INTRODUCTION: Suicide is an important public health problem. Providing evidence-based psychosocial interventions to individuals presenting with self-harm is recognised as an important suicide prevention strategy. Therefore, it is crucial to understand which intervention is most effective in preventing self-harm repetition. We will evaluate the comparative efficacy of psychosocial interventions for the prevention of self-harm in adults. METHODS AND ANALYSIS: We will perform a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) testing psychosocial interventions for the prevention of self-harm repetition. We will include RCTs in adults (mean age: 18 years or more) who presented with self-harm in the 6 months preceding enrolment in the trial. Interventions will be categorised according to their similarities and underpinning theoretical approaches (eg, cognitive behavioural therapy, case management). A health sciences librarian will update and adapt the search strategy from the most recent Cochrane pairwise systematic review on this topic. The searches will be performed in MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), CINAHL (EBSCO), Cochrane Central (Wiley), Cochrane Protocols (Wiley), LILACS and PSYNDEX from 1 July 2020 (Cochrane review last search date) to 1 September 2023. The primary efficacy outcome will be self-harm repetition. Secondary outcomes will include suicide mortality, suicidal ideation and depressive symptoms. Retention in treatment (ie, drop-outs rates) will be analysed as the main acceptability outcome. Two reviewers will independently assess the study eligibility and risk of bias (using RoB-2). An NMA will be performed to synthesise all direct and indirect comparisons. Ranked forest plots and Vitruvian plots will be used to represent graphically the results of the NMA. Credibility of network estimates will be evaluated using Confidence in NMA (CINeMA). ETHICS AND DISSEMINATION: As this is the protocol for an aggregate-data level NMA, ethical approval will not be required. Results will be disseminated at national/international conferences and in peer-review journals. TRIAL REGISTRATION NUMBER: CRD42021273057.
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Comportamento Autodestrutivo , Suicídio , Adulto , Humanos , Adolescente , Metanálise em Rede , Intervenção Psicossocial , Comportamento Autodestrutivo/prevenção & controle , Saúde Pública , Revisões Sistemáticas como Assunto , Metanálise como AssuntoRESUMO
BACKGROUND: Children and young people's (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails. METHODS: A group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up. RESULTS: ICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children's Global Assessment Scale were agreed. CONCLUSIONS: This paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.
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Serviços Comunitários de Saúde Mental , Transtornos Mentais , Adolescente , Criança , Humanos , Transtornos Mentais/diagnóstico , Transtornos Mentais/terapia , Prova Pericial , Assistência Ambulatorial , HospitalizaçãoRESUMO
BACKGROUND: Adopting a common elements approach, this practitioner review aims to highlight specific treatment elements that are common to interventions with demonstrated benefits in randomized controlled trials (RCTs) for reducing suicide attempts and self-harm in youth. Identification of common treatment elements among effective interventions offers a key strategy for clarifying the most robust features of effective interventions and improving our ability to implement effective treatment and decrease the lag between scientific advances and clinical care. METHODS: A systematic search of RCTs evaluating interventions targeting suicide/self-harm in youth (ages 12-18) yielded a total of 18 RCTs assessing 16 different manualized interventions. An open coding process was used to identify common elements present within each intervention trial. Twenty-seven common elements were identified and classified into format, process, and content categories. All trials were coded for the inclusion of these common elements by two independent raters. RCTs were also classified into those where trial results supported improvements in suicide/self-harm behavior (n = 11 supported trials) and those without supported evidence (n = 7 unsupported trials). RESULTS: Compared with unsupported trials, the 11 supported trials shared the following elements: (a) inclusion of therapy for both the youth and family/caregivers; (b) an emphasis on relationship-building and the therapeutic alliance; (c) utilization of an individualized case conceptualization to guide treatment; (d) provided skills training (e.g. emotion regulation skills) to both youth and their parents/caregivers; and (e) lethal means restriction counseling as part of self-harm monitoring and safety planning. CONCLUSIONS: This review highlights key treatment elements associated with efficacy that community practitioners can incorporate in their treatments for youth presenting with suicide/self-harm behaviors.
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Comportamento Autodestrutivo , Aliança Terapêutica , Adolescente , Humanos , Tentativa de Suicídio/prevenção & controle , Tentativa de Suicídio/psicologia , Comportamento Autodestrutivo/prevenção & controle , Comportamento Autodestrutivo/psicologia , Resultado do TratamentoRESUMO
INTRODUCTION: Self-harm and suicide are major public health concerns among children and adolescents. Many risk and protective factors for suicide and self-harm have been identified and reported in the literature. However, the capacity of these identified risk and protective factors to guide assessment and management is limited due to their great number. This protocol describes an ongoing systematic review and meta-analysis which aims to examine longitudinal studies of risk factors for self-harm and suicide in children and adolescents, to provide a comparison of the strengths of association of the various risk factors for self-harm and suicide and to shed light on those that require further investigation. METHODS AND ANALYSIS: We perform a systematic search of the literature using the databases EMBASE, PsycINFO, Medline, CINAHL and HMIC from inception up to 28 October 2020, and the search will be updated before the systematic review publication. Additionally, we will contact experts in the field, including principal investigators whose peer-reviewed publications are included in our systematic review as well as investigators from our extensive research network, and we will search the reference lists of relevant reviews to retrieve any articles that were not identified in our search. We will extract relevant data and present a narrative synthesis and combine the results in meta-analyses where there are sufficient data. We will assess the risk of bias for each study using the Newcastle-Ottawa Scale and present a summary of the quantity and the quality of the evidence for each risk or protective factor. ETHICS AND DISSEMINATION: Ethical approval will not be sought as this is a systematic review of the literature. Results will be published in mental health journals and presented at conferences focused on suicide prevention. PROSPERO REGISTRATION NUMBER: CRD42021228212.