Childhood attention-deficit hyperactivity disorder: socioeconomic inequalities in symptoms, impact, diagnosis and medication.

BACKGROUND: Children from disadvantaged backgrounds are at greater risk of attention-deficit hyperactivity disorder (ADHD)-related symptoms, being diagnosed with ADHD, and being prescribed ADHD medications. We aimed to examine how inequalities manifest across the 'patient journey', from perceptions of impacts of ADHD symptoms on daily life, to the propensity to seek and receive a diagnosis and treatment. METHODS: We investigated four 'stages': (1) symptoms, (2) caregiver perception of impact, (3) diagnosis and (4) medication, in two data sets: UK Millennium Cohort Study (MCS, analytic n ~ 9,000), with relevant (parent-reported) information on all four stages (until 14 years); and a population-wide 'administrative cohort', which includes symptoms (child health checks) and prescriptions (dispensing records), born in Scotland, 2010-2012 (analytic n ~ 100,000), until ~6 years. We described inequalities according to maternal occupational status, with percentages and relative indices of inequality (RII). RESULTS: The prevalence of ADHD symptoms and medication receipt was considerably higher in the least compared to the most advantaged children in the administrative cohort (RIIs of 5.9 [5.5-6.4] and 8.1 [4.2-15.6]) and the MCS (3.08 [2.68-3.55], 3.75 [2.21-6.36]). MCS analyses highlighted complexities between these two stages, however, those from least advantaged backgrounds, with ADHD symptoms, were the least likely to perceive impacts on daily life (15.7% vs. average 19.5%) and to progress from diagnosis to medication (44.1% vs. average 72.5%). CONCLUSIONS: Despite large inequalities in ADHD symptoms and medication, parents from the least advantaged backgrounds were less likely to report impacts of ADHD symptoms on daily life, and their children were less likely to have received medication postdiagnosis, highlighting how patient journeys differed according to socioeconomic circumstances.

Olanzapine for young PEople with aNorexia nervosa (OPEN): A protocol for an open-label feasibility study.

INTRODUCTION: Antipsychotics are routinely prescribed off-label for anorexia nervosa (AN) despite limited evidence. This article presents a protocol of a study aiming to assess the feasibility of a future definitive trial on olanzapine in young people with AN. METHODS AND ANALYSIS: In an open-label, one-armed feasibility study, 55 patients with AN or atypical AN, aged 12-24, receiving outpatient, inpatient or day-care treatment who are considered for olanzapine treatment will be recruited from NHS sites based in England. Assessments will be conducted at screening, baseline and at 8-, 16 weeks, 6- and 12 months. Primary feasibility parameters will be proportions of patients who agree to take olanzapine and who adhere to treatment and complete study assessments. Qualitative methods will be used to explore acceptability of the intervention and study design. Secondary feasibility parameters will be changes in body mass index, psychopathology, side effects, health-related quality of life, carer burden and proportion of participants who would enrol in a future randomised controlled trial. The study is funded by the National Institute for Health Research via Health Technology Assessment programme. DISCUSSION: Olanzapine for young PEople with aNorexia nervosa will inform a future randomised controlled trial on the efficacy and safety of prescribing olanzapine in young people with AN.

Mental Health Admissions to Paediatric Wards Study (MAPS): a protocol for the analysis of Hospital Episode Statistics (HES) data.

INTRODUCTION: Children and young people (CYP) presenting with a mental health (MH) crisis are frequently admitted to general acute paediatric wards as a place of safety. Prior to the pandemic, a survey in England showed that CYP occupied 6% of general paediatric inpatient beds due to an MH crisis, and there have been longstanding concerns about the quality of care to support these patients in this setting. Mental Health Admissions to Paediatric Wards Study aims to generate a theory of change (ToC) model to improve the quality of care for CYP admitted to acute paediatric services after presenting in a MH crisis. METHODS AND ANALYSIS: We will undertake a national (England), sequential, mixed methods study to inform a ToC framework alongside a stakeholder group consisting of patients, families/carers and healthcare professionals (HCPs). Our study consists of four work packages (WP) undertaken over 30 months. WP1 is limited to using national routine administrative data to identify and characterise trends in MH admissions in acute paediatric wards in England between 2015- 2022. ETHICS AND DISSEMINATION: WP1 received ethical approval (Ref 23/NW/0192). We will publish the overall synthesis of data and the final ToC to improve care of CYP with MH crisis admitted to general acute paediatric settings. As coproducers of the ToC, we will work with our stakeholder group to ensure wide dissemination of findings. Potential impacts will be on service development, new models of care, training and workforce planning.

Inequalities in mental health service utilisation by children and young people: a population survey using linked electronic health records from Northwest London, UK.

BACKGROUND: Mental healthcare services for children and young people (CYP) are a very limited resource in the UK. To prevent health inequalities, measures to increase overall capacity must sit alongside measures that ensure utilisation matches need. AIM: Our aim was to identify subgroups of CYP with unexpectedly low mental health service utilisation, presumably representing unmet need, and to assess whether there is area variation in the socioeconomic gradient of mental healthcare use. METHODS: This is a cross-sectional population survey of CYP (aged 5-24 years) using electronic health records from the Discover Now research platform, covering approximately 95% of the Northwest London resident population of 2.4 million people. RESULTS: The total sample comprised 764 327 CYP, of whom 2.1% attended a mental healthcare appointment in 2021 (95% CI 2.1% to 2.2%), our outcome measure. Lower socioeconomic status (our main exposure factor) was related to higher occurrence of mental healthcare appointments (+5% for each quintile increase in deprivation (95% CI 2% to 7%, p<0.001]). However, interaction analyses showed that the boroughs with unexpectedly low utilisation rates were also those not showing a clear trend between socioeconomic conditions and services utilisation (interaction p<0.001), suggesting that in these boroughs the occurrence of mental disorders in disadvantaged people was not captured by our analysis based on service utilisation. In some London boroughs, we found lower-than-expected activity for the most disadvantaged CYP. CONCLUSIONS: The mental healthcare needs of many CYP from socioeconomically deprived areas of Northwest London may be unmet. More information is needed to confirm our results.

Mindcraft, a Mobile Mental Health Monitoring Platform for Children and Young People: Development and Acceptability Pilot Study.

BACKGROUND: Children and young people's mental health is a growing public health concern, which is further exacerbated by the COVID-19 pandemic. Mobile health apps, particularly those using passive smartphone sensor data, present an opportunity to address this issue and support mental well-being. OBJECTIVE: This study aimed to develop and evaluate a mobile mental health platform for children and young people, Mindcraft, which integrates passive sensor data monitoring with active self-reported updates through an engaging user interface to monitor their well-being. METHODS: A user-centered design approach was used to develop Mindcraft, incorporating feedback from potential users. User acceptance testing was conducted with a group of 8 young people aged 15-17 years, followed by a pilot test with 39 secondary school students aged 14-18 years, which was conducted for a 2-week period. RESULTS: Mindcraft showed encouraging user engagement and retention. Users reported that they found the app to be a friendly tool helping them to increase their emotional awareness and gain a better understanding of themselves. Over 90% of users (36/39, 92.5%) answered all active data questions on the days they used the app. Passive data collection facilitated the gathering of a broader range of well-being metrics over time, with minimal user intervention. CONCLUSIONS: The Mindcraft app has shown promising results in monitoring mental health symptoms and promoting user engagement among children and young people during its development and initial testing. The app's user-centered design, the focus on privacy and transparency, and a combination of active and passive data collection strategies have all contributed to its efficacy and receptiveness among the target demographic. By continuing to refine and expand the app, the Mindcraft platform has the potential to contribute meaningfully to the field of mental health care for young people.

Economic evaluations of interventional opportunities for the management of mental-physical multimorbidity: a systematic review.

OBJECTIVES: Economic evaluations of interventions for people with mental-physical multimorbidity, including a depressive disorder, are sparse. This study examines whether such interventions in adults are cost-effective. DESIGN: A systematic review. DATA SOURCES: MEDLINE, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Scopus, Web of Science and NHS EED databases were searched until 5 March 2022. ELIGIBILITY CRITERIA: We included studies involving people aged ≥18 with two or more chronic conditions (one being a depressive disorder). Economic evaluation studies that compared costs and outcomes of interventions were included, and those that assessed only costs or effects were excluded. DATA EXTRACTION AND SYNTHESIS: Two authors independently assessed risk of bias in included studies using recommended checklists. A narrative analysis of the characteristics and results by type of intervention and levels of healthcare provision was conducted. RESULTS: A total of 19 studies, all undertaken in high-income countries, met inclusion criteria. Four intervention types were reported: collaborative care, self-management, telephone-based and antidepressant treatment. Most (14 of 19) interventions were implemented at the organisational level and were potentially cost-effective, particularly, the collaborative care for people with depressive disorder and diabetes, comorbid major depression and cancer and depression and multiple long-term conditions. Cost-effectiveness ranged from £206 per quality-adjusted life year (QALY) for collaborative care programmes for older adults with diabetes and depression at primary care clinics (USA) to £79 723 per QALY for combining collaborative care with improved opportunistic screening for adults with depressive disorder and diabetes (England). Conclusions on cost-effectiveness were constrained by methodological aspects of the included studies: choice of perspectives, time horizon and costing methods. CONCLUSIONS: Economic evaluations of interventions to manage multimorbidity with a depressive disorder are non-existent in low-income and middle-income countries. The design and reporting of future economic evaluations must improve to provide robust conclusions. PROSPERO REGISTRATION NUMBER: CRD42022302036.

Evaluating the implementation and impact of a new model of care for integrating children and young people's acute mental healthcare in a paediatric setting: a protocol for a realist, mixed-methods approach.

INTRODUCTION: The mental health of children and young people in the UK has been declining and has continued to worsen throughout the pandemic, leading to an increase in mental health-related emergencies. In response, the Best for You programme was developed as a new service designed to integrate mental healthcare for children and young people between acute hospital and community services. The programme is comprised of four new services: a rapid assessment young people's centre with dual-trained staff, a co-located day service offering family-based care,a digital hub, designed to integrate with the fourth element of the model, namely community support and mental health services. This evaluation protocol aims to assess the development, implementation and outcomes of the Best for You programme and develops a scalable model that could be implemented in other parts of the National Health Service (NHS). METHODS AND ANALYSIS: This mixed-methods realist evaluation aims to delineate the components of the system to assess their interdependent relationships within a wider context. Data collection will include interviews, participant observations, focus groups and the collection of local quantitative healthcare data. The research will be conducted across four phases. Phase 1-captures the development of the underlying programme theory. Phase 2-a process evaluation testing the programme theory. Phase 3- an outcome and economic evaluation. Phase 4-consolidation of learning from phases 1-3 to identify barriers, facilitators and wider contextual factors that have shaped implementation drawing on the Consolidated Framework for Implementation Research. ETHICS AND DISSEMINATION: Ethical approval for the evaluation was received from the NHS local ethics committee. Embedded within the evaluation is a formative review to feedback and share learning with stakeholders to scale-up the programme. Findings from this study will be disseminated in peer-reviewed journals as well as presentations to be useful to service user organisations and networks.

The need for future research into the assessment and monitoring of eating disorder risk in the context of obesity treatment.

In adolescents and adults, the co-occurrence of eating disorders and overweight or obesity is continuing to increase, and the prevalence of eating disorders is higher in people with higher weight compared to those with lower weight. People with an eating disorder with higher weight are more likely to present for weight loss than for eating disorder treatment. However, there are no clinical practice guidelines on how to screen, assess, and monitor eating disorder risk in the context of obesity treatment. In this article, we first summarize current challenges and knowledge gaps related to the identification and assessment of eating disorder risk and symptoms in people with higher weight seeking obesity treatment. Specifically, we discuss considerations relating to the validation of current self-report measures, dietary restraint, body dissatisfaction, binge eating, and how change in eating disorder risk can be measured in this setting. Second, we propose avenues for further research to guide the development and implementation of clinical and research protocols for the identification and assessment of eating disorders in people with higher weight in the context of obesity treatment. PUBLIC SIGNIFICANCE: The number of people with both eating disorders and higher weight is increasing. Currently, there is little guidance for clinicians and researchers about how to identify and monitor risk of eating disorders in people with higher weight. We present limitations of current research and suggest future avenues for research to enhance care for people living with higher weight with eating disorders.

Categorising high-cost high-need children and young people.

OBJECTIVES: To describe the characteristics of high-cost high-need children and young people (CYP) (0-24 years) in England. METHODS: Retrospective observational study using data from the Clinical Practice Research Database linked to Hospital Episode Statistics in 2014/2015 and 2015/2016. Healthcare utilisation of primary and secondary care services were calculated, and costs were estimated using Healthcare Resource Group for secondary care and Personal Social Services Research Unit for primary care. High-cost high-need CYP were defined as the top 5% of users by cost. RESULTS: 3891 of 73 392 CYP made up the top 5% that were classified as high-cost high-need, and this group accounted for 54% of total annual costs. In this population, 7.3% were males <5 years and 11.0% were females 20-24 years. Inpatient care (acute) accounted for 63% of known spending in high-cost high-need patients. Total mean monthly cost per patient was 22.7 times greater in the high-cost high-need group compared with all other patients (£4417 vs £195). 29% of CYP in the high-cost high-need group in 2014/2015 were also classified as high-cost high-need in the following year. CONCLUSIONS: These findings indicate the importance of further understanding and anticipating trends in CYP health spending to optimise care, reduce costs and inform new models of care. This includes integrated services, a further look into societal factors in reducing health inequalities and a particular focus of mental health services, the demand of which increases with age.

Cost-effectiveness of specialist eating disorders services for children and adolescents with anorexia nervosa: a national surveillance study.

BACKGROUND: Evidence suggests specialist eating disorders services for children and adolescents with anorexia nervosa have the potential to improve outcomes and reduce costs through reduced hospital admissions. This study aimed to evaluate the cost-effectiveness of assessment and diagnosis in community-based specialist child and adolescent mental health services (CAMHS) compared to generic CAMHS for children and adolescents with anorexia nervosa. METHOD: Observational, surveillance study of children and adolescents aged 8 to 17, in contact with community-based CAMHS in the UK or Republic of Ireland for a first episode of anorexia nervosa. Data were reported by clinicians at baseline, 6 and 12-months follow-up. Outcomes included the Children's Global Assessment Scale (CGAS) and percentage of median expected body mass for age and sex (%mBMI). Service use data included paediatric and psychiatric inpatient admissions, outpatient and day-patient attendances. A joint distribution of incremental mean costs and effects for each group was generated using bootstrapping to explore the probability that each service is the optimal choice, subject to a range of values a decision-maker might be willing to pay for outcome improvements. Uncertainty was explored using cost-effectiveness acceptability curves. RESULTS: Two hundred ninety-eight children and adolescents met inclusion criteria. At 12-month follow-up, there were no significant differences in total costs or outcomes between specialist eating disorders services and generic CAMHS. However, adjustment for pre-specified baseline covariates resulted in observed differences favouring specialist services, due to significantly poorer clinical status of the specialist group at baseline. Cost-effectiveness analysis using CGAS suggests that the probability of assessment in a specialist service being cost-effective compared to generic CAMHS ranges from 90 to 50%, dependent on willingness to pay for improvements in outcome. CONCLUSIONS: Assessment in a specialist eating disorders service for children and adolescents with anorexia nervosa may have a higher probability of being cost-effective than assessment in generic CAMHS. TRIAL REGISTRATION: ISRCTN12676087 . Date of registration 07/01/2014.

Specialist eating disorders services may improve outcomes and reduce hospitalisations for children and adolescents with anorexia nervosa. Reductions in hospitalisation could save money for the NHS and are better for young people because hospitalisation disrupts their home life, social life and education. This study evaluated outcomes and costs of specialist eating disorders services compared to general child and adolescent mental health services (CAMHS) for children and adolescents with anorexia nervosa.Children and adolescents were identified by contacting child and adolescent psychiatrists in the UK and Ireland and asking them to report any new cases of anorexia nervosa. These psychiatrists identified 298 young people aged 8 to 17 with an anorexia nervosa diagnosis for the first time. The psychiatrists provided information on the health services these young people used and how they were doing when they were first diagnosed and 6 months and 1 year later.Children and adolescents in specialist services were more severely ill than those in CAMHS when they were first diagnosed. Despite this, care for the young people in specialist services cost about the same as for those diagnosed in CAMHS, and their outcomes after 1 year were similar. This work showed that specialist services may be better value for money than CAMHS.

Burden of child and adolescent obesity on health services in England.

OBJECTIVE: To assess the numbers of obese children and young people (CYP) eligible for assessment and management at each stage of the childhood obesity pathway in England. DESIGN: Pathway modelling study, operationalising the UK National Institute for Health and Care Excellence guidance on childhood obesity management against national survey data. SETTING: Data on CYP aged 2-18 years from the Health Survey for England 2006 to 2013. MAIN OUTCOME MEASURES: Clinical obesity (body mass index (BMI) >98th centile), extreme obesity (BMI ≥99.86th centile); family history of cardiovascular disease or type 2 diabetes; obesity comorbidities defined as primary care detectable (hypertension, orthopaedic or mobility problems, bullying or psychological distress) or secondary care detectable (dyslipidaemia, hyperinsulinaemia, high glycated haemoglobin, abnormal liver function). RESULTS: 11.2% (1.22 million) of CYP in England were eligible for primary care assessment and for community lifestyle modification. 2.6% (n=283 500) CYP were estimated to be likely to attend primary care. 5.1% (n=556 000) were eligible for secondary care referral. Among those aged 13-18 years, 8.2% (n=309 000) were eligible for antiobesity drug therapy and 2.4% (90 500) of English CYP were eligible for bariatric surgery. CYP from the most deprived quintile were 1.5-fold to 3-fold more likely to be eligible for obesity management. CONCLUSIONS: There is a mismatch between population burden and available data on service use for obesity in CYP in England, particularly among deprived young people. There is a need for consistent evidence-based commissioning of services across the childhood obesity pathway based on population burden.

Assessment and treatment of eating disorders in children and adolescents.

Feeding and eating disorders (FEDs) are serious mental health disorders that cause impairments in physical health, development, cognition and psychosocial function and can go undetected for months or years. They are characterised by disturbed eating behaviour associated with concerns about weight and shape or by disinterest in food, phobic avoidance or avoidance due to sensory aspects of food. Restrictive forms of FEDs lead to significant weight loss requiring intervention. Without specific knowledge of these conditions, they can evade detection, delaying time to diagnosis and treatment and potentially influencing outcome. This review article focuses on the key factors involved in the psychiatric assessment and treatment of four feeding or eating disorders (EDs): anorexia nervosa, avoidant-restrictive food intake disorder, bulimia nervosa and binge eating disorder. They have been chosen for discussion as they are most likely to be encountered in both a psychiatric and paediatric setting. It emphasises the importance of a family-focused, developmentally appropriate and multidisciplinary approach to care. It does not address aspects of medical assessment and treatment. Other feeding or EDs not included in this article are pica, rumination disorder, other specified feeding and eating disorder and unspecified feeding and eating disorder.

Low levels of knowledge on the assessment of underweight in children and adolescents among middle-grade doctors in England and Wales.

BACKGROUND: Safe assessment of severe underweight in children is important but experience suggests a frequent lack of understanding. Here we sought evidence from a wide spectrum of trainees. METHODS: Cross-sectional telephone survey of an on-call middle-grade paediatric doctor in hospitals providing acute inpatient general paediatric care in England and Wales. RESULTS: Response rate was 100%. Only 50% identified BMI as the appropriate measure for underweight in children. Most did not identify any clinical cardiovascular complications of severe underweight. Only 13% identified corrected QT time (QTc) as an important ECG finding. Knowledge of the refeeding syndrome was poor with 20% unable to define it at all, 21% able to identify some clinical features and 57% aware of potential phosphate abnormalities. CONCLUSIONS: Knowledge base among middle-grades doctors in England and Wales on this topic is worryingly poor, particularly in relation to several life-threatening features. Existing and new training approaches should recognise this.

Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders.

OBJECTIVE: To explore the role of specialist outpatient eating disorders services and investigate how direct access to these affects rates of referral, admissions for inpatient treatment, and continuity of care. METHOD: Services beyond primary care in Greater London retrospectively identified adolescents who presented with an eating disorder over a 2-year period. Data concerning service use were collected from clinical casenotes. RESULTS: In areas where specialist outpatient services were available, 2-3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care. DISCUSSION: Developing specialist outpatient services with direct access from primary care is likely to lead to improvements in treatment and reduce overall costs.

Medical instability and growth of children and adolescents with early onset eating disorders.

OBJECTIVE: Little is known about the physical burden of early onset eating disorders (EOEDs). Most published data on physical instability and growth in malnutrition come from specialist centres, or from the developing world where aetiology differs. The authors present data on physical status at presentation from population-based surveillance systems in the UK and Ireland. DESIGN: Prospective surveillance study. PARTICIPANTS: All suspected cases of EOED in children under 13 years of age reported by paediatricians and psychiatrists via the British Paediatric Surveillance System (BPSU) and Child and Adolescent Psychiatric Surveillance System (CAPSS) in the UK and Ireland from March 2005 to May 2006 (15 months). RESULTS: 208 cases were identified (24% reported by paediatricians). Median age was 11.8 years (IQR 1.74). 171 (82%) were female (78% premenarcheal and 60% prepubertal). 74% of males were prepubertal. 35% of cases had medical instability at presentation (60% bradycardia, 54% hypotension, 34% dehydration, 26% hypothermia). 52% of cases required admission at diagnosis (73% to a paediatric ward). 41% of cases with medical instability were not underweight, that is, they had body mass index (BMI) z-scores above -2.0 (2nd centile). Sensitivities for identifying medical instability with BMI z-score <-3 or 70% median BMI were 31% and 15%, respectively. Menarcheal status did not predict risk of medical instability. CONCLUSIONS: EOEDs present with severe levels of physical instability and frequently to paediatricians. As anthropological indices alone are poor markers for medical instability, clinical assessment is essential. Doctors providing care for children have a central role in both the recognition and management of EOEDs.