The effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management programme in primary school children: results of the STARS cluster randomised controlled trial.

BACKGROUND: We evaluated the effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management (TCM) programme as a universal intervention, given schools' important influence on child mental health. METHODS: A two-arm, pragmatic, parallel group, superiority, cluster randomised controlled trial recruited three cohorts of schools (clusters) between 2012 and 2014, randomising them to TCM (intervention) or Teaching As Usual (TAU-control). TCM was delivered to teachers in six whole-day sessions, spread over 6 months. Schools and teachers were not masked to allocation. The primary outcome was teacher-reported Strengths and Difficulties Questionnaire (SDQ) Total Difficulties score. Random effects linear regression and marginal logistic regression models using Generalised Estimating Equations were used to analyse the outcomes. TRIAL REGISTRATION: ISRCTN84130388. RESULTS: Eighty schools (2075 children) were enrolled; 40 (1037 children) to TCM and 40 (1038 children) to TAU. Outcome data were collected at 9, 18, and 30-months for 96, 89, and 85% of children, respectively. The intervention reduced the SDQ-Total Difficulties score at 9 months (mean (s.d.):5.5 (5.4) in TCM v. 6.2 (6.2) in TAU; adjusted mean difference = -1.0; 95% CI-1.9 to -0.1; p = 0.03) but this did not persist at 18 or 30 months. Cost-effectiveness analysis suggested that TCM may be cost-effective compared with TAU at 30-months, but this result was associated with uncertainty so no firm conclusions can be drawn. A priori subgroup analyses suggested TCM is more effective for children with poor mental health. CONCLUSIONS: TCM provided a small, short-term improvement to children's mental health particularly for children who are already struggling.

The agreement between the referrer, practitioner and research diagnosis of autistic spectrum conditions among children attending child and adolescent mental health services.

We aimed to explore the levels of agreement about the diagnoses of Autistic Spectrum Conditions between the referrer, CAMHS practitioner and a research diagnosis, as well as the stability of the practitioner's diagnosis over time in a secondary analysis of data from 302 children attending two Child and Adolescent Mental Health Services over two years. Kappa coefficient was used to assess the agreement between the referrer and research diagnosis. Kendall's tau b coefficient was used to assess the agreement between the practitioner and the research diagnosis assigned using the Development and Well-Being Assessment, as well as the agreement between the referrer's indication of presenting problems and the practitioner diagnosis. Diagnostic stability was explored in children with and without a research diagnosis of Autistic Spectrum Condition. There was a moderate level of agreement between the referrer and research diagnosis (Kappa = 0.51) and between practitioner's and research diagnosis (Kendall's tau = 0.60) at baseline, which reduced over the subsequent two years. Agreement between the referrer and practitioner's diagnosis at baseline was fair (Kendall's tau = 0.36).The greatest diagnostic instability occurred among children who practitioners considered to have possible Autistic Spectrum Conditions but who did not meet research diagnostic criteria. Further studies could explore the approaches used by practitioners to reach diagnoses and the impact these may have on diagnostic stability in Autistic Spectrum Conditions. Standardised assessment using a clinically rated diagnostic framework has a potential role as an adjunct to standard clinical care and might be particularly useful where practitioners are uncertain.

Investigating the agreement between the clinician and research diagnosis of attention deficit hyperactivity disorder and how it changes over time; a clinical cohort study.

BACKGROUND: Attention Deficit Hyperactivity Disorder (ADHD) is a common reason for referral to Child and Adolescent Mental Health Services (CAMHS), but families experience long delays between first professional contact and diagnosis, which risks development of secondary impairments. This study explores the agreement between clinician and research diagnoses of ADHD among children attending CAMHS, and their access to interventions. From the limited literature, we anticipated fluctuation and delays, but no other study has focused prospectively on ADHD diagnoses. METHODS: This was a secondary analysis of a cohort of children attending two CAMHS between 2006 and 2009. The sample included 288 consecutive referrals of children aged between 5 and 11 years. Parents and teachers completed the Development and Well-Being Assessment (DAWBA) when the child was recruited to the study, which provided the research diagnosis of ADHD from the baseline. Clinicians reported no, possible, or definite diagnosis of ADHD and interventions provided at 6-monthly intervals for up to 2 years while the child attended CAMHS. We assessed agreement between the diagnoses using Kendall's Tau-B. RESULTS: Of the 101 children with a research diagnosis of ADHD, 26 received a definite clinician diagnosis during 2-year follow-up, and 47 received a possible clinician diagnosis. The chance-corrected agreement was poor at all time points (Kendall's Tau-B 0.14-0.48). Clinician diagnoses were unstable, particularly if possible ADHD was recorded at the initial assessment. Of those with a research diagnosis, 15 were prescribed medication and 11 were offered parent training. CONCLUSIONS: The use of standardised diagnostic assessments could reduce diagnostic uncertainty and increase access to evidence-based interventions.

Innovations in Practice: Feasibility of the development and well-being assessment as an adjunct to clinical assessment in child and adolescent mental health services.

BACKGROUND: Child and Adolescent Mental Health services (CAMHS) might benefit from the use of structured diagnostic assessments as an adjunct to clinical assessment. Such assessments will only support clinical practice if their completion avoids too great a burden to parents and services, and if the resulting information is useful to practitioners. METHOD: Parents were asked to complete the Development And Well-Being Assessment (DAWBA) before their initial appointment at a community CAMHS, and DAWBAs were disclosed to the assessing practitioners in a random half of cases. Parents and Practitioners were asked to complete a questionnaire about their experience of the DAWBA. Parents completed the experience of services questionnaire 6 months after the baseline. RESULTS: Most parents found the interview easy to understand. Many reported that the experience of completing the interview changed the way that they thought about their child's difficulties in a positive manner. Practitioner reports were also mainly positive. The mean helpfulness score adjusted for the clustering of cases within practitioners out of 1-5 for very unhelpful to very helpful was 4.04 (95% Confidence Interval: 3.89-4.18). There was no association between practitioner access to the DAWBA and parent reported satisfaction on the Experiences of Services Questionnaire (mean difference 0.74, 95% confidence interval -0.59-02.06, p0.27). CONCLUSIONS: With the right supporting arrangements in place, the DAWBA would be a feasible assessment tool in community CAMHS.

Can standardized diagnostic assessment be a useful adjunct to clinical assessment in child mental health services? A randomized controlled trial of disclosure of the Development and Well-Being Assessment to practitioners.

PURPOSE: While research demands standardized diagnostic assessments as an indication of sufficient methodological rigour, there is debate about their application to clinical practice. The Development and Well-Being Assessment (DAWBA) provides a structured assessment of psychiatric disorder. Since it can be completed on-line, it could be used by Child and Adolescent Mental Health Services with few additional demands on staff. Access to the standardized diagnostic information as an adjunct to clinical assessment could reduce the number of appointments spent on assessment, free up practitioner time to work on engagement and improve clinical outcomes by increasing the accuracy of assessment and thus access to the appropriate evidence-based treatment. METHOD: Randomized controlled trial of the disclosure of the DAWBA to the assessing practitioner (n = 117) versus assessment at normal (n = 118) and analysed by "intention to disclose". RESULTS: Exposure to the DAWBA may increase agreement between the DAWBA and practitioners about some anxiety disorders, but detected no other statistically significant increased agreement for other disorders, nor a reduced need for further assessment, the number of difficulties recognised or influence on outcomes. CONCLUSIONS: The results may be explained by the inadequacy of the DAWBA, lack of statistical power to detect any effects that were present or a reluctance of some practitioners to use the DAWBA in their assessment. Future research might benefit from exploring the use of the DAWBA or similar assessments as a referral rather than an assessment tool, and exploring how practitioners and parents experience and use the DAWBA and what training might optimise the utility of the DAWBA to clinical practice.

Psychological therapy for mood instability within bipolar spectrum disorder: a randomised, controlled feasibility trial of a dialectical behaviour therapy-informed approach (the ThrIVe-B programme).

BACKGROUND: A subgroup of those with bipolar spectrum disorders experience ongoing mood fluctuations outside of full episodes. We conducted a randomised, controlled feasibility study of a Dialectical Behavioural Therapy-informed approach for bipolar mood fluctuations (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). Our study aimed to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme. Participants were required to meet diagnostic criteria for a bipolar spectrum disorder and report frequent mood swings outside of acute episodes. They were randomised to treatment as usual (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points were at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point. To evaluate feasibility and acceptability we examined recruitment and retention rates, completion rates for study measures, adverse events and feedback from participants on their experience of study participation and therapy. RESULTS: Of the target 48 participants, 43 were recruited (22 in the intervention arm; 21 in the control arm), with a recruitment rate of 3.9 participants per month. At 9 months 74% of participants engaged in research follow-up assessment, exceeding the pre-specified criterion of 60%. There were no serious concerns about the safety of the research procedures or the intervention. On one of the four candidate primary outcome measures, the 95% CI for the between-group mean difference score excluded the null effect and included the minimal clinically important difference, favouring the intervention arm, whilst on no measure was there evidence of deterioration in the intervention arm relative to the control arm. Attendance of the intervention (50% attending at least half of the mandatory sessions) was below the pre-specified continuation criterion of 60%, and qualitative feedback from participants indicated areas that may have hampered or facilitated engagement. CONCLUSIONS: It is broadly feasible to conduct a trial of this design within the population of people with frequent bipolar mood swings. Changes should be made to the therapy to increase uptake, such as simplifying content and considering individual rather than group delivery. Trial registration ISRCTN: ISRCTN54234300. Registered 14th July 2017, http://www.isrctn.com/ISRCTN54234300.

The Incredible Years® Teacher Classroom Management programme and its impact on teachers' professional self-efficacy, work-related stress, and general well-being: Results from the STARS randomized controlled trial.

BACKGROUND: Teaching is a stressful occupation with poor retention. The Incredible Years® Teacher Classroom Management (TCM) programme is a training programme that research has demonstrated may be an effective intervention for improving children's mental health, but little research has explored any impacts there may be on the teachers' own professional confidence and mental health. AIMS: In this paper, we evaluate whether TCM may lead to changes in teachers' well-being, namely a reduction in burnout and an improvement in self-efficacy and mental health. SAMPLE: Eighty schools across the South West of England were recruited between September 2012 and September 2014. Headteachers were asked to nominate one class teacher to take part. METHODS: Eighty teachers were randomized to either attend a TCM course (intervention) or not (control). TCM was delivered to groups of up to 12 teachers in six whole-day workshops that were evenly spread between October and April. At baseline and 9-month follow-up, we measured teachers' mental health using the Everyday Feelings Questionnaire (EFQ), burnout using the Maslach Burnout Inventory-General Survey (MBI-GS), and self-efficacy using the Teachers' Sense of Efficacy Scale-Short (TSES-Short). RESULTS: Using linear regression models, there was little evidence of differences at follow-up between the intervention and control teachers on the outcomes (the smallest p-value was .09). CONCLUSIONS: Our findings did not replicate previous research that TCM improved teachers' sense of efficacy. However, there were limitations with this study including low sample size.

Clinical practitioner's attitudes towards the use of Routine Outcome Monitoring within Child and Adolescent Mental Health Services: a qualitative study of two Child and Adolescent Mental Health Services.

Routine Outcome Monitoring (ROM) is held as a greatly important part of practice across many Health Care Services, both in the NHS and in private practice. Yet despite this, there has been little research into the attitudes of practitioners towards ROM. This paper looks at the attitudes of 50 clinicians from two Child and Adolescent Mental Health Services in greater London. The findings showed that although the practitioners were not overwhelming positive in their attitudes to ROM, neither were they overwhelming negative, and many of their concerns involved practical issues surrounding ROM that are potentially soluble. Practitioner engagement in ROM is key if ROM is to be used constructively to reflect on practice.