Wellbeing while waiting evaluating social prescribing in CAMHS: study protocol for a hybrid type II implementation-effectiveness study.

BACKGROUND: Social prescribing is a mechanism of connecting patients with non-medical forms of support within the community and has been shown to improve mental health and wellbeing in adult populations. In the last few years, it has been used in child and youth settings with promising results. Currently, pathways are being developed for social prescribing in Child and Adolescent Mental Health Services (CAMHS) to support children and young people on treatment waiting lists. The Wellbeing While Waiting study will evaluate whether social prescribing benefits the mental health and wellbeing of children and young people. METHODS: This study utilises an observational, hybrid type II implementation-effectiveness design. Up to ten CAMHS who are developing social prescribing pathways as part of a programme run across England with support from the Social Prescribing Youth Network will participate. Outcomes for children and young people receiving social prescribing whilst on CAMHS waiting lists will be compared to a control group recruited prior to the pathway roll-out. Questionnaire data will be collected at baseline, 3 months and 6 months. Primary outcomes for children and young people are mental health symptoms (including anxiety, depression, stress, emotional and behavioural difficulties). Secondary outcomes include: loneliness, resilience, happiness, whether life is worthwhile, life satisfaction, and service use. An implementation strand using questionnaires and interviews will explore the acceptability, feasibility, and suitability of the pathway, potential mechanisms of action and their moderating effects on the outcomes of interest, as well as the perceived impact of social prescribing. Questionnaire data will be analysed mainly using difference-in-differences or controlled interrupted time series analysis. Interview data will be analysed using reflexive thematic analysis. DISCUSSION: The Wellbeing While Waiting study will provide the first rigorous evidence of the impact of social prescribing for children and young people on waiting lists for mental health treatment. Findings will help inform the prioritisation, commissioning, and running of social prescribing in other CAMHS. To maximise impact, findings will be available on the study website ( https://sbbresearch.org ) and disseminated via national and international networks. TRIAL REGISTRATION: N/A.

Gender difference in the change of adolescents' mental health and subjective wellbeing trajectories.

Gender differences in adolescents' mental health problems have been extensively reported. Yet, there is limited research in exploring longitudinal trends in mental health and wellbeing between boys and girls. This study investigated any emerging developmental trends of gender differences in mental health problems and subjective wellbeing for young people from early to mid-adolescence in England. A longitudinal group of 8612 young people's mental health and subjective wellbeing trajectories were investigated between the period of ages 11/12 and 13/14. Mental health difficulties and subjective wellbeing were measured using the child self-report Strengths and Difficulties Questionnaire (SDQ) and Short Warwick and Edinburgh Wellbeing Scale (SWEMWBS), respectively. Any gender difference in the change of adolescents' mental health and subjective wellbeing over 3 year period were estimated using multi-level regression while accounting for various socio-demographic and resilience factors. Young people are at increased risk of mental health problems between the ages of 11 and 14, particularly girls. The overall difficulty levels reported by girls were significantly higher than boys across a range of mental health problems and subjective wellbeing. These developmental trends persisted after controlling for a broad range of potential confounders. Young people has shown clear signs of mental distress as they get older. This escalation was particularly evident among girls. Distress can come at the time of significant physical, emotional, and social changes in an adolescents' life, and can be heightened during secondary school transition. This evidence highlights the importance of early intervention to reduce risk of distress.

Predictors of amounts of child and adolescent mental health service use.

The aim of this study was to build evidence about how to tailor services to meet the individual needs of young people by identifying predictors of amounts of child and adolescent mental health service use. We conducted a secondary analysis of a large administrative dataset from services in England was conducted using the Mental Health Services Data Set (years 2016-17 and 2017-18). The final sample included N = 27,362 episodes of care (periods of service use consisting of at least two attended care contacts and less than 180 days between care contacts) from 39 services. There were 50-10,855 episodes per service. The descriptive statistics for episodes of care were: Mage = 13 years, SDage = 4.71, range = 0-25 years; 13,785 or 50% male. Overall, there were high levels of heterogeneity in number of care contacts within episodes of care: M = 11.12, SD = 28.28, range = 2-1529. Certain characteristics predicted differential patterns of service use. For example, young people with substance use (beta = 6.29, 95% CI = 5.06-7.53) or eating disorders (beta = 4.30, 95% CI = 3.29-5.30) were particularly more likely to have higher levels of service use. To build on this, evidence is needed about predictors of child and adolescent mental health treatment outcome and whether the same characteristics predict levels of improvement as well as levels of service use.

The impact of universal, school based, interventions on help seeking in children and young people: a systematic literature review.

Reviews into universal interventions to improve help seeking in young people focus on specific concepts, such as behaviour, do not differentiate between interpersonal and intrapersonal help seeking, and often report on statistical significance, rather than effect size. The aim of this review was to address the gaps highlighted above, to investigate the impact of universal, school-based interventions on help-seeking in children and young people, as well as to explore longer term impact. Four databases were searched. Data were extracted on country of origin, design, participant, school, and intervention characteristics, the help-seeking concept measured (e.g. knowledge, attitude/intention, behaviour), the duration between baseline and each follow-up (if applicable) and effect sizes at each follow-up. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Overall, 14 different interventions met inclusion criteria. The majority of the studies were rated low in the quality assessment. Three constructs were most frequently reported a) intrapersonal attitudes towards help-seeking, b) interpersonal attitudes towards help-seeking and c) intrapersonal intended help-seeking. Findings around intervention effect were mixed. There was tentative evidence that interventions impacting interpersonal attitudes produced small effect sizes when measured between 3 and 6 months post intervention and that when effect sizes were initially observed intrapersonal attitudes, this remained at 3-6 month follow-up. Further work should pay attention to implementation factors, understanding the core ingredients needed to deliver effective interventions and whether embedding mental health education could help sustain or top up effect sizes from help-seeking interventions.

The impact of area level mental health interventions on outcomes for secondary school pupils: Evidence from the HeadStart programme in England.

In light of the dramatic rise in mental health disorders amongst adolescents seen in the past decade across the world, there is an urgent need for robust evidence on what works to combat this trend. This paper provides the first robust evaluation of the impacts on school outcomes of 6-year funding programme (HeadStart) for area-level mental health interventions for adolescents. Exploiting educational administrative data on ten cohorts of state-educated secondary school students, we use the synthetic control method to construct counterfactual outcomes for areas that received the funding. We show that the funding did not affect students' absenteeism or academic attainment, but it prevented around 800 students (c. 10% of students typically excluded yearly) from being excluded in its first year. The transient nature of this effect suggests that sustained funding for intervention may be a necessary but not sufficient condition to maintain programme effectiveness over time.

Predictors of child and adolescent mental health treatment outcome.

BACKGROUND: To examine the predictors of treatment outcome or improvement in mental health difficulties for young people accessing child and adolescent mental health services. METHODS: We conducted a secondary analysis of routinely collected data from services in England using the Mental Health Services Data Set. We conducted multilevel regressions on N = 5907 episodes from 14 services (Mage = 13.76 years, SDage = 2.45, range = 8-25 years; 3540 or 59.93% female) with complete information on mental health difficulties at baseline. We conduct similar analyses on N = 1805 episodes from 10 services (Mage = 13.59 years, SDage = 2.33, range = 8-24 years; 1120 or 62.05% female) also with complete information on mental health difficulties at follow up. RESULTS: Girls had higher levels of mental health difficulties at baseline than boys (ß = 0.28, 95% CI = 0.24-0.32). Young people with higher levels of mental health difficulties at baseline also had higher levels of deterioration in mental health difficulties at follow up (ß = 0.72, 95% CI = 0.67-0.76), and girls had higher levels of deterioration in mental health difficulties at follow up than boys (ß = 0.09, 95% CI = 0.03-0.16). Young people with social anxiety, panic disorder, low mood, or self-harm had higher levels of mental health difficulties at baseline and of deterioration in mental health difficulties at follow up compared to young people without these presenting problems. CONCLUSIONS: Services seeing higher proportions of young people with higher levels of mental health difficulties at baseline, social anxiety, panic disorder, low mood, or self-harm may be expected to show lower levels of improvement in mental health difficulties at follow up.

The role of mental health symptomology and quality of life in predicting referrals to special child and adolescent mental health services.

BACKGROUND: Children and adolescents' mental health problems have been largely assessed with conventional symptom scales, for example, Strengths and Difficulties Questionnaire (SDQ) given that it is one of the mostly widely used measures in specialist Child and Adolescent Mental Health Services (CAMHS). However, this emphasis on symptom scales might have missed some important features of the mental health challenges that children and young people experience including day to day functioning and life satisfaction aspect (i.e. qualify of life). METHOD: The study examined longitudinal association between a young person's self-perceptions of quality of life and mental health difficulties and referral to specialist CAMHS service using a population cohort study (Targeted Mental Health in Schools service data) nested within a large-scale linkage between school (National Pupil Data base) and child mental health service administrative data (South London and Maudsley NHS Foundation Trust children and adolescent mental health services health records). Cox proportional hazard regression to estimate crude and adjusted hazard ratios (HRs) for the association between participant psychopathology, and incidence of CAMHS referral. RESULTS: Pupils experiencing more behavioural difficulties, had an increased incidence of CAMHS referral (adjusted hazard ratio 1.1, 95% confidence interval 1.0-1.2). However, pupils who reported higher health related quality of life had a lower incidence of CAMHS referral over the follow-up period (adjusted hazard hario 0.94, 95% confidence interval 0.9-0.98). CONCLUSION: Children and young people's perception of their quality of life should be considered at the stages of a clinical needs assessment.

Chronic illness in childhood and early adolescence: A longitudinal exploration of co-occurring mental illness.

Chronic health conditions are hypothesized to disrupt the typical trajectory of child and adolescent development, and subsequently lead to increased levels of mental illness. However, due to methodological limitations in existing studies, this theory remains to be fully substantiated by empirical research. This study aimed to more thoroughly test hypotheses in the field. This study used data from the Avon Longitudinal Study of Parents and Children to examine the co-occurrence of mental illness among children with chronic illness in late childhood into early adolescence and explore mediating factors in these outcomes. Children with chronic health problems presented with a disproportionate rate of psychiatric illness at 10 years, and these chronic health problems continued to be associated with poor mental health outcomes at 13 years and 15 years. These outcomes were mediated by high levels of peer victimization and health-related school absenteeism. This study suggests that chronic illness may impact on functioning and social development in early adolescence, and consequently lead to increased rates of mental illness. Examining rates of school absenteeism and peer victimization may be key to identifying children at risk over time.

Can mental health competence reduce the higher risk of smoking initiation among teenagers with parents who smoke?

BACKGROUND: Parental smoking strongly influences adolescent smoking, yet few studies have examined factors that may protect against this. We investigated whether skills-based components of positive mental health ('mental health competence', MHC) modified the association between parental and teenager smoking, in the UK-representative Millennium Cohort Study (approximately 18 000 children, born 2000-02; analytic sample: n = 10 133). METHODS: Cohort members (CMs) reported at 14 years (y) whether they had ever smoked cigarettes. A dichotomized variable indicated whether one/both parents smoked when CMs were 11 y. A four-class latent MHC measure captured learning skills and prosocial behaviours at 11 y: High, High-Moderate, Moderate, Low. We examined effect measure modification (on the additive scale) by comparing risk differences (RDs) for CM smoking according to parental smoking, within each MHC class. We then estimated RDs for CM smoking according to combinations of parental smoking and MHC. Analyses accounted for confounding, sample design, attrition and item missingness. RESULTS: CMs were more likely to smoke cigarettes if their parent(s) smoked (27%) than CMs with no parent(s) who smoked (11%; RD: 16%). When stratified by MHC, RDs were stronger for low MHC (21%; 95% CI 11-31%) than other MHC classes (ranging: 7-11%). Compared to CMs with high MHC and non-smoker parents, those with low MHC and parent(s) who smoked had an RD of 28% (95% CI 20-36%). This was greater than the sum of RDs for those with low MHC and non-smoker parent(s) [7% (2-14%)] plus those with high MHC and whose parent(s) smoked [11% (7-15%)]. There was limited effect measure modification by moderate or High-Moderate MHC. CONCLUSION: Improving MHC to moderate levels may help reduce intergenerational transference of smoking.

Effectiveness of current psychological interventions to improve emotion regulation in youth: a meta-analysis.

BACKGROUND: Research investigating the role of emotion regulation (ER) in the development and treatment of psychopathology has increased in recent years. Evidence suggests that an increased focus on ER in treatment can improve existing interventions. Most ER research has neglected young people, therefore the present meta-analysis summarizes the evidence for existing psychosocial intervention and their effectiveness to improve ER in youth. A systematic review and meta-analysis was conducted according to the PRISMA guidelines. Twenty-one randomized-control-trials (RCTs) assessed changes in ER following a psychological intervention in youth exhibiting various psychopathological symptoms. We found moderate effect sizes for current interventions to decrease emotion dysregulation in youth (g = - 0.46) and small effect sizes to improve emotion regulation (g = 0.36). Significant differences between studies including intervention components, ER measures and populations studied resulted in large heterogeneity. This is the first meta-analysis that summarizes the effectiveness for existing interventions to improve ER in youth. The results suggest that interventions can enhance ER in youth, and that these improvements correlate with improvements in psychopathology. More RCTs including larger sample sizes, different age groups and psychopathologies are needed to increase our understanding of what works for who and when.

School characteristics and children's mental health: A linked survey-administrative data study.

Mental health difficulties are childhood-onset with lifelong health, social and economic consequences. Children spend a large amount of time in schools, making schools an important context for mental health prevention and support. We examine how school composition and school climate, controlling for individual child-level characteristics, are associated with children's mental health difficulties (emotional and behavioural difficulties). Data from 23,215 children from 648 primary schools in England were analysed to examine the associations of school composition (size, gender, socioeconomic and ethnicity) and school climate with mental health (emotional symptoms, behavioural symptoms and above clinical cut-off scores) adjusting for individual child socio-demographic characteristics. We find that between 3% and 4.5% of the variation in children's mental health outcomes could be attributed to schools. Of this, small proportions were explained by school composition (1.4 to 3.8%) and larger proportions were explained by school climate (29.5 to 48.8%). Lower school socio-economic status was associated with higher behavioural symptoms (coef = 0.02 [95%CI: 0.01-0.04]) and slightly raised odds of high mental health difficulties (OR = 1.05, 95% CI: 1.01,1.09). More positive school climate was associated with lower emotional (coef = -0.09 [95%CI:-0.11,-0.08]) and behavioural (coef = -0.13 [95% CI,-0.15:-0.11]) symptoms and lower odds of mental health difficulties (OR = 0.78, 95%CI:0.74,0.81). Some associations between school factors and mental health were moderated by child sex and SES. School composition factors were weakly associated with children's mental health, whereas school climate explained a larger amount of between-school variation and appears a good target for universal prevention of mental health difficulties in children.

An mHealth Intervention (ReZone) to Help Young People Self-Manage Overwhelming Feelings: Cluster-Randomized Controlled Trial.

BACKGROUND: Mental health difficulties in young people are increasing, and there is a need for evidence on the effectiveness of digital interventions to increase opportunities for supporting mental health in young people. Such studies are complicated due to issues of implementation and adoption, outcome measurement, and appropriate study designs. OBJECTIVE: The objective of this study was to examine the effectiveness of an mHealth intervention (ReZone) in reducing mental health difficulties in young people. METHODS: The cluster-randomized controlled trial enrolled 409 participants aged 10-15 years, and classes were allocated to ReZone or management as usual. Self-reported questionnaires were completed at baseline and 3-month follow-up. RESULTS: There were no significant differences between the ReZone condition and management as usual in the self-reported outcome measures. However, there were 3467 usage sessions, which corresponds to 16.9 times per student (total of 205 students) in classes allocated to ReZone. CONCLUSIONS: It is essential to publish studies that do not show significant differences, as these findings can still contribute to the literature, help in learning, and inform the direction of future work. The results reported in this paper could be due to a range of reasons, including whether ReZone has the scope to impact change or limitations related to the setting, context, and appropriateness of an RCT. The findings of this study suggest that ReZone was implemented and adopted. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.7019.

The Child Outcome Rating Scale: validating a four-item measure of psychosocial functioning in community and clinic samples of children aged 10-15.

Psychosocial functioning is considered an important and valued outcome in relation to young people's mental health as a construct distinct from psychiatric symptomology, especially in the light of an increasing focus on transdiagnostic approaches. Yet, the level of psychosocial functioning is rarely directly asked of young people themselves, despite the widespread recognition that the young person's perspective is valuable and is often at odds with those of other reporters, such as parents or professionals. One possible reason for this is that the field lacks a clear agreed tool to capture this information in a non-burdensome way. To begin to address this gap, this paper describes psychometric analysis of the Child Outcome Rating Scale (CORS), a brief and highly accessible self-report measure of young people's psychosocial functioning already used extensively by mental health professionals around the world but with only limited data on psychometric robustness. Using large community (n = 7822) and clinic (n = 2604) samples, we explore the factor structure, construct validity, internal consistency, differential item functioning, and sensitivity of the CORS. We found that the CORS stands up to psychometric scrutiny, having found satisfactory levels of reliability, validity, and sensitivity in this sample. We also found that the CORS is suitable for use with young people as old as 15 years old. That the CORS has been found to be psychometrically robust while being highly feasible (brief, simple, easy to administer) for use in busy clinical settings, combined with the fact that the CORS has already been widely adopted by clinicians and young people, suggests CORS may be an important tool for international use.

Maternal mental health at 5 years and childhood overweight or obesity at 11 years: evidence from the UK Millennium Cohort Study.

BACKGROUND/OBJECTIVES: Maternal psychological distress is associated with a range of adverse child outcomes. We sought to determine whether children's exposure to medium or severe distress at 5 years was associated with increased risks of overweight and obesity when they were aged 11 years. We also investigated whether any association was attenuated after accounting for potential confounding and mediating factors. SUBJECTS/METHODS: We analysed data from the UK Millennium Cohort Study, a nationally representative sample with data collected throughout childhood, imputing missing covariates (analytic sample: n = 9206). Multinomial regression was used to examine whether maternal psychological distress (Kessler-6 scale, using medium and severe score thresholds) at 5 years of age predicted children's objectively measured overweight and obesity at 11 years, adjusting for sex and ethnicity. We then carried out a series of models incorporating potential confounders (early life and socio-demographic, recorded at 9 months) and mediators (physical activity and dietary factors, at 7 years) in turn, and then simultaneously. RESULTS: A third of mothers reported distress when their child was aged 5 years (29% medium; 4% severe distress), and over a quarter of children were overweight at 11 years (22% overweight; 6% obese). Risks of obesity at 11 years increased with severity of maternal distress at 5 years (medium distress: relative risk ratio (RRR) = 1.43, 95% confidence interval [CI] 1.17-1.75; severe RRR = 2.27, CI 1.42-3.63). Adjusting for each set of explanatory factors in turn (particularly early years and socio-demographic confounding factors) reduced but did not eliminate these elevated risks. However, risks were attenuated in the fully adjusted model (medium: RRR = 1.14, CI 0.92-1.41; severe: RRR = 1.26, CI 0.75-2.11). CONCLUSIONS: We demonstrated that maternal psychological distress, particularly if severe, at 5 years was associated with risk of obesity (but not overweight) at 11 years. Accounting for potential explanatory factors attenuated this association to non-significance, suggesting a range of mechanisms may be implicated. Future research should seek to disentangle the potentially complex pathways linking explanatory factors, maternal distress and child obesity.

Prevalence of mental health problems in schools: poverty and other risk factors among 28 000 adolescents in England.

Current mental health provision for children is based on estimates of one in ten children experiencing mental health problems. This study analyses a large-scale community-based dataset of 28 160 adolescents to explore school-based prevalence of mental health problems and characteristics that predict increased odds of experiencing them. Findings indicate the scale of mental health problems in England is much higher than previous estimates, with two in five young people scoring above thresholds for emotional problems, conduct problems or hyperactivity. Gender, deprivation, child in need status, ethnicity and age were all associated with increased odds of experiencing mental health difficulties. DECLARATIONS OF INTEREST: None.

Temporal effects of maternal psychological distress on child mental health problems at ages 3, 5, 7 and 11: analysis from the UK Millennium Cohort Study.

BACKGROUND: Psychological distress is common among women of childbearing age, and limited longitudinal research suggests prolonged exposure to maternal distress is linked to child mental health problems. Estimating effects of maternal distress over time is difficult due to potential influences of child mental health problems on maternal distress and time-varying confounding by family circumstances. METHODS: We analysed the UK Millennium Cohort Study, a nationally representative sample with data collected throughout childhood. Adopting a marginal structural modelling framework, we investigated effects of exposure to medium/high levels of maternal psychological distress (Kessler-6 score 8+) on child mental health problems (Strengths and Difficulties Questionnaire borderline/abnormal behaviour cut-off) using maternal and child mental health data at 3, 5, 7 and 11 years, accounting for the influence of child mental health on subsequent maternal distress, and baseline and time-varying confounding. RESULTS: Prior and concurrent exposures to maternal distress were associated with higher levels of child mental health problems at ages 3, 5, 7 and 11 years. For example, elevated risks of child mental health problems at 11 years were associated with exposure to maternal distress from 3 years [risk ratio (RR) 1.27 (95% confidence interval (CI) 1.08-1.49)] to 11 years [RR 2.15 (95% CI 1.89-2.45)]. Prolonged exposure to maternal distress at ages 3, 5, 7 and 11 resulted in an almost fivefold increased risk of child mental health problems. CONCLUSIONS: Prior, concurrent and, particularly, prolonged exposure to maternal distress raises risks for child mental health problems. Greater support for mothers experiencing distress is likely to benefit the mental health of their children.

Associations between mental health competence and indicators of physical health and cognitive development in eleven year olds: findings from the UK Millennium Cohort Study.

BACKGROUND: Positive mental health may support healthy development in childhood, although few studies have investigated this at a population level. We aimed to construct a measure of mental health competence (MHC), a skills-based assessment of positive mental health, using existing survey items in a representative sample of UK children, and to investigate its overlap with mental health difficulties (MHD), socio-demographic patterning, and relationships with physical health and cognitive development. METHODS: We analysed the UK Millennium Cohort Study (MCS) when children were aged 11 years. Maternal (n = 12,082) and teacher (n = 6739) reports of prosocial behaviours (PS) and learning skills (LS) were entered into latent class models to create MHC measures. Using descriptive statistics, we examined relationships between MHC and MHD, and the socio-demographic patterning of MHC. Associations between MHC and physical health and cognitive development were examined with relative risk ratios [RRR] (from multinomial models): BMI status (healthy weight, overweight, obesity); unintentional injuries since age 7 (none, 1, 2+); asthma symptoms (none, 1, 2+); and tertiles of test scores for verbal ability, spatial working memory and risk-taking. Models were adjusted for potential confounding. RESULTS: Four MHC classes were identified [percentages for maternal and teacher reports, respectively]: high MHC (high PS, high LS) [37%; 39%], high-moderate MHC (high PS, moderate LS) [36%; 26%]; moderate MHC (moderate PS, moderate LS) [19%; 19%]; low MHC (moderate PS, low LS) [8%; 16%]. Higher MHC was less common in socially disadvantaged children. While MHC and MHD were associated, there was sufficient separation to indicate that MHC captures more than the absence of MHD. Compared to children with high MHC, those in other MHC classes tended to have poorer physical health and cognitive development, particularly those with low MHC or high-moderate MHC. For example, children with maternal-report Low MHC were more likely to have experienced 2+ unintentional injuries (RRR: 1.5 [1.1-2.1]) and to have lower verbal ability scores (RRR: 2.5 [1.9-3.2]). Patterns of results were similar for maternal- and teacher-report MHC. CONCLUSION: MHC is not simply the inverse of MHD, and high MHC is associated with better physical health and cognitive development. Findings suggest that interventions to improve MHC may support healthy development, although they require replication.

Mental health difficulties, attainment and attendance: a cross-sectional study.

Evidence for the association between mental health difficulties and academic outcomes is sparse and shows mixed results. The aim of this study was to investigate the association between educational attainment, absenteeism and mental health difficulties while controlling for various child characteristics such as special educational needs and socioeconomic background. 15,301 Year 7 pupils (mean age 11.91; SD = 0.28) from England completed the Strengths and Difficulties Questionnaire. Attainment, persistent absenteeism and child characteristics were derived from the National Pupil Database. Multilevel regression analysis showed that mental health difficulties were negatively associated with attainment and positively associated with persistent absenteeism. When all mental health difficulties were modelled simultaneously, behavioural difficulties, hyperactivity/attention difficulties and difficulties with peers were negatively associated with attainment. Emotional difficulties and hyperactivity/attention difficulties were positively associated with persistent absenteeism. The results of the current study highlight the importance of integration between mental health support and policy creation in relation to mental health difficulties and wellbeing in schools.

A qualitative exploration of the role of leadership in service transformation in child and adolescent mental health services.

BACKGROUND: Recent policy in England has called on services for children and young people's mental health and well-being to develop and deliver local transformation plans to increase the provision of evidence-based, outcomes-informed and service user-informed treatments. The role of local leadership in service transformation is poorly understood, despite evidence suggesting it is key to enacting change. PURPOSE: To understand the role of local leaders and frontline practitioners in service transformation in child and adolescent mental health services. METHODOLOGY: This study was a secondary analysis of semistructured interviews with n = 20 leaders and n = 29 frontline practitioners in child and adolescent mental health services taking part in a service transformation programme. RESULTS: Leaders' role in service transformation in child and adolescent mental health services (CAMHS) was to: (a) foster impetus for transformation by demonstrating passion and commitment for change, (b) support practitioners in developing microsystem improvements and (c) bridging the organisation's goals with available resources. CONCLUSIONS: When developing transformation plans for child and adolescent mental health services, local leaders should be transparent about reasoning and processes, enable practitioners to tailor implementation to need and provide ongoing support. Practitioner engagement needs careful planning given its crucial role in enabling collaboration that will facilitate change.

Factors to consider in the introduction of huddles on clinical wards: perceptions of staff on the SAFE programme.

OBJECTIVES: To explore paediatric hospital staff members' perceptions of the emerging benefits and challenges of the huddle, a new safety improvement initiative, as well as the barriers and facilitators to its implementation. DESIGN: A qualitative study was conducted using semi-structured interviews to explore staff perspectives and experiences. SETTING: Situation Awareness For Everyone (SAFE), a safety improvement programme, was implemented on a sample of National Health Service (NHS) paediatric wards from September 2014 to June 2016. Previously untested in England, the huddle was a central component of the programme. PARTICIPANTS: Semi-structured interviews were conducted with 76 staff members on four wards ~4 months after the start of the programme. RESULTS: A thematic analysis showed that staff perceived the huddle as helping to increase their awareness of important issues, improve communication, facilitate teamwork, and encourage a culture of increased efficiency, anticipation and planning on the ward. Challenges of the huddle included added pressure on staff time and workload, and the potential for junior nurses to be excluded from involvement, thus perhaps inadvertently reinforcing medical hierarchies. Staff also identified several barriers and facilitators to the huddle process, including the importance of senior nursing and medical staff leadership and managing staff time and capacity issues. CONCLUSIONS: The findings point towards the potential efficacy of the huddle as a way of improving hospital staff members' working environments and clinical practice, with important implications for other sites seeking to implement such safety improvement initiatives.