Personalised interventions for subgroups of children with conduct problems.

BACKGROUND: Conduct problems are a range of disruptive behaviours in childhood that are associated with long-term adverse outcomes in adolescence and adulthood, including antisocial behaviour, substance misuse, and poor academic achievement. Children with conduct problems can vary according to age of onset, comorbidities, and environmental factors, and it has been suggested that certain groups of children may have different treatment outcomes. Therefore, it is important to assess the extent to which personalised interventions for different groups of children with conduct problems may affect outcomes. To our knowledge, this is the first review to systematically identify and appraise the effectiveness of personalised interventions, adapted, or developed, for prespecified subgroups of children with conduct problems. OBJECTIVES: To assess whether personalised interventions, adapted or developed for subgroups of children with conduct problems are effective in improving outcomes. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search was 1 February 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs), in any setting, in children (aged two to 12 years) with conduct problems and within a prespecified subgroup, comparing a personalised intervention with a non-personalised intervention, waitlist control, or treatment as usual. Personalised interventions included adaptations to standard practice, such as parent-training programmes; other recommended interventions for children with conduct problems; or interventions developed specifically to target subgroups of children with conduct problems. We excluded non-personalised and non-psychological interventions (e.g. pharmacological or dietary intervention). Prespecified subgroups of children with conduct problems, however defined, were eligible for inclusion. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. child conduct problems or disruptive behaviour and 2. ADVERSE EVENTS: Our secondary outcomes were 3. personalised treatment outcomes relevant to each subgroup, 4. parenting skills and knowledge, 5. family functioning, engagement and decreased dropout, and 6. educational outcomes. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We identified 13 RCTs (858 participants). Seven studies were conducted in the USA, five in Australia, and one in Germany. Eleven studies reported their source of funding, with five studies receiving grants from the National Institute of Mental Health. In total, 15 different funders supported the studies included in the review. We separated subgroups of children with conduct problems into three broad categories: children with co-occurring conditions (e.g. emotional difficulties), parent characteristics (e.g. conflict between parents), or familial/environmental circumstances (e.g. rural families). All studies delivered a personalised intervention that was adapted or developed for a prespecified subgroup of children with conduct problems. We rated all trials at unclear or high risk of bias in most domains. Below, we report the results of improvement in child conduct problems and disruptive behaviour, personalised treatment outcomes, and parenting skills and knowledge for our main comparison: personalised versus non-personalised interventions. Improvement in child conduct problems and disruptive behaviour Compared with a non-personalised intervention, a personalised intervention may result in a slight improvement in child conduct problems or disruptive behaviour measured using the Eyberg Child Behavior Inventory (ECBI) Problem subscale in the short term (mean difference (MD) -3.04, 95% confidence interval (CI) -6.06 to -0.02; 6 studies, 278 participants; P = 0.05), but may have little to no effect on improving child conduct problems or disruptive behaviour measured by the ECBI Intensity subscale (MD -6.25, 95% CI -16.66 to 4.15; 6 studies, 278 participants; P = 0.24), or the Externalising subscale of the Child Behaviour Checklist (CBCL) (MD -2.19, 95% CI -6.97 to 2.59; 3 studies, 189 participants, P = 0.37) in the short term. We graded the certainty of evidence as very low for all three outcomes, meaning any estimate of effect is very uncertain.  Personalised treatment outcomes, relevant to each subgroup Although six studies reported personalised treatment outcomes, relevant to each subgroup, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive. Parenting skills and knowledge Although seven studies reported parenting skills and knowledge, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive.  Adverse events None of the trials reported monitoring adverse events. Summary of results In summary, there is limited evidence that personalised intervention improves child conduct problems, personalised treatment outcomes, relevant to each subgroup, or parenting skills and knowledge compared with a non-personalised intervention. AUTHORS' CONCLUSIONS: There is limited evidence for the effectiveness of personalised interventions for subgroups of children with conduct problems. The certainty of evidence for all outcomes was very low, meaning that we have very little confidence in the estimated effects and the true effects may be different to our findings, which will limit the relevance of our findings to clinical decisions. To overcome the limitations of the evidence, large-scale RCTs are needed to determine whether personalised interventions, adapted or developed, for subgroups of children with conduct problems are effective in improving outcomes. Consensus on the most appropriate measures to use in these studies is needed in order to facilitate cross-study comparisons. Persistent conduct problems predict a range of adverse long-term outcomes, so future research should investigate the medium- and long-term effects of personalised treatments. Studies are needed in low- and middle-income countries as well as studies recruiting children aged between nine and 12 years, as they were under-represented in the studies.

A Qualitative Study of the Influences on Clinical Academic Physicians' Postdoctoral Career Decision Making.

PURPOSE: To describe the influences on clinical academic physicians' postdoctoral career decision making. METHOD: Thirty-five doctoral trainee physicians from University College London took part in semistructured interviews in 2015 and 2016. Participants were asked open-ended questions about their career to date, their experiences undertaking a PhD, and their career plans post PhD. The interviews were audio-recorded and transcribed. Thematic analysis was used to generate, review, and define themes from the transcripts. Emerging differences and similarities in participants' reasons for pursuing a PhD were then grouped to produce typologies to explore how their experiences influenced their career decision making. RESULTS: Participants described four key reasons for undertaking a PhD, which formed the basis of the four typologies identified. These reasons included the following: to pursue a clinical academic career; to complete an extensive period of research to understand whether a clinical academic career was the desired path forward; to improve clinical career prospects; and to take a break from clinical training. CONCLUSIONS: These findings highlight the need to target efforts at retaining clinical academic physicians according to their reasons for pursuing a PhD and their subsequent experiences with the process. Those responsible for overseeing clinical training must be well informed of the long-term benefits of training academically qualified physicians. In light of current political uncertainty, universities, hospitals, and external agencies alike must increase their efforts to inspire and assuage early-career clinical academic physicians' fears regarding their academic future.

Service users' perceptions about their hospital admission elicited by service user-researchers or by clinicians.

OBJECTIVE Service users may express positive, ambivalent, or negative views of their hospital admission. The objective of this study was to determine whether the background of the interviewer-service user-researcher or clinician-influences the information elicited. The primary outcome was the level of perceived coercion on admission, and secondary outcomes were perceived pressures on admission, procedural justice, perceived necessity for admission, satisfaction with services, and willingness to consent to participate in the study. METHODS Participants voluntarily and involuntarily admitted to three hospitals in Ireland were randomly allocated to be interviewed at hospital discharge by either a service user-researcher or a clinician. Interviewers used the MacArthur Admission Experience Survey and the Client Satisfaction Questionnaire. RESULTS A total of 161 participants were interviewed. No differences by interviewer status or by admission status (involuntary or voluntary) were found in levels of perceived coercion, perceived pressures, procedural justice, perceived necessity, or satisfaction with services. Service users were more likely to decline to participate if their consent was sought by a service user-researcher (24% versus 8%, p=.003). CONCLUSIONS Most interviewees gave positive accounts of their admission regardless of interviewer status. The findings indicate that clinicians and researchers can be more confident that service users' positive accounts of admissions are not attributable to a response bias. Researchers can also feel more confident in directly comparing the results of studies undertaken by clinicians and by service user-researchers.