A good investment: longer-term cost savings of sensitive parenting in childhood.

BACKGROUND: Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan. The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested. METHODS: Design: Longitudinal study with follow-up from 2012 to 2016. SETTING: UK multicentre study cohort (London, South-East England). PARTICIPANTS: 174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4-6 years then followed up in early adolescence (mean age 12.1 years). MEASURES: The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent-child interaction. RESULTS: Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security. CONCLUSIONS: This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. Savings are likely to increase as individuals grow older since early parenting quality predicts health, behavioural and occupational outcomes in adulthood. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

Outcomes and costs of skilled support for people with severe or profound intellectual disability and complex needs.

BACKGROUND: With increasing reductions in funding for social care across many countries, the need to ensure that resources are used to best effect is becoming increasingly important, in particular for those with severe and complex needs. METHODS: In order to explore the outcomes and costs of skilled support for this group of people, quality of life was assessed for 110 people in 35 services in England. Information on costs was also collected. RESULTS: People who received consistently good active support experienced better outcomes in terms of several quality of life domains. Good support did not require significantly more staff time, and there was no evidence of higher total costs for those receiving good support. CONCLUSIONS: The inclusion of active support in government guidance and local commissioning practices related to people with severe intellectual disabilities is likely to improve user outcomes. Observation should be an important element in measuring service quality.

The cost of love: financial consequences of insecure attachment in antisocial youth.

BACKGROUND: Knowing that your parent or caregiver will be there for you in times of emotional need and distress is a core aspect of the human experience of feeling loved and being securely attached. In contrast, an insecure attachment pattern is found in many antisocial youth and is related to less sensitive caregiving. Such youth are often distrustful of adults and authority figures, and are at high risk of poor outcomes. As they become adults, they require extensive health, social and economic support, costing society ten times more than their well-adjusted peers. However, it is not known whether insecure attachment itself is associated with higher costs in at-risk youth, independently of potential confounders, nor whether cost differences are already beginning to emerge early in adolescence. METHODS: Sample: A total of 174 young people followed up aged 9-17 years (mean 12.1, SD 1.8): 85 recruited with moderate antisocial behaviour (80th percentile) from a school screen aged 4-6 years; 89 clinically referred with very high antisocial behaviour (98th percentile) aged 3-7 years. MEASURES: Costs by detailed health economic and service-use interview; attachment security to mother and father from interview; diagnostic interviews for oppositional and conduct problems; self-reported delinquent behaviour. RESULTS: Costs were greater for youth insecurely attached to their mothers (secure £6,743, insecure £10,199, p = .001) and more so to fathers (secure £1,353, insecure £13,978, p < .001). These differences remained significant (mother p = .019, father p < .001) after adjusting for confounders, notably family income and education, intelligence and antisocial behaviour severity. CONCLUSIONS: Attachment insecurity is a significant predictor of public cost in at-risk youth, even after accounting for covariates. Since adolescent attachment security is influenced by caregiving quality earlier in childhood, these findings add support to the public health case for early parenting interventions to improve child outcomes and reduce the financial burden on society.

The Earlier the Better? Individual Participant Data and Traditional Meta-analysis of Age Effects of Parenting Interventions.

Strong arguments have been made for early intervention for child problems, stating that early is more effective than later, as the brain is more malleable, and costs are lower. However, there is scant evidence from trials to support this hypothesis, which we therefore tested in two well-powered, state-of-the-art meta-analyses with complementary strengths: (a) Individual participant data (IPD) meta-analysis of European trials of Incredible Years parenting intervention (k = 13, n = 1696; age = 2-11); (b) Larger, trial-level robust variance estimation meta-analysis of a wider range of parenting programs (k = 156, n = 13,378, Mage  = 2-10) for reducing disruptive behavior. Both analyses found no evidence that intervention earlier in childhood was more effective; programs targeted at a narrower age range were no more effective than general ones.

Research Review: Harnessing the power of individual participant data in a meta-analysis of the benefits and harms of the Incredible Years parenting program.

BACKGROUND: Parenting programs aim to reduce children's conduct problems through improvement of family dynamics. To date, research on the precise benefits and possible harms of parenting programs on family well-being has been unsystematic and likely to be subject to selective outcome reporting and publication bias. Better understanding of program benefits and harms requires full disclosure by researchers of all included measures, and large enough numbers of participants to be able to detect small effects and estimate them precisely. METHODS: We obtained individual participant data for 14 of 15 randomized controlled trials on the Incredible Years parenting program in Europe (total N = 1,799). We used multilevel modeling to estimate program effects on 13 parent-reported outcomes, including parenting practices, children's mental health, and parental mental health. RESULTS: Parental use of praise, corporal punishment, threats, and shouting improved, while parental use of tangible rewards, monitoring, or laxness did not. Children's conduct problems and attention deficit hyperactivity disorder (ADHD) symptoms improved, while emotional problems did not. Parental mental health (depressive symptoms, self-efficacy, and stress) did not improve. There was no evidence of harmful effects. CONCLUSIONS: The Incredible Years parenting program improves the aspects of family well-being that it is primarily designed to improve: parenting and children's conduct problems. It also improves parent-reported ADHD symptoms in children. Wider benefits are limited: the program does not improve children's emotional problems or parental mental health. There are no signs of harm on any of the target outcomes.

Transition Care in Anorexia Nervosa Through Guidance Online from Peer and Carer Expertise (TRIANGLE): Study Protocol for a Randomised Controlled Trial.

TRIANGLE is a multicentre trial investigating whether the addition of a novel intervention for patients and carers (ECHOMANTRA) to treatment as usual (TAU) improves outcomes for people with anorexia nervosa (AN). ECHOMANTRA is based on the cognitive interpersonal model of AN and includes assessments, workbooks, videos, online groups and joint Skype sessions for patients and carers. People receiving intensive hospital treatment (N = 380) will be randomised to TAU or TAU plus ECHOMANTRA. Participants will be assessed over an 18-month period following randomisation. The primary outcome is patient psychological well-being at 12 months postrandomisation. Secondary outcomes include (i) patient's weight, eating disorder symptoms, motivation to change, quality of life and number of days in hospital at 12 months postrandomisation and (ii) carer's psychological well-being, burden and skills at 12 months (some outcomes will be assessed at 18 months postrandomisation). The results from this trial will establish the effectiveness of ECHOMANTRA. TRIAL REGISTRATION: ISRCTN registry ISRCTN14644379, 08/12/2016. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

People with intellectual disabilities at the end of their lives: The case for specialist care?

BACKGROUND: People with intellectual disabilities have a shorter life expectancy, but healthcare improvements mean that they are beginning to live longer, with associated health difficulties. This means that there is an urgent need to focus research on ageing as well as end-of-life care. This study aimed to explore a specialist intellectual disability service for older people who are dying and how it related to their quality of life and to costs associated with care provided. METHOD: Data were collected for nine residents and 15 staff members of the specialist service. A single case study design with mixed methods including observations, interviews, standardized questionnaires and costs analysis was utilized. RESULTS: We found positive results regarding overall quality of life, although individuals had limited social networks. Placement fees paid by local health trusts and social services departments were slightly higher than the estimated cost of care reflecting good financial management by a small voluntary sector organization. CONCLUSION: Whilst the philosophical arguments around "specialist" care persist, this service fills a gap in intellectual disability care provision.

Two-year follow-up of the MOSAIC trial: A multicenter randomized controlled trial comparing two psychological treatments in adult outpatients with broadly defined anorexia nervosa.

OBJECTIVE: This study reports follow-up data from a multicenter randomized controlled trial (n = 142) comparing the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with broadly defined anorexia nervosa (AN). At 12 months postrandomization, all patients had statistically significant improvements in body mass index (BMI), eating disorder (ED) symptomatology and other outcomes with no differences between groups. MANTRA was more acceptable to patients. The present study assessed whether gains were maintained at 24 months postrandomization. METHODS: Follow-up data at 24 months were obtained from 73.2% of participants. Outcome measures included BMI, ED symptomatology, distress, impairment, and additional service utilization during the study period. Outcomes were analyzed using linear mixed models. RESULTS: There were few differences between groups. In both treatment groups, improvements in BMI, ED symptomatology, distress levels, and clinical impairment were maintained or increased further. Estimated mean BMI change from baseline to 24 months was 2.16 kg/m(2) for SSCM and 2.25 kg/m(2) for MANTRA (effect sizes of 1.75 and 1.83, respectively). Most participants (83%) did not require any additional intensive treatments (e.g., hospitalization). Two SSCM patients became overweight through binge-eating. DISCUSSION: Both treatments have value as outpatient interventions for patients with AN. © 2016 Crown copyright. International Journal of Eating Disorders. (Int J Eat Disord 2016; 49:793-800).

Clinical service use as people with Attention Deficit Hyperactivity Disorder transition into adolescence and adulthood: a prospective longitudinal study.

BACKGROUND: While Attention Deficit Hyperactivity Disorder (ADHD) often persists into adulthood, little is known about the needs and service use among adolescents and young adults with ADHD. The present study followed-up a cohort diagnosed with ADHD as children and assessed their: 1) needs, 2) correlates of contact with clinical services, and 3) experiences of transition from child to adult health services. METHODS: Ninety one young people aged 14-24 were recruited from the UK subset of the International Multi-Centre ADHD Genetics (IMAGE) Project. Affected young people and parents conducted face-to-face interviews and self-completion questionnaires including a modified version of the Client Services Receipt Inventory, The Barkley's ADHD rating scale, The Clinical Interview Schedule-Revised, and the Zarit Burden Interview. Changes in key need characteristics (e.g. ADHD symptoms and impairments) over a 3-year period were examined using fixed effect models. Generalised Estimating Equations (GEE) were used to explore how key characteristics (such as ADHD symptoms) were associated with contact with clinical services across the three years. RESULTS: At baseline 62 % met diagnostic criteria for ADHD and presented with a range of ADHD related impairments, psychiatric comorbidities, and significant caregiver burden. While ADHD symptoms and related impairments lessened significantly over the three years, psychiatric comorbidities and caregiver burden remained stable. The strongest correlate of contact with clinical services was age (OR 0.65 95 % CI 0.49-0.84) with the odds of reported contact with clinical services decreasing by 35 % for each year increase in age at baseline and by 25 % for each year increase in age over time. Only 9 % of the sample had experienced a transfer to adult services, with the majority reporting unmet needs in healthcare transition. CONCLUSIONS: Despite continuing needs, few were in contact with adult health services or had received sufficient help with transition between child and adult health services. The main determinant of health service use for adolescents and young adults with ADHD is age - not needs. Service models should address the needs of ADHD individuals who are no longer children.

Two-year Follow-up of a Pragmatic Randomised Controlled Trial Examining the Effect of Adding a Carer's Skill Training Intervention in Inpatients with Anorexia Nervosa.

BACKGROUND: Active family engagement improves outcomes from adolescent inpatient care, but the impact on adult anorexia nervosa is uncertain. AIM: The aim of this study was to describe the 2-year outcome following a pragmatic randomised controlled trial in which a skill training intervention (Experienced Caregivers Helping Others) for carers was added to inpatient care. METHOD: Patient, caregiver and service outcomes were measured for 2 years following discharge from the index inpatient admission. RESULTS: There were small-sized/moderate-sized effects and consistent improvements in all outcomes from both patients and carers in the Experienced Caregivers Helping Others group over 2 years. The marked change in body mass index and carers' time caregiving following inpatient care was sustained. Approximately 20% of cases had further periods of inpatient care. CONCLUSION: In this predominately adult anorexia nervosa sample, enabling carers to provide active support and management skills may improve the benefits in all symptom domains that gradually follow from a period of inpatient care.

Development and validation of a scale to measure caregiver skills in eating disorders.

OBJECTIVE: The aim of this study was to develop and validate a new questionnaire designed to measure caregiver skills that, in line with the interpersonal component of the cognitive interpersonal maintenance model (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006), may be helpful in the support of people with anorexia nervosa (AN). A further aim is to assess whether this scale is sensitive to change following skills-based caregiver interventions. METHOD: The Caregiver Skills (CASK) scale was developed by a group of clinicians and caregivers. Preliminary versions of the scale devised for both caregivers and parents were given at baseline and at follow-up after two studies of caregiver interventions (a clinical trial of the effectiveness of guided self-help and training workshops). Exploratory and confirmatory factor analyses (CFA) were used to test the factorial structure of the CASK scale. Cronbach's alpha was used to measure internal consistency of the CASK scales. RESULTS: Exploratory Factor Analysis suggested a six component solution (Bigger Picture, Self-Care, Biting-Your-Tongue, Insight and Acceptance, Emotional Intelligence and Frustration Tolerance) and this model was confirmed with CFA. Significant clinically relevant correlations were found between the CASK scales and other standardised measures of caregivers' attitudes and behaviours. Furthermore, greater improvements on abilities measured by the CASK scale were found in caregivers who received skills-training than caregivers assigned to a 'treatment as usual' condition. DISCUSSION: The CASK scale is a measure of the fidelity of interventions based on the cognitive interpersonal maintenance model and is sensitive to the intensity of the intervention provided.

Use of services and associated costs for young adults with childhood hyperactivity/conduct problems: 20-year follow-up.

BACKGROUND: Although childhood hyperactivity and conduct problems are associated with difficulties in adulthood, little is known about later service use or public expenditure costs in the UK. AIMS: To describe the use of services and calculate recent (past 6 months) and early adulthood (since the age of 18 years) public expenditure costs incurred by young adults who had hyperactivity and/or conduct problems during childhood. METHOD: A 20-year follow-up of a community sample of 6- to 7-year-old boys (n = 83) with hyperactivity only, conduct problems only, mixed hyperactivity and conduct problems, and no behaviour problems (control). Information was obtained about service use; recent (past 6 months), and early adulthood (since age 18 years) public expenditure costs were calculated. RESULTS: High levels of childhood conduct problems were associated with a two- to threefold increase in early adulthood costs, mainly driven by criminal justice contacts. Although the mixed problems group had the highest recent costs in terms of receipt of benefits and health and social care, they had the lowest criminal justice costs. CONCLUSIONS: High levels of early childhood conduct problems are particularly associated with increased health, social care and criminal justice costs in adulthood.

One-day cognitive-behavioural therapy self-confidence workshops for people with depression: randomised controlled trial.

BACKGROUND: Despite its high prevalence, help-seeking for depression is low. AIMS: To assess the effectiveness and cost-effectiveness of 1-day cognitive-behavioural therapy (CBT) self-confidence workshops in reducing depression. Anxiety, self-esteem, prognostic indicators as well as access were also assessed. METHOD: An open randomised controlled trial (RCT) waiting list control design with 12-week follow-up was used (trial registration: ISRCTN26634837). A total of 459 adult participants with depression (Beck Depression Inventory (BDI) scores of ≥ 14) self-referred and 382 participants (83%) were followed up. RESULTS: At follow-up, experimental and control participants differed significantly on the BDI, with an effect size of 0.55. Anxiety and self-esteem also differed. Of those who participated, 25% were GP non-consulters and 32% were from Black and minority ethnic groups. Women benefited more than men on depression scores. The intervention has a 90% chance of being considered cost-effective if a depression-free day is valued at £14. CONCLUSIONS: Self-confidence workshops appear promising in terms of clinical effectiveness, cost-effectiveness and access by difficult-to-engage groups.

Annual research review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders.

BACKGROUND: Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses. SCOPE AND METHODS: The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012. FINDINGS: Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8). CONCLUSION: Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.

Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial.

PURPOSE OF THE STUDY: to examine the costs and cost-effectiveness of 'second-generation' telecare, in addition to standard support and care that could include 'first-generation' forms of telecare, compared with standard support and care that could include 'first-generation' forms of telecare. DESIGN AND METHODS: a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care. PRIMARY OUTCOME MEASURE: incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective. RESULTS: cost per additional QALY was £297,000. Cost-effectiveness acceptability curves indicated that the probability of cost-effectiveness at a willingness-to-pay of £30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of £161,000 per QALY. IMPLICATIONS: while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs. TRIAL REGISTRATION NUMBER: ISRCTN 43002091.

Experienced Carers Helping Others (ECHO): protocol for a pilot randomised controlled trial to examine a psycho-educational intervention for adolescents with anorexia nervosa and their carers.

Experienced Carers Helping Others (ECHO) is an intervention for carers of people with eating disorders. This paper describes the theoretical background and protocol of a pilot multicentre randomised controlled trial that will explore the use of two variants of ECHO for improving outcomes for adolescents with anorexia nervosa (AN) referred for outpatient care. Adolescent patients and their carers (typically parents and close others in a supportive role) will be recruited from 38 eating disorder outpatient services across the UK. Carers will be randomly allocated to receive 'ECHOc' guided self-help (in addition to treatment as usual), 'ECHO' self-help only (in addition to treatment as usual) or treatment as usual only. Primary outcomes are a summary measure of the Short Evaluation of Eating Disorders at 6- and 12-month follow-ups. Secondary outcomes are general psychiatric morbidity of AN patients and carer, carers' coping and behaviour, and change in healthcare use and costs at 6- and 12-month follow-ups. Therapist effects will be examined, and process evaluation of ECHOc will be completed. The findings from this pilot trial will be used in preparation for executing a definitive trial to determine the impact of the preferred variant of ECHO to improve treatment outcomes for AN.

Investigating changes in use of services by high-need families following the Helping Families Programme, an innovative parenting intervention for children with severe and persistent conduct problems.

BACKGROUND: Interventions aimed at high-need families have difficulty demonstrating short-term impact on child behaviour. Measuring impact on use of services could provide short-term indication of longer term benefits. METHOD: During a feasibility pilot study we collected data on service use and attitudes to services from a small sample of parents from high-need families, before and after receiving the Helping Families Programme. RESULTS: Respondents provided a range of opinions on a variety of social and community services received. CONCLUSIONS: The study demonstrates the potential of short-term changes in enhanced service use data for building hypotheses of longer term change.

Caregiving and coping in carers of people with anorexia nervosa admitted for intensive hospital care.

OBJECTIVE: The aim of the study was to examine how carers cope practically and emotionally with caring for individuals with anorexia nervosa who require intensive hospital care. METHOD: This study explores objective burden (time spent with caregiving and number of tasks), subjective burden (psychological distress), and social support in a sample of parents (n = 224) and partners (n = 28) from a consecutive series of patients (n = 178) admitted to inpatient units within the United Kingdom. RESULTS: Most time was spent providing emotional support and less with practical tasks. Time spent with caregiving was associated with carer distress and was fully mediated by carer burden. This was ameliorated by social support. Partners received minimal support from others, and we found similar levels of burden and distress for mothers and partners. DISCUSSION: The data indicate that professional and social support alleviates carer distress and may be of particular value for partners who are more isolated than parents. The data also suggest that time spent with practical support may be of more value than emotional support.

Carers' assessment, skills and information sharing: theoretical framework and trial protocol for a randomised controlled trial evaluating the efficacy of a complex intervention for carers of inpatients with anorexia nervosa.

Experienced Carers Helping Others (ECHO) is a guided self-help intervention for carers of people with eating disorders to reduce distress and ameliorate interpersonal maintaining factors to improve patient outcomes. The aim of this paper is to describe the theoretical background and protocol of a randomised controlled trial that will establish whether ECHO has a significant beneficial effect for carers and the person they care for. Individuals with anorexia nervosa and carers will be recruited from eating disorder inpatient/day patient hospital services in the UK. Primary outcomes are time until relapse post-discharge (patient) and distress (carer) at 12 months post-discharge. Secondary outcomes are body mass index, eating disorder symptoms, psychosocial measures and health economic data for patients and carers. Carers will be randomised (stratified by site and illness severity) to receive ECHO (in addition to treatment as usual) or treatment as usual only. Potential difficulties in participant recruitment and delivery of the intervention are discussed.

Costing children's speech, language and communication interventions.

BACKGROUND: There are few economic evaluations of speech and language interventions. Such work requires underpinning by an accurate estimate of the costs of the intervention. This study seeks to address some of the complexities of this task by applying existing approaches of cost estimation to interventions described in published effectiveness studies. AIMS: The study has two aims: to identify a method of estimating unit costs based on the principle of long-run marginal opportunity costs; and to illustrate the challenges in estimating unit costs for speech and language interventions. METHOD & PROCEDURES: Descriptions of interventions were extracted from eight papers and combined with information on the unit cost of speech and language therapists to identify information requirements for a full-cost estimation of an intervention. OUTCOMES & RESULTS: Four challenges were found relating to the level of detail about the therapists, the participants, the scope of activities and parents. Different assumptions made about any of these elements will have a marked effect on the cost of the intervention. CONCLUSIONS & IMPLICATIONS: Nationally applicable unit cost data for speech and language therapists can be used as a reference point, but sufficient descriptive data about delivery and receipt of the intervention are key to accuracy.