The association between emotional disorder and absence from school in children and young people

Anxiety and depressive disorders (“emotional disorders”) are common and impairing mental health conditions in children and young people (CYP), and they may be associated with absence from school. In this thesis I explore the association between emotional disorder and school absence through four original research studies. Firstly, a systematic review (Study One) is presented that evaluates the existing evidence for an association between emotional disorder and poor school attendance. This is followed by two studies that investigate cross-sectional (Study Two) and longitudinal bi-directional (Study Three) relationships between emotional disorder and school absence using data from a large population survey of CYP in the UK. Finally, a qualitative study (Study Four) is presented that explores educational practitioners’ beliefs about risk factors for attendance problems. Findings from the systematic review (Study One) suggested that emotional disorders are associated with higher levels of various “types” of absence. However, the ability to derive clear conclusions was undermined by limitations of the included studies and methodological heterogeneity between them, particularly in terms of how school attendance was measured. The quantitative cross-sectional study (Study Two) revealed strong relationships between several measures of emotional disorder and total, authorised and unauthorised school absence. The strongest relationships were observed for depression, particularly in relation to unauthorised absence. The longitudinal study (Study Three) demonstrated that depression and teacher-reported emotional difficulties predict unauthorised absence three years later, while authorised absence predicts teacher- and parent-reported emotional difficulties three years later. The qualitative study (Study Four) demonstrated that although school staff acknowledge mental health problems as a risk factor for attendance problems, they focus on anxiety rather than other mental health conditions, including depression. Taken together, the findings from this thesis provide evidence for a strong association between emotional disorder and school absence, which may be causal and bi-directional in nature. Implications of the research for clinical and educational practice, as well as for future research in this field, are discussed

Emotional disorder and absence from school: Findings from the 2004 British Child and Adolescent Mental Health Survey

This is the final version. Available on open access from Springer via the DOI in this recordBackground Emotional disorder may be associated with absence from school, but the existing evidence is methodologically weak. We studied the relationships between anxiety, depression and emotional difficulties, and school absence (total, authorised and unauthorised) using data from the 2004 British Child and Adolescent Mental Health Survey (BCAMHS). Method The BCAMHS was a cross-sectional, community survey of 7977 five to 16 year olds. Emotional disorder was assessed using the Development and Wellbeing Assessment (DAWBA), and emotional difficulties using the Strengths and Difficulties Questionnaire (SDQ) completed by teachers and parents. Teachers reported days absent in the previous school term. Multivariable negative binomial regression was used to examine the impact of emotional disorder and difficulties on absence. Age, gender and general health were explored as moderators. Results Anxiety, depression and emotional difficulties were associated with higher rates of all types of absence (rate ratios for total absence: anxiety 1.69 (1.39 to 2.06) p<0.001; depression 3.40 (2.46 to 4.69) p<0.001; parent-reported emotional difficulties 1.07 (1.05 to 1.10) p<0.001; teacher-reported emotional difficulties 1.10 (1.08 to 1.13) p<0.001). The strongest association was observed for depression and unauthorised absence. Relationships were stronger for secondary compared to primary school children. Conclusions Health and educational professionals should be aware that children with poor attendance may be experiencing emotional ill health, regardless of absence type. Absence may provide a useful tool to identify those who require additional mental health support. Findings highlight the widespread burden of emotional disorder and the need to support those with emotional ill health in continuing to access education.University of ExeterWellcome TrustNational Institute for Health Research (NIHR

Secondary school educational practitioners’ experiences of school attendance problems and interventions to address them: A qualitative study

This is the author accepted manuscript. The final version is available from Taylor & Francis (Routledge) via the DOI in this record.School attendance problems are associated with a range of adverse consequences, and educational practitioners play a role in identifying and responding to attendance problems. This qualitative study explored educational practitioners’ experiences of working with students with attendance problems and interventions to address them. Focus groups were conducted with sixteen practitioners across three secondary schools. Data were analysed using thematic analysis. Attendance problems were considered resource-intensive and emotionally challenging. Practitioners expressed difficulty understanding causes, although individual/family factors were emphasised over school factors. A range of interventions were described, including adaptations to school context and providing emotional support. Views on punitive approaches were mixed. Individualised interventions implemented at the first sign of problems, and a team approach, were considered important. Findings highlight the important role of educational practitioners in identifying attendance problems and implementing interventions. Recommendations include early intervention, team-work, and emotional support for students with, and staff responding to, attendance problems.This work was supported by a PhD studentship from the University of Exeter Medical School, UK

The association between child and adolescent emotional disorder and poor attendance at school: a systematic review protocol.

This is the final version of the article. Available from BioMed Central via the DOI in this record.BACKGROUND: Anxiety and depression are common in young people and are associated with a range of adverse outcomes. Research has suggested a relationship between emotional disorder and poor school attendance, and thus poor attendance may serve as a red flag for children at risk of emotional disorder. This systematic review aims to investigate the association between child and adolescent emotional disorder and poor attendance at school. METHODS: We will search electronic databases from a variety of disciplines including medicine, psychology, education and social sciences, as well as sources of grey literature, to identify any quantitative studies that investigate the relationship between emotional disorder and school attendance. Emotional disorder may refer to diagnoses of mood or anxiety disorders using standardised diagnostic measures, or measures of depression, anxiety or "internalising symptoms" using a continuous scale. Definitions for school non-attendance vary, and we aim to include any relevant terminology, including attendance, non-attendance, school refusal, school phobia, absenteeism and truancy. Two independent reviewers will screen identified papers and extract data from included studies. We will assess the risk of bias of included studies using the Newcastle-Ottawa Scale. Random effects meta-analysis will be used to pool quantitative findings when studies use the same measure of association, otherwise a narrative synthesis approach will be used. DISCUSSION: This systematic review will provide a detailed synthesis of evidence regarding the relationship between childhood emotional disorder and poor attendance at school. Understanding this relationship has the potential to assist in the development of strategies to improve the identification of and intervention for this vulnerable group. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016052961.This research is being carried out as part of a PhD studentship funded by the University of Exeter Medical School

Poor school attendance and exclusion: A systematic review protocol on educational risk factors for self-harm and suicidal behaviours

This is the final version. Available from BMJ Publishing Group via the DOI in this record.Introduction Schools have an important role in recognising and preventing self-harm and suicidal behaviour in their students, however little is known about which educational factors are associated with heightened risk We will systematically review the existing evidence on two key educational performance indicators that are routinely collected by school administrative systems: School attendance and exclusion We will investigate their association with self-harm and suicidal behaviour in school-age children and adolescents Knowledge of this association could help inform suicide prevention strategies at clinical, school and population levels Methods and analysis We will conduct a systematic search of Medline, EMBASE, PsycINFO, British Education Index and Education Resources Information Centre (ERIC) from 1 January 1990, and conduct a manual search for additional references We aim to identify studies that explore the association between poor school attendance or exclusion and self-harm or suicidal behaviours in school-age children and adolescents Two independent reviewers will screen titles, abstracts and full-text documents and independently extract relevant data for analysis Study quality will be assessed using a modified Newcastle-Ottawa Scale A descriptive analysis will be performed, and where appropriate, results will be combined in meta-analyses Ethics and dissemination This is a systematic review of published literature, and therefore ethical approval will not be sought We will publish reports in health and education journals, present our work at conferences focused on school mental health and communicate our findings to practitioners and managers in public health, education and child mental health.Wellcome TrustMedical Research Council (MRC)National Institute of Health Research (NIHR

Intervention development and treatment success in UK Health Technology Assessment funded trials of physical rehabilitation: a mixed methods analysis

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordData availability statement: No data are available.Objectives Physical rehabilitation is a complex process, and trials of rehabilitation interventions are increasing in number but often report null results. This study aimed to establish treatment success rates in physical rehabilitation trials funded by the National Institute of Health Research Health Technology Assessment (NIHR HTA) programme and examine any relationship between treatment success and the quality of intervention development work undertaken. Design This is a mixed methods study. Setting This study was conducted in the UK. Methods The NIHR HTA portfolio was searched for all completed definitive randomised controlled trials of physical rehabilitation interventions from inception to July 2016. Treatment success was categorised according to criteria developed by Djulbegovic and colleagues. Detailed textual data regarding any intervention development work were extracted from trial reports and supporting publications and informed the development of quality ratings. Mixed methods integrative analysis was undertaken to explore the relationship between quantitative and qualitative data using joint displays. Results Fifteen trials were included in the review. Five reported a definitive finding, four of which were in favour of the ‘new’ intervention. Eight trials reported a true negative (no difference) outcome. Integrative analysis indicated those with lower quality intervention development work were less likely to report treatment success. Conclusions Despite much effort and funding, most physical rehabilitation trials report equivocal findings. Greater focus on high quality intervention development may reduce the likelihood of a null result in the definitive trial, alongside high quality trial methods and conduct.National Institute for Health Research (NIHR

Diagnostic accuracy of routine antenatal determination of fetal RHD status across gestation: population based cohort study.

To assess the accuracy of fetal RHD genotyping using cell-free fetal DNA in maternal plasma at different gestational ages

Use of cffDNA to avoid administration of anti-D to pregnant women when the fetus is RhDnegative: Implementation in the NHS. BJOG doi

Objective To determine whether a policy of offering cffDNA testing to all RhD-negative women at about 16 weeks&apos; gestation to avoid anti-D administration when the fetus is RhD-negative could be implemented successfully in the NHS without additional funding. Design Prospectively planned observational service implementation pilot and notes audit. Setting Three maternity services in the South West of England. Population All RhD-negative women in a 6-month period. Methods Prospective, intervention, cross-sectional observational study, using pre-intervention data as controls. Main outcome measures Proportion of suitable women who offered and accepted the test. Accuracy of the cffDNA result as assessed by cord blood group result. Fall in anti-D doses administered. Results 529 samples were received; three were unsuitable. The results were reported as RhD-positive (n = 278), RhD-negative (n = 185) or inconclusive, treat as positive (n = 63). Cord blood results were available in 502 (95%) and the only incorrect result was one case of a false positive (cffDNA reported as positive, cord blood negative -and so given anti-D unnecessarily). The notes audit showed that women who declined this service were correctly managed and that anti-D was not given when the fetus was predicted to be RhD-negative. The total use of anti-D doses fell by about 29% which equated to about 35% of RhD-negative women not receiving anti-D in their pregnancy unnecessarily. Conclusions We recommend this service is extended to all UK NHS services

Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial

Background Depression is a common, debilitating, and costly disorder. Many patients request psychological therapy, but the best-evidenced therapy—cognitive behavioural therapy (CBT)—is complex and costly. A simpler therapy—behavioural activation (BA)—might be as effective and cheaper than is CBT. We aimed to establish the clinical efficacy and cost-effectiveness of BA compared with CBT for adults with depression. Methods In this randomised, controlled, non-inferiority trial, we recruited adults aged 18 years or older meeting Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder from primary care and psychological therapy services in Devon, Durham, and Leeds (UK). We excluded people who were receiving psychological therapy, were alcohol or drug dependent, were acutely suicidal or had attempted suicide in the previous 2 months, or were cognitively impaired, or who had bipolar disorder or psychosis or psychotic symptoms. We randomly assigned participants (1:1) remotely using computer-generated allocation (minimisation used; stratified by depression severity [Patient Health Questionnaire 9 (PHQ-9) score of <19 vs ≥19], antidepressant use, and recruitment site) to BA from junior mental health workers or CBT from psychological therapists. Randomisation done at the Peninsula Clinical Trials Unit was concealed from investigators. Treatment was given open label, but outcome assessors were masked. The primary outcome was depression symptoms according to the PHQ-9 at 12 months. We analysed all those who were randomly allocated and had complete data (modified intention to treat [mITT]) and also all those who were randomly allocated, had complete data, and received at least eight treatment sessions (per protocol [PP]). We analysed safety in the mITT population. The non-inferiority margin was 1·9 PHQ-9 points. This trial is registered with the ISCRTN registry, number ISRCTN27473954. Findings Between Sept 26, 2012, and April 3, 2014, we randomly allocated 221 (50%) participants to BA and 219 (50%) to CBT. 175 (79%) participants were assessable for the primary outcome in the mITT population in the BA group compared with 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the PP population in the BA group compared with 151 (69%) in the CBT group. BA was non-inferior to CBT (mITT: CBT 8·4 PHQ-9 points [SD 7·5], BA 8·4 PHQ-9 points [7·0], mean difference 0·1 PHQ-9 points [95% CI −1·3 to 1·5], p=0·89; PP: CBT 7·9 PHQ-9 points [7·3]; BA 7·8 [6·5], mean difference 0·0 PHQ-9 points [–1·5 to 1·6], p=0·99). Two (1%) non-trial-related deaths (one [1%] multidrug toxicity in the BA group and one [1%] cancer in the CBT group) and 15 depression-related, but not treatment-related, serious adverse events (three in the BA group and 12 in the CBT group) occurred in three [2%] participants in the BA group (two [1%] patients who overdosed and one [1%] who self-harmed) and eight (4%) participants in the CBT group (seven [4%] who overdosed and one [1%] who self-harmed). Interpretation We found that BA, a simpler psychological treatment than CBT, can be delivered by junior mental health workers with less intensive and costly training, with no lesser effect than CBT. Effective psychological therapy for depression can be delivered without the need for costly and highly trained professionals. Funding National Institute for Health Research

Noninvasive Prenatal Diagnosis of Fetal Trisomy 18 and Trisomy 13 by Maternal Plasma DNA Sequencing

Massively parallel sequencing of DNA molecules in the plasma of pregnant women has been shown to allow accurate and noninvasive prenatal detection of fetal trisomy 21. However, whether the sequencing approach is as accurate for the noninvasive prenatal diagnosis of trisomy 13 and 18 is unclear due to the lack of data from a large sample set. We studied 392 pregnancies, among which 25 involved a trisomy 13 fetus and 37 involved a trisomy 18 fetus, by massively parallel sequencing. By using our previously reported standard z-score approach, we demonstrated that this approach could identify 36.0% and 73.0% of trisomy 13 and 18 at specificities of 92.4% and 97.2%, respectively. We aimed to improve the detection of trisomy 13 and 18 by using a non-repeat-masked reference human genome instead of a repeat-masked one to increase the number of aligned sequence reads for each sample. We then applied a bioinformatics approach to correct GC content bias in the sequencing data. With these measures, we detected all (25 out of 25) trisomy 13 fetuses at a specificity of 98.9% (261 out of 264 non-trisomy 13 cases), and 91.9% (34 out of 37) of the trisomy 18 fetuses at 98.0% specificity (247 out of 252 non-trisomy 18 cases). These data indicate that with appropriate bioinformatics analysis, noninvasive prenatal diagnosis of trisomy 13 and trisomy 18 by maternal plasma DNA sequencing is achievable