Implementing brief and low-intensity psychological interventions for children and young people with internalizing disorders: a rapid realist review

INTRODUCTION: Many children fail to receive the mental health treatments they need, despite strong evidence demonstrating efficacy of brief and low-intensity psychological interventions. This review identifies the barriers and facilitators to their implementation. SOURCES OF DATA: PsycInfo, EMBASE and Medline were searched and a systematic approach to data extraction using Normalization Process Theory highlighted key mechanisms and contextual factors. AREAS OF AGREEMENT: Ten interventions from 9 papers, including 371 young people, were included. Studies identified organizational demands, lack of implementation strategy and stigma as barriers to implementation, and clear training and plans for implementation as facilitators. AREAS OF CONTROVERSY: No standardized implementation outcomes were used across papers so meta-analysis was not possible. GROWING POINTS: Barriers and facilitators have been clearly identified across different settings. AREAS TIMELY FOR DEVELOPING RESEARCH: Longitudinal studies can identify methods and processes for enhancing long-term implementation and considers ways to monitor and evaluate uptake into routine practice

Training paediatric hospital workforces to deliver low-intensity CBT for children and young people with mental health needs in the context of long term conditions

Introduction: Despite children and young people (CYP) with long term conditions (LTCs) having significantly elevated mental health needs, accessing evidence-based psychological support remains difficult. Previous work suggests low-intensity CBT (LICBT) interventions are effective for CYP with mental health needs in the context of LTCs. If embedded in hospitals LICBT may increase access and better integrate physical and mental health care. This new provision is currently being implemented in paediatric hospitals across the UK. A vital part of successful implementation is effective training. The current paper describes hybrid training in LICBT interventions delivered to staff from a range of health care settings. The aim of the study was to analyse the effectiveness of, and satisfaction with, this training. // Methods: Two days of hybrid training in LICBT for mental health needs in the context of LTCs were delivered to staff. Attendees were introduced to LICBT strategies to support CYP with anxiety, depression and challenging behaviour. A brief questionnaire and evaluation form were completed before and after training on attendees’ understanding of the topics covered and their views of the training (usefulness, relevance, preparedness). // Results: Thirteen attendees completed the questionnaire before and after training was completed. Total scores significantly increased from pre-training to post-training. Qualitative feedback indicated the majority found the training highly relevant to their work and enjoyed the hybrid model. // Conclusion: These findings support the acceptability and effectiveness of two-day hybrid training as part of enabling a paediatric hospital workforce to deliver psychological support for CYP with LTCs. Future training could consider this format to help overcome barriers to successful implementation. This work highlights the opportunity a new or existing workforce holds in integrating psychological therapies into existing physical health care pathways, coordinating care and ensuring equitable access to mental health support for CYPs, irrespective of their LTCs

Applying an Established Exposure Response Prevention Protocol for Young People With Tourette Syndrome in an Intensive, Group Format: A Feasibility Study

Background: The motor and vocal tics that characterise Tourette syndrome are stigmatizing and impact on quality of life. Behavioural interventions such as Exposure Response Prevention or Comprehensive Behavioural Interventions for Tics are first line treatment for Tourette syndrome, but availability is limited. This study is the first to explore the impact of an established manualised Exposure Response Prevention treatment protocol, developed for individual therapy, but here uniquely delivered intensively, to a group. // Methods: A naturalistic study comprised of a consecutive series of children (N = 20), aged 8–16 years (M = 12, SD = 2.17) were offered Exposure Response Prevention in one of two groups, delivered in series within a specialist clinic. Young people received the equivalent of 12 sessions (matching the manualised individual protocol). // Results: The YGTSS and Giles de la Tourette Syndrome Quality of Life Scale for Children and Adolescents (Satisfaction Scale) showed significant improvement following treatment with moderate to large effect sizes. Thirty-five percent of children demonstrated a reliable improvement on the YGTSS Global Tic Severity score. // Conclusions: These data suggest an established Exposure Response Prevention protocol can be delivered in an intensive, group setting with a positive clinical outcome. Replication in a randomized controlled trial is an important next step

Growth mindset in young people awaiting treatment in a paediatric mental health service: a mixed methods pilot of a digital single-session intervention

BACKGROUND: Wait times are significant in child mental health services but may offer opportunity to promote growth mindsets in young people with physical and mental health needs. A digital growth mindset single-session intervention is effective in young people, but its use in paediatric settings has not been examined. This mixed methods pilot aimed to assess the intervention’s feasibility, acceptability, and impact in this population. METHOD: Patients aged 8–18 on waiting lists in a paediatric hospital’s specialist mental health service were offered the intervention remotely. Treatment completion and retention rates, symptoms of depression and anxiety, perceived control, and personality mindset were assessed at baseline, post-treatment, and follow-ups. Semi-structured interviews to explore the intervention’s acceptability were conducted post-treatment. RESULTS: Twenty-five patients completed the intervention and 17 patients and three carers/parents were interviewed. Outcomes showed small to large improvements across time-points. Most patients reported finding the intervention enjoyable, accessible, and instilled a hope for change. They valued elements of the intervention but made suggestions for improvement. CONCLUSIONS: The digital growth mindset single-session intervention is feasible, acceptable, and potentially beneficial for young people with physical and mental health needs on waiting lists. Further research is warranted to examine its effectiveness and mechanism of change

Cost-effectiveness of a mental health drop-in center for young people with long-term physical conditions

BACKGROUND: Paediatric patients being treated for long-term physical health conditions (LTCs) have elevated mental health needs. However, mental health services in the community are difficult to access in the usual course of care for these patients. The Lucy Project – a self-referral drop-in access point—was a program to address this gap by enrolling patients for low-intensity psychological interventions during their treatment for LTCs. In this paper, we evaluate the cost-effectiveness of the Lucy Project. METHODS: Using a pre-post design, we evaluate the cost-effectiveness of the intervention by calculating the base-case incremental cost-effectiveness ratio (ICER) using outcomes data and expenses recorded by project staff. The target population was paediatric patients enrolled in the program with an average age of 9 years, treated over a time horizon of 6 months. Outcome data were collected via the Paediatric Quality of Life Inventory, which was converted to health utility scores using an instrument found in the literature. The QALYs were estimated using these health utility scores and the length of the intervention. We calculate a second, practical-case incremental cost-effectiveness ratio using streamlined costing figures with maximum capacity patient enrolment within a one-year time horizon, and capturing lessons learned post-trial. RESULTS: The base-case model showed an ICER of £21,220/Quality Adjusted Life Years (QALY) gained, while the practical model showed an ICER of £4,359/QALY gained. The practical model suggests the intervention garners significant gains in quality of life at an average cost of £309 per patient. Sensitivity analyses reveal use of staff time was the greatest determinant of the ICER, and the intervention is cost-effective 75% of the time in the base-case model, and 94% of the time in the practical-case model at a cost-effectiveness threshold of £20,000/QALY gained. CONCLUSIONS: We find the base-case intervention improves patient outcomes and can be considered cost-effective according to the National Institute for Health and Care Excellence (NICE) threshold of £20,000—£30,000/QALY gained, and the practical-case intervention is roughly four times as cost-effective as the base-case. We recommend future studies incorporate a control group to corroborate the effect size of the intervention

Habit Reversal Training and Educational group treatments for children with Tourette Syndrome: a preliminary randomised controlled trial.

Quality of life of children with Tourette Syndrome (TS) is impacted greatly by its symptoms and their social consequences. Habit Reversal Training (HRT) is effective but has not, until now, been empirically evaluated in groups. This randomised controlled trial evaluated feasibility and preliminary efficacy of eight HRT group sessions compared to eight Education group sessions. Thirty-three children aged 9-13 years with TS or Chronic Tic Disorder took part. Outcomes evaluated were tic severity and quality of life (QoL). Tic severity improvements were found in both groups. Motor tic severity (Yale Global Tic Severity Scale) showed greatest improvements in the HRT group. Both groups showed a strong tendency toward improvements in patient reported QoL. In conclusion, group-based treatments for TS are feasible and exposure to other children with tics did not increase tic expression. HRT led to greater reductions in tic severity than Education. Implications, such as cost-effectiveness of treatment delivery, are discussed

Changes and adaptations in a national specialist paediatric mental health service in response to Covid-19

We discuss how we adapted as a service to continue meeting needs during COVID-19, how further research is warranted on the mental health of the paediatric population as a result of the pandemic, and how services may address these needs

Administration of Acts Act Amendment Act, 1979, No. 56

It has been suggested that childhood obsessive-compulsive disorder (OCD) may be a risk factor for the development of an eating disorder (ED) later in life, but prospective studies are lacking. We aimed to determine the prevalence of ED at follow-up and clinical predictors in a longitudinal clinical sample of adolescents/young adults diagnosed with OCD in childhood. All contactable (n=231) young people with OCD assessed over 9 years at a national and specialist paediatric OCD clinic were included in this study. At follow-up, 126 (57%) young people and parents completed the ED section of the Developmental and Well-being Assessment. Predictors for ED were investigated using logistic regression. In total, 16 participants (12.7%) had a diagnosis of ED at follow-up. Having an ED was associated with female gender and persistent OCD at follow-up. There was a trend for family history of ED being predictive of ED diagnosis. Five (30%) of those who developed an ED at follow-up had ED symptoms or food-related obsessions/compulsions at baseline. A difference in predictors for an ED versus other anxiety disorders at follow-up was identified. This study provides initial evidence that baseline clinical predictors such as female gender and family history of ED might be specific to the later development of ED in the context of childhood OCD. Clinicians should be alert to ED subthreshold symptoms in young girls presenting with OCD. Future longitudinal studies are needed to clarify the relationship between childhood OCD and later ED

Feasibility, acceptability and preliminary effectiveness of a mental health drop-in centre for the siblings of young people attending a paediatric hospital

Siblings of children with long-term conditions (LTCs) can have significantly elevated mental health needs, but these are often overlooked. A pragmatic single-arm feasibility pilot assessed feasibility, acceptability and preliminary effectiveness of a drop-in centre in a paediatric hospital addressing mental health needs of patients with LTCs, their carers and siblings. The drop-in centre accepted self-referral and supplemented existing provision offering a suite of interventions, including signposting, diagnostic assessments and/or guided self-help. This paper reports on feasibility, acceptability and preliminary outcomes of this centre for siblings. Eighteen siblings aged 2-17 used the centre. Sixteen of their parents completed the Strengths and Difficulties Questionnaires at baseline and 6 months post-baseline, and ten completed parent-reported PedsQL across two time points. Preliminary effectiveness results demonstrated a decrease in mental health symptoms with large effect size (score reduction of 3.44, 95% CI [1.25, 5.63], d = 0.84) and small effect on quality of life, with scores increasing from a median of 69.91, 95% CI [53.57, 91.67], to a median of 80.44, 95% CI [67.39, 89.13], r = 0.11 for these siblings. 88% of parents were satisfied with this provision for their sibling child. This study highlights the feasibility and value of assessing siblings for emotional and behavioural difficulties and providing them with an accessible, effective and acceptable intervention