Crispin Day

Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior

Evidence-based interventions are often unavailable in everyday clinical settings. This may partly reflect practitioners’ assumptions that research evidence does not reflect “real-world” conditions. To examine this further, we systematically assessed the clinical effectiveness of parent management training (PMT) for the treatment of child disruptive behavior across different real-world practice contexts. We identified 28 relevant randomized controlled trials from a systematic search of electronic bibliographic databases and conducted a meta-analysis of child outcomes across trials. Planned subgroup analyses involved comparisons between studies grouped according to individual real-world practice criteria and total real-world practice criteria scores, reflecting the extent to which PMT was delivered by non-specialist therapists, to a clinic-referred population, in a routine setting, and as part of a routine service. Meta-analysis revealed a significant overall advantage for PMT compared with waitlist control conditions. Subgroup analyses did not demonstrate significant differences in effect size estimates according to the total number of real-world practice criteria met by studies. Moreover, no consistent relationships were found between specific practice criteria and effect size estimates. In conclusion, PMT appears to be an effective treatment for children with disruptive behavior problems. There was no clear evidence that conducting PMT in real-world practice contexts is a deterrent to achieving effective child behavior outcomes, although relative advantage to “usual care” was not directly examined and the power of the analysis was limited as a result of significant heterogeneity. More research is needed to investigate whether this finding is generalizable to other psychological interventions. Suggestions are also made for developing more differentiated criteria to assist with evaluating the specific applicability of research evidence to different care providers.

Parental help-seeking in primary care for child and adolescent mental health concerns: qualitative study

BACKGROUND Child and adolescent mental health problems are common in primary care. However, few parents of children with mental health problems express concerns about these problems during consultations. AIMS To explore the factors influencing parental help-seeking for children with emotional or behavioural difficulties. METHOD Focus group discussions with 34 parents from non-specialist community settings who had concerns about their childs mental health. All groups were followed by validation groups or semi-structured interviews. RESULTS Most children had clinically significant mental health symptoms or associated impairment in function. Appointment systems were a key barrier, as many parents felt that short appointments did not allow sufficient time to address their childs difficulties. Continuity of care and trusting relationships with general practitioners (GPs) who validated their concerns were perceived to facilitate help-seeking. Parents valued GPs who showed an interest in their child and family situation. Barriers to seeking help included embarrassment, stigma of mental health problems, and concerns about being labelled or receiving a diagnosis. Some parents were concerned about being judged a poor parent and their child being removed from the family should they seek help. CONCLUSIONS Primary healthcare is a key resource for children and young people with emotional and behavioural difficulties and their families. Primary care services should be able to provide ready access to health professionals with an interest in children and families and appointments of sufficient length so that parents feel able to discuss their mental health concerns.

A systematic review of reviews of interventions to promote mental health and prevent mental health problems in children and young people

There is a growing policy imperative to promote positive mental health as well as prevent the development of mental health problems in children. This paper summarises the findings of published systematic reviews evaluating such interventions. A search was undertaken of ten electronic databases using a combination of medical subject headings (MeSH) and free text searches. Systematic reviews covering mental health promotion or mental illness prevention interventions aimed at infants, children or young people up to age 19 were included. Reviews of drug and alcohol prevention programmes and programmes to prevent childhood abuse and neglect were excluded because these have been the subject of recent good quality reviews of reviews. A total of 27 systematic reviews were included. These targeted a range of risk and protective factors, and a range of populations (including parents and children). While many lacked methodological rigour, overall the evidence is strongly suggestive of the effectiveness of a range of interventions in promoting positive mental well‐being, and reducing key risk factors for mental illness in children. Based on this evidence, arguments are advanced for the preferential provision of early preventive programmes.

Children's key concerns: piloting a qualitative approach to understanding their experience of mental health care.

This article reports the piloting of an approach to apply the principles of child involvement to service experience research. The approach aimed to systematically explore the service concerns of children who had received mental health care. Eleven children who had previously attended mental health services took part in focus groups to discuss their experience. Thematic content analysis of transcribed interviews revealed 13 themes that potentially could help to identify childrens key concerns and clarify the notion of child-centred care. The themes suggested the potential importance of childrens expectations about therapy, and their concerns relating to the process, content and outcome may be important to their experience of care. The possible implications for child-centred clinical practice and service provision are discussed.

Evaluation of a peer led parenting intervention for disruptive behaviour problems in children: community based randomised controlled trial

Objective To evaluate the effectiveness of a peer led parenting intervention delivered to socially disadvantaged families. Design Randomised controlled trial. Setting Schools and children’s centres in a socially deprived borough of inner London. Participants Parental caregivers seeking help with managing the problem behaviours of 116 index children, aged 2-11 years; 59 families were randomised to the intervention and 57 to a waitlist control condition. Intervention Empowering parents, empowering communities is an eight week (two hours each week), manualised programme delivered to groups of parents by trained peer facilitators from the local community. Main outcome measures Child problems (number and severity), parental stress, and parenting competencies were assessed before and after the intervention using standardised parent reported measures. Results Significantly greater improvements in positive parenting practices and child problems were observed in the intervention group compared with the waitlist group, with no difference in parental stress between the groups. An intention to treat analysis for the primary outcome measure, the intensity subscale of the Eyberg child behaviour inventory, showed an intervention effect size of 0.38 (95% confidence interval 0.01 to 0.75, P=0.01). The intervention group had high rates of treatment retention (91.5%) and user satisfaction. Conclusion The peer led parenting intervention significantly reduced child behaviour problems and improved parenting competencies. This is a promising method for providing effective and acceptable parenting support to families considered hard to reach by mainstream services. Trial registration Current Controlled Trials ISRCTN01962337.

Child and Family Outcomes of the European Early Promotion Project

This chapter concerns the outcomes for the families involved in the European Early Promotion Project and presents data collected when the children were between six and eight weeks old and when they were 24 months old. A total of 824 families were recruited from the five countries involved. At baseline, differences were found between country samples in the extent and type of need (Finnish families having the lowest risk factor rates and Serbia the highest, for example), but recruitment was generally successful in including families from the whole range of need, excluding those with the most severe physical and psychiatric problems. Although not randomised, Intervention families (receiving the EEPP service) were reasonably matched with Comparison families (receiving usual services) on most variables initially, except in Greece, where Intervention families were somewhat more at risk. At 24 months, in spite of low intensity of service provision and methodological difficulties likely to reduce effects, there was evidence, particularly in Greece, of differences in outcome favouring the Intervention group, who also showed significantly higher levels of satisfaction with the intervention they had received. It was concluded that the service merits further exploration to assist in understanding promotional and preventative processes.

The effectiveness and quality of routine child and adolescent mental health care outreach clinics

OBJECTIVES Little evidence has been available about the functioning and outcomes of child mental health services operating at the primary care interface. This study investigated the effectiveness and quality of one particular model of outreach clinic. DESIGN The study used a quasi-experimental design comparing outcomes of children attending the outreach clinics with a waiting list comparison. The intervention group (n=88) was assessed at referral, four months and twelve months later. The comparison group (n=99) completed measures at referral and four months. METHOD The main carers of participant children completed self-report measures of problem severity, impact, burden, parental stress and parent satisfaction. Clinicians provided clinical activity information. RESULTS There were significant reductions in childrens problem severity, distress and impairment, particularly for behavioural difficulties. In contrast, the results showed no effect upon the outcomes of childrens emotional problems or parental stress. High ratings of satisfaction were obtained for many aspects of care. CONCLUSIONS The children receiving care through this system of decentralised, outreach clinics derived clinical benefits that were maintained over time. The outreach clinics received strong consumer support suggesting the service offered a high level of acceptability to parents.

Community Child Mental-Health Services: A Framework for the Development of Parenting Initiatives

There is considerable variation in the structure, style and content of parenting initiatives in the UK. While there has been a rapid expansion of such programmes, there is no clear framework for systematic provision and no strong evidence base for their effectiveness. This discussion article briefly reviews the position of parenting initiatives in the UK. It then goes on to describe the development of a tiered child mental-health service and some of the recent initiatives undertaken by the North Southwark Community Child and Family Service. This primary child mental-health care service aims to increase the effectiveness and availability of child mental-health promotion, prevention, early and continuing intervention. It is proposed that this type of service framework can be used to ensure the development of coherent, targeted and collaborative parenting initiatives.

Child mental health practitioners’ knowledge and experiences of children’s educational needs and services

The improved joint working between child and adolescent mental health services (CAMHS) and schools is a policy priority. Although there have been a range of school-based initiatives and studies on teachers’ awareness of mental health issues, there has been limited evidence on the training needs of CAMHS practitioners. The aim of this study was to explore how much CAMHS staff know about educational issues and how confident they feel working collaboratively with education colleagues. Ninety-six staff from four specialist CAMHS completed a questionnaire with 40 items on perceptions of knowledge, practice and attitudes towards educational issues and services, and three case vignettes. Despite the fact that participants reported frequent contact with children with education-related needs and with education services, they also highlighted concerns about their level of training and skills in this regard. Perceptions of knowledge and attitudes significantly predicted response to case vignettes. Previous training and experience were associated with knowledge, but did not predict case vignettes scores. The results suggest that training of CAMHS staff should be integral to all services in helping improve their understanding of school and education systems, improve clinical skills in detecting education-related mental health problems, and develop strategies in increasing joint working.

What Can Education Teach Child Mental Health Services? Practitioners' Perceptions of Training and Joint Working.

The importance of joint working between educational and child mental health professionals is well documented but there are numerous challenges and only limited training models. While the evidence base and training programmes for educationalists regarding child mental health is growing, training mental health professionals about education is more limited. This study presents the views of 36 child mental health and education professionals from four service localities in England regarding their experiences of joint working and perceptions of training, including a preliminary evaluation of a training programme designed to bridge this gap. The findings indicate that participants perceived that a degree of knowledge in education matters is important, and reported that this could be acquired through the development of relationships with educational professionals, setting up link posts and joint training; they also described challenges related to building experience and to resource constraints. Participants were generally positive about the training package and reported that there was a clear training need in this area.