Miranda Wolpert

High integrity mental health services for children: focusing on the person, not the problem

M Wolpert and colleagues discuss how the principles of high integrity healthcare can improve mental health services for children and young people

New approaches to measurement and management for high integrity health systems

We need better tools to achieve the next generation reforms essential for delivering care that matters most to patients, say Albert Mulley and colleagues

Child- and school-level predictors of children’s bullying behavior: A multilevel analysis in 648 primary schools

A great deal of bullying behavior takes place at school, however, existing literature has predominantly focused on individual characteristics of children associated with bullying with less attention on school-level factors. The current study, comprising 23,215 children (51% boys) recruited from Year 4 or Year 5 (M = 9.06 years, SD = .56 years) from 648 primary schools in England, aimed to examine the independent and combined influence of child- and school-level predictors on bullying behavior in primary school. Children provided information on bullying behavior and school climate. Demographic characteristics of children were obtained from the National Pupil Database, and demographic characteristics of schools were drawn from EduBase. Multilevel logistic regression models showed that individual child gender, ethnicity, deprivation and special educational needs status all predicted bullying behavior. Of the school-level predictors, only overall school deprivation and school climate were predictive of bullying behavior once child-level predictors were taken into account. There was a significant interaction between child- and school-level deprivation; high-deprivation schools were a risk factor for bullying only for children that came from nondeprived backgrounds, whereas deprived children reported engaging in bullying behavior irrespective of school-level deprivation. Given the independent and combined role of child- and school-level factors for bullying behavior, the current study has implications for targeted school interventions to tackle bullying behavior, both in terms of identifying high-risk children and identifying high-risk schools.

Goal formulation and tracking in child mental health settings: when is it more likely and is it associated with satisfaction with care?

Goal formulation and tracking may support preference-based care. Little is known about the likelihood of goal formulation and tracking and associations with care satisfaction. Logistic and Poisson stepwise regressions were performed on clinical data for Nxa0=xa03757 children from 32 services in the UK (Magexa0=xa011; SDagexa0=xa03.75; most common clinician-reported presenting problem was emotional problemsxa0=xa055.6%). Regarding the likelihood of goal formulation, it was more likely for pre-schoolers, those with learning difficulties or those with both hyperactivity disorder and conduct disorder. Regarding the association between goal formulation and tracking and satisfaction with care, parents of children with goals information were more likely to report complete satisfaction by scoring at the maximum of the scale. Findings of the present research suggest that goal formulation and tracking may be an important part of patient satisfaction with care. Clinicians should be encouraged to consider goal formulation and tracking when it is clinically meaningful as a means of promoting collaborative practice.

What approaches for promoting shared decision‐making are used in child mental health? A scoping review

OBJECTIVEnWhilst the benefits of shared decision-making (SDM) have been promoted across different health settings, its implementation is complex, particularly for children and young people with mental health difficulties. The aim of this scoping review was to identify and describe SDM approaches (tools, techniques, and technologies) used in child and youth mental health.nnnMETHODnElectronic databases and grey literature were searched. Papers were included if they satisfied these criteria: English language; described an SDM approach (tool, technique, or technology); included sufficient detail on the SDM approach for quality assessment; did not use only a questionnaire to provide feedback on SDM or related concepts (e.g., therapeutic alliance) without another SDM approach; child or adolescent population (up to 18xa0years); carers of children or adolescents; and mental health setting. Screening and data extraction were performed by two co-authors, and each included record was quality assessed against a set of essential ingredients of SDM identified by previous studies.nnnRESULTSnOf the 8,153 initial results, 22 were eligible for final inclusion. These could be grouped into six approaches: therapeutic techniques, psychoeducational information, decision aids, action planning or goal setting, discussion prompts, and mobilizing patients to engage. The quality of approaches identified ranged from one to seven of the nine essential elements of SDM.nnnCONCLUSIONnEvidence suggests that a range of approaches are being developed to support SDM in child and youth mental health. Rigorous research evaluating the effectiveness of these approaches is urgently needed, particularly from the perspective of children and young people.

Factors to consider in the introduction of huddles on clinical wards: perceptions of staff on the SAFE programme

ObjectivesnTo explore paediatric hospital staff members perceptions of the emerging benefits and challenges of the huddle, a new safety improvement initiative, as well as the barriers and facilitators to its implementation.nnnDesignnA qualitative study was conducted using semi-structured interviews to explore staff perspectives and experiences.nnnSettingnSituation Awareness For Everyone (SAFE), a safety improvement programme, was implemented on a sample of National Health Service (NHS) paediatric wards from September 2014 to June 2016. Previously untested in England, the huddle was a central component of the programme.nnnParticipantsnSemi-structured interviews were conducted with 76 staff members on four wards ~4 months after the start of the programme.nnnResultsnA thematic analysis showed that staff perceived the huddle as helping to increase their awareness of important issues, improve communication, facilitate teamwork, and encourage a culture of increased efficiency, anticipation and planning on the ward. Challenges of the huddle included added pressure on staff time and workload, and the potential for junior nurses to be excluded from involvement, thus perhaps inadvertently reinforcing medical hierarchies. Staff also identified several barriers and facilitators to the huddle process, including the importance of senior nursing and medical staff leadership and managing staff time and capacity issues.nnnConclusionsnThe findings point towards the potential efficacy of the huddle as a way of improving hospital staff members working environments and clinical practice, with important implications for other sites seeking to implement such safety improvement initiatives.

Using patient-reported outcome measures to improve service effectiveness for supervisors: a mixed-methods evaluation of supervisors' attitudes and self-efficacy after training to use outcome measures in child mental health

BACKGROUNDnPatient-reported outcome measures (PROMs) are recommended by healthcare systems internationally, but there are a number of barriers to implementation. The aim of this research was to examine the impact of training supervisors in using PROMs on clinical practice, given the importance of leadership when changing behaviour.nnnMETHODnData included pre-post questionnaires from 42 supervisors, interviews after training with six supervisees and nonparticipant observations of nine video-recorded supervision sessions.nnnRESULTSnAfter training, supervisors had more positive attitudes to administering PROMs and using feedback from PROMs and had higher levels of self-efficacy about using PROMs in supervision.nnnCONCLUSIONSnFindings are in line with the growing body of evidence that training child mental health staff to use PROMs may be associated with changes in attitudes, self-efficacy and use of PROMs.

Using flawed, uncertain, proximate and sparse (FUPS) data in the context of complexity: learning from the case of child mental health

The use of routinely collected data that are flawed and limited to inform service development in healthcare systems needs to be considered, both theoretically and practically, given the reality in many areas of healthcare that only poor-quality data are available for use in complex adaptive systems. Data may be compromised in a range of ways. They may be flawed, due to missing or erroneously recorded entries; uncertain, due to differences in how data items are rated or conceptualised; proximate, in that data items are a proxy for key issues of concern; and sparse, in that a low volume of cases within key subgroups may limit the possibility of statistical inference. The term ‘FUPS’ is proposed to describe these flawed, uncertain, proximate and sparse datasets. Many of the systems that seek to use FUPS data may be characterised as dynamic and complex, involving a wide range of agents whose actions impact on each other in reverberating ways, leading to feedback and adaptation. The literature on the use of routinely collected data in healthcare is often implicitly premised on the availability of high-quality data to be used in complicated but not necessarily complex systems. This paper presents an example of the use of a FUPS dataset in the complex system of child mental healthcare. The dataset comprised routinely collected data from services that were part of a national service transformation initiative in child mental health from 2011 to 2015. The paper explores the use of this FUPS dataset to support meaningful dialogue between key stakeholders, including service providers, funders and users, in relation to outcomes of services. There is a particular focus on the potential for service improvement and learning. The issues raised and principles for practice suggested have relevance for other health communities that similarly face the dilemma of how to address the gap between the ideal of comprehensive clear data used in complicated, but not complex, contexts, and the reality of FUPS data in the context of complexity.

Developing a case mix classification for child and adolescent mental health services: the influence of presenting problems, complexity factors and service providers on number of appointments*

Abstract Background: Case-mix classification is a focus of international attention in considering how best to manage and fund services, by providing a basis for fairer comparison of resource utilization. Yet there is little evidence of the best ways to establish case mix for child and adolescent mental health services (CAMHS). Aim: To develop a case mix classification for CAMHS that is clinically meaningful and predictive of number of appointments attended and to investigate the influence of presenting problems, context and complexity factors and provider variation. Method: We analysed 4573 completed episodes of outpatient care from 11 English CAMHS. Cluster analysis, regression trees and a conceptual classification based on clinical best practice guidelines were compared regarding their ability to predict number of appointments, using mixed effects negative binomial regression. Results: The conceptual classification is clinically meaningful and did as well as data-driven classifications in accounting for number of appointments. There was little evidence for effects of complexity or context factors, with the possible exception of school attendance problems. Substantial variation in resource provision between providers was not explained well by case mix. Conclusion: The conceptually-derived classification merits further testing and development in the context of collaborative decision making.

Changes in severity of psychosocial difficulties in adolescents accessing specialist mental healthcare in England (2009–2014)

In England, clinicians and professional organisations report that higher numbers of adolescents with more severe psychosocial difficulties are accessing specialist services. A lack of national data on patterns of access to specialist services means there is limited information to inform policy. We examined whether severity of psychosocial difficulties in adolescents accessing mental healthcare has changed over time. Adolescents seen in specialist child mental healthcare in 2009 vs. 2014 were matched on demographics and problem types using propensity score matching; final sample Nxa0=xa02776 adolescents. We found: 1) stability over time in overall severity of difficulties, 2) an increase in severity of young womens emotional problems, and 3) a decrease in adolescents conduct problems. The findings suggest the intriguing possibility that the criteria for accessing mental healthcare are not universally rising, but rather the patterns in access to specialist services may mirror epidemiological changes in severity of psychosocial difficulties in the population.