Sarah Pass

Implementation of routine outcome measurement in child and adolescent mental health services in the United Kingdom: a critical perspective

The aim of this commentary is to provide an overview of clinical outcome measures that are currently recommended for use in UK Child and Adolescent Mental Health Services (CAMHS), focusing on measures that are applicable across a wide range of conditions with established validity and reliability, or innovative in their design. We also provide an overview of the barriers and drivers to the use of Routine Outcome Measurement (ROM) in clinical practice.

A qualitative process evaluation of electronic session-by-session outcome measurement in child and adolescent mental health services

BackgroundRegular monitoring of patient progress is important to assess the clinical effectiveness of an intervention. Recently, initiatives within UK child and adolescent mental health services (CAMHS) have advocated the use of session-by-session monitoring to continually evaluate the patient’s outcome throughout the course of the intervention. However, the feasibility and acceptability of such regular monitoring is unknown.MethodSemi-structured qualitative interviews were conducted with clinicians (n = 10), administrative staff (n = 8) and families (n = 15) who participated in a feasibility study of an electronic session-by-session outcome monitoring tool, (SxS), which is based on the Strengths and Difficulties Questionnaire (SDQ). This study took place in three CAMHS clinics in Nottinghamshire. The interview transcripts were thematically analysed.ResultsWe found clinicians accepted the need to complete outcome measures, particularly valuing those completed by the patient. However, there were some difficulties with engaging clinicians in this practice and in the training offered. Generally, patients were supportive of completing SxS in the waiting room prior to the clinic session and assistance with the process from administrative staff was seen to be a key factor. Clinicians and families found the feedback reports created from SxS to be helpful for tracking progress, facilitating communication and engagement, and as a point of reflection. The use of technology was considered positively, although some technological difficulties hindered the completion of SxS. Clinicians and families appreciated the brevity of SxS, but some were concerned that a short questionnaire could not adequately encapsulate the complexity of the patient’s issues.ConclusionsThe findings show the need for appropriate infrastructure, mandatory training, and support to enable an effective system of session-by-session monitoring. Our findings indicate that clinicians, administrative staff and young people and their parents/carers would support regular monitoring if the system is easy to implement, with a standard ‘clinic-wide’ adoption of the procedure, and the resulting data are clinically useful.

Primary school teachers’ attitudes about children with attention deficit/hyperactivity disorder and the role of pharmacological treatment:

Background: Clinical experience and research suggest that teachers’ attitudes about attention deficit/hyperactivity disorder (ADHD) are an important factor influencing access to specialist assessment and treatment, including medication. Methods: We performed a thematic analysis of comments written by primary school teachers who participated in a case-vignette study investigating the ability of teachers to recognise ADHD. Teachers read one of four types of vignette describing the behaviour of a nine-year-old child who met diagnostic criteria for ADHD (either a boy or a girl with inattentive or combined subtype of ADHD). They answered questions (identical for all types of vignette) about their views regarding the problems and their management. Teachers were invited to add their own comments. Results: Altogether 496 teachers from 110 schools completed the questionnaire: 250 (50%) teachers from 94 schools wrote at least one comment, adding up to 341 comments. Regarding their views on the need to refer the child to specialist services, 32 teachers made comments that reflected caution. The most frequent comments were that it was too early to say whether a referral was necessary, the problems were not severe enough or the main support would come from school. Teachers also reported a lack of knowledge about specialist services or criticised them. When asked whether medication might be beneficial for the child, 125 teachers expressed hesitant or negative views: that it was premature to express an opinion about medication or too soon to give medication to the child; that medication was not necessary or should not be used at all; or that the problems were not severe enough or were emotional in nature. Only five teachers reported having a positive experience of the effect of medication. Conclusion: Teachers’ comments suggested a strong preference in using within-school strategies for the management of children with ADHD. Teachers were reluctant to endorse medication for DHD and expressed negative views about its use. Health services should support teachers’ management of ADHD-related behaviours in school and provide information to increase teachers’ ability to identify the need for a referral to specialist health services.

Protocol Evaluating the effectiveness of a school-based group programme for parents of children at risk of ADHD: the ‘PArents, Teachers and CHildren WORKing Together (PATCHWORK)’ cluster RCT protocol

Introduction Early intervention for childhood behavioural problems may help improve health and educational outcomes in affected children and reduce the likelihood of developing additional difficulties. The National Institute for Health and Clinical Excellence guidelines for attention deficit/hyperactivity disorder (ADHD), a common childhood behavioural disorder, recommend a stepped care approach for the identification and management of these problems. Parents of children with high levels of hyperactivity and inattention may benefit from intervention programmes involving behavioural management and educational approaches. Such interventions may be further enhanced by providing training and feedback to teachers about the strategies discussed with parents. In relation to children with high levels of hyperactivity, impulsiveness and inattention, we aim to test the feasibility and effectiveness of a parenting programme (with and without an accompanying teacher session) in primary schools. Methods and analysis This clustered (at the level of school) randomised controlled trial (RCT) focuses on children in their first four school years (ages 4–8 years) in the East Midlands area of England. Parents will complete a screening measure, the Strengths and Difficulties Questionnaire, to identify children with high levels of hyperactivity/inattention. Three approaches to reducing hyperactivity and attention problems will be compared: a group programme for parents (parent-only intervention); group programme for parents combined with feedback to teachers (combined intervention); and waiting list control (no intervention). Differences between arms on the short version of Conners’ Parent and Teacher Rating Scales Revised will be compared and also used to inform the sample size required for a future definitive cluster RCT. A preliminary cost-effectiveness analysis will also be conducted. Ethics and dissemination The outcomes of this study will inform policy makers about the feasibility, acceptability and effectiveness of delivering targeted behavioural interventions within a school setting. The study has received ethical approval from the University of Nottingham Medical School Ethics Committee. Trial registration ISRCTN87634685