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We explore the potential of mindfulness-based cognitive therapy, a skills-based intervention that provides participants with sustainable tools for adaptive responses to stress and negative mood, for the large group of young people with depression or anxiety who only partially or briefly respond to currently available first-line interventions.
Declaration of interest
T.B. is the co-author of a book on mindfulness-based cognitive therapy (MBCT) and has received fees and honoraria for teaching MBCT workshops. W.K. is Director of the University of Oxford Mindfulness Centre. He donates all speaker fees to the not-for-profit Oxford Mindfulness Foundation. J.F. has been paid to deliver mindfulness-based intervention (MBI) programmes in the workplace and has delivered MBIs to elite performers at his own expense.
Optimal transition from child to adult services involves continuity, joint care, planning meetings and information transfer; commissioners and service providers therefore need data on how many people require that service. Although attention-deficit hyperactivity disorder (ADHD) frequently persists into adulthood, evidence is limited on these transitions.
To estimate the national incidence of young people taking medication for ADHD that require and complete transition, and to describe the proportion that experienced optimal transition.
Surveillance over 12 months using the British Paediatric Surveillance Unit and Child and Adolescent Psychiatry Surveillance System, including baseline notification and follow-up questionnaires.
Questionnaire response was 79% at baseline and 82% at follow-up. For those aged 17–19, incident rate (range adjusted for non-response) of transition need was 202–511 per 100 000 people aged 17–19 per year, with successful transition of 38–96 per 100 000 people aged 17–19 per year. Eligible young people with ADHD were mostly male (77%) with a comorbid condition (62%). Half were referred to specialist adult ADHD and 25% to general adult mental health services; 64% had referral accepted but only 22% attended a first appointment. Only 6% met optimal transition criteria.
As inclusion criteria required participants to be on medication, these estimates represent the lower limit of the transition need. Two critical points were apparent: referral acceptance and first appointment attendance. The low rate of successful transition and limited guideline adherence indicates significant need for commissioners and service providers to improve service transition experiences.
Perspectives of young people with eating disorders and their parents on helpful aspects of care should be incorporated into evidence-based practice and service design, but data are limited.
To explore patient and parent perspectives on positive and negative aspects of care for young people with eating disorders.
Six online focus groups with 19 young people aged 16–25 years with existing or past eating disorders and 11 parents.
Thematic analysis identified three key themes: the need to (a) shift from a weight-focused to a more holistic, individualised and consistent care approach, with a better balance in targeting psychological and physical problems from an early stage; (b) improve professionals' knowledge and attitude towards patients and their families at all levels of care from primary to ‘truly specialist’; (c) enhance peer and family support.
Young people and parents identified an array of limitations in approaches to care for young people with eating disorders and raised the need for change, particularly a move away from a primarily weight-focused treatment and a stronger emphasis on psychological needs and individualised care.
There is limited research that explores the association between exclusion from school and mental health, but it seems intuitively plausible that the recognition of mental difficulties by key teachers and parents would influence the likelihood of exclusion from school.
A secondary analysis of the British Child and Adolescent Mental Health survey 2004, (n = 7997) and the 2007 follow-up (n = 5326) was conducted. Recognition of difficulty was assessed via a derived variable that combined the first item of the Impact supplement of the Strengths and Difficulties Questionnaire which asked parents and teachers if they thought that the child has difficulties with emotions, behaviour and concentration, and the presence/absence of psychiatric disorder measured by the Development and Well-being Assessment.
Adjusted logistic regression models demonstrated that children with recognised difficulties were more likely to be excluded [adjusted odds ratio (OR) 5.78, confidence interval 3.45–9.64, p < 0.001], but children with unrecognised difficulties [adjusted OR 3.58 (1.46–8.81) p < 0.005] or recognised subclinical difficulties [adjusted OR 3.42 (2.04–5.73) p < 0.001] were also more likely to be excluded than children with no difficulties. Children with conduct disorder and attention deficit hyperactivity disorder were most likely to be excluded compared with other types of disorder.
Exclusion from school may result from a failure to provide timely and effective support rather than a failure to recognise psychopathology.
Although school-based programmes for the identification of children and young people (CYP) with mental health difficulties (MHD) have the potential to improve short- and long-term outcomes across a range of mental disorders, the evidence-base on the effectiveness of these programmes is underdeveloped. In this systematic review, we sought to identify and synthesise evidence on the effectiveness and cost-effectiveness of school-based methods to identify students experiencing MHD, as measured by accurate identification, referral rates, and service uptake.
Electronic bibliographic databases: MEDLINE, Embase, PsycINFO, ERIC, British Education Index and ASSIA were searched. Comparative studies were included if they assessed the effectiveness or cost-effectiveness of strategies to identify students in formal education aged 3–18 years with MHD, presenting symptoms of mental ill health, or exposed to psychosocial risks that increase the likelihood of developing a MHD.
We identified 27 studies describing 44 unique identification programmes. Only one study was a randomised controlled trial. Most studies evaluated the utility of universal screening programmes; where comparison of identification rates was made, the comparator test varied across studies. The heterogeneity of studies, the absence of randomised studies and poor outcome reporting make for a weak evidence-base that only generate tentative conclusions about the effectiveness of school-based identification programmes.
Well-designed pragmatic trials that include the evaluation of cost-effectiveness and detailed process evaluations are necessary to establish the accuracy of different identification models, as well as their effectiveness in connecting students to appropriate support in real-world settings.
There is a growing concern about the mental health of children and young people (CYP) in the UK, with increasing demand for counselling services, admissions for self-harm and referrals to mental health services. We investigated whether there have been similar recent trends in selected mental health outcomes among CYP in national health surveys from England, Scotland and Wales.
Data were analysed from 140 830 participants (4–24 years, stratified into 4–12, 13–15, 16–24 years) in 36 national surveys in England, Scotland and Wales, 1995–2014. Regression models were used to examine time trends in seven parent/self-reported variables: general health, any long-standing health condition, long-standing mental health condition; Warwick–Edinburgh Mental Wellbeing Score (WEMWBS), above-threshold Strengths and Difficulties Questionnaire Total (SDQT) score, SDQ Emotion (SDQE) score, General Health Questionnaire (GHQ) score.
Across all participants aged 4–24, long-standing mental health conditions increased in England (0.8–4.8% over 19 years), Scotland (2.3–6.0%, 11 years) and Wales (2.6–4.1%, 7 years) (all p < 0.001). Among young children (4–12 years), the proportion reporting high SDQT and SDQE scores decreased significantly among both boys and girls in England [SDQE: odds ratio (OR) 0.97 (0.96–0.98), p < 0.001] and girls in Scotland [SDQE: OR 0.96 (0.93–0.99), p = 0.005]. The proportion with high SDQE scores (13–15 years) decreased in England [OR 0.98 (0.96–0.99), p = 0.006] but increased in Wales [OR 1.07 (1.03–1.10), p < 0.001]. The proportion with high GHQ scores decreased among English women (16–24 years) [OR 0.98 (0.98–0.99), p = 0.002].
Despite a striking increase in the reported prevalence of long-standing mental health conditions among UK CYP, there was relatively little change in questionnaire scores reflecting psychological distress and emotional well-being.
We evaluated the effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management (TCM) programme as a universal intervention, given schools’ important influence on child mental health.
A two-arm, pragmatic, parallel group, superiority, cluster randomised controlled trial recruited three cohorts of schools (clusters) between 2012 and 2014, randomising them to TCM (intervention) or Teaching As Usual (TAU-control). TCM was delivered to teachers in six whole-day sessions, spread over 6 months. Schools and teachers were not masked to allocation. The primary outcome was teacher-reported Strengths and Difficulties Questionnaire (SDQ) Total Difficulties score. Random effects linear regression and marginal logistic regression models using Generalised Estimating Equations were used to analyse the outcomes. Trial registration: ISRCTN84130388.
Eighty schools (2075 children) were enrolled; 40 (1037 children) to TCM and 40 (1038 children) to TAU. Outcome data were collected at 9, 18, and 30-months for 96, 89, and 85% of children, respectively. The intervention reduced the SDQ-Total Difficulties score at 9 months (mean (s.d.):5.5 (5.4) in TCM v. 6.2 (6.2) in TAU; adjusted mean difference = −1.0; 95% CI−1.9 to −0.1; p = 0.03) but this did not persist at 18 or 30 months. Cost-effectiveness analysis suggested that TCM may be cost-effective compared with TAU at 30-months, but this result was associated with uncertainty so no firm conclusions can be drawn. A priori subgroup analyses suggested TCM is more effective for children with poor mental health.
TCM provided a small, short-term improvement to children's mental health particularly for children who are already struggling.
The increased proportion of UK children diagnosed with autism spectrum disorder (ASD) has been attributed to improved identification, rather than true increase in incidence.
To explore whether the proportion of children with diagnosis of ASD and/or the proportion with associated behavioural traits had increased over a 10-year period.
A cross-cohort comparison using regression to compare prevalence of diagnosis and behavioural traits over time. Participants were children aged 7 years assessed in 1998/1999 (n=8139) and 2007/2008 (n=13831).
During 1998/1999, 1.09% (95% CI 0.86–1.37) of children were reported as having ASD diagnosis compared with 1.68% (95% CI 1.42–2.00) in 2007/2008: risk ratio (RR)=1.55 (95% CI 1.17–2.06), P=0.003. The proportion of children in the population with behavioural traits associated with ASD was also larger in the later cohort: RR=1.61 (95% CI 1.35–1.92), P<0.001. Increased odds of diagnosis at the later time point was partially accounted for by adjusting for the increased proportion of children with ASD-type traits.
Increased ASD diagnosis may partially reflect increase in rates of behaviour associated with ASD and/or greater parent/teacher recognition of associated behaviours.
The Transitions of Care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK) study was a multistage, multicentre study of adolescents' transitions between child and adult mental health services undertaken in England. We conducted a secondary analysis of the TRACK study data to investigate healthcare provision for young people (n = 64) with ongoing mental health needs, who were not transferred from child and adolescent mental health services (CAMHS) to adult mental health services mental health services (AMHS).
The most common outcomes were discharge to a general practitioner (GP; n =29) and ongoing care with CAMHS (n = 13), with little indication of use of third-sector organisations. Most of these young people had emotional/neurotic disorders (n = 31, 48.4%) and neurodevelopmental disorders (n = 15, 23.4%).
GPs and CAMHS are left with the responsibility for the continuing care of young people for whom no adult mental health service could be identified. GPs may not be able to offer the skilled ongoing care that these young people need. Equally, the inability to move them decreases the capacity of CAMHS to respond to new referrals and may leave some young people with only minimal support.
Presentation at an accident and emergency (A&E) department is a key
opportunity to engage with a young person who self-harms. The needs of
this vulnerable group and their fears about presenting to healthcare
services, including A&E, are poorly understood.
To examine young people's perceptions of A&E treatment following
self-harm and their views on what constitutes a positive clinical
Secondary analysis of qualitative data from an experimental online
discussion forum. Threads selected for secondary analysis represent the
views of 31 young people aged 16–25 with experience of self-harm.
Participants reported avoiding A&E whenever possible, based on their
own and others' previous poor experiences. When forced to seek emergency
care, they did so with feelings of shame and unworthiness. These feelings
were reinforced when they received what they perceived as punitive
treatment from A&E staff, perpetuating a cycle of shame, avoidance
and further self-harm. Positive encounters were those in which they
received ‘treatment as usual’, i.e. non-discriminatory care, delivered
with kindness, which had the potential to challenge negative
self-evaluation and break the cycle.
The clinical needs of young people who self-harm continue to demand
urgent attention. Further hypothesis testing and trials of different
models of care delivery for this vulnerable group are warranted.
Impaired parenting may lie on the causal pathway between paternal depression
and children's outcomes. We use the first four surveys of the Millennium
Cohort Study to investigate the association between paternal depressive
symptoms and fathers' parenting (negative, positive and involvement).
Findings suggest that postnatal paternal depressive symptoms are associated
with fathers' negative parenting. This has implications for the design of
intervention programmes for parents with depression and young children.
Teacher-pupil relationships have been found to mediate behavioural,
social and psychological outcomes for children at different ages
according to teacher and child report but most studies have been
To explore later psychiatric disorder among children with problematic
Secondary analysis of a population-based cross-sectional survey of
children aged 5-16 with a 3-year follow-up.
Of the 3799 primary-school pupils assessed, 2.5% of parents reported
problematic teacher-pupil relationships; for secondary-school pupils
(n=3817) this rose to 6.6%. Among secondary-school
pupils, even when children with psychiatric disorder at baseline were
excluded and we adjusted for baseline psychopathology score, problematic
teacher-pupil relationships were statistically significantly related to
higher levels of psychiatric disorder at 3-year follow-up (odds ratio
(OR) = 1.93, 95% CI 1.07-3.51 for any psychiatric disorder, OR=3.00, 95%
CI 1.37-6.58 for conduct disorder). Results for primary-school pupils
were similar but non-significant at this level of adjustment.
This study underlines the need to support teachers and schools to develop
positive relationships with their pupils.
Transfer of care from one healthcare provider to another is often understood as a suboptimal version of the process of transition.
To separate and evaluate concepts of transfer and transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS).
In a retrospective case-note survey of young people reaching the upper age boundary at six English CAMHS, optimal transition was evaluated using four criteria: continuity of care, parallel care, a transition planning meeting and information transfer.
Of 154 cases, 76 transferred to AMHS. Failure to transfer resulted mainly from non-referral by CAMHS (n = 12) and refusal by service users (n = 12) rather than refusal by AMHS (n = 7). Four cases met all criteria for optimal transition, 13 met none; continuity of care in(n = 63) was met most often.
Transfer was common but good transition rare. Reasons for failure to transfer differ from barriers to transition. Transfer should be investigated alongside transition in research and service development.
Co-operative learning is widely accepted as a pedagogical practice that can be employed in classrooms to stimulate students' interest in learning through collaborative interaction with their peers. When children work co-operatively, they learn to listen to what others have to say, give and receive help and discuss different ideas, and in so doing, they learn to develop mutual understandings of the topic at hand. However, whilst co-operative learning provides opportunities for students to dialogue, concern has been expressed about the quality of the discourse that often emerges if students are left to engage in discussions without training in how to interact with others. This chapter discusses the teacher's role in promoting effective small-group discourse. It presents two studies of teachers' discourse during co-operative and small-group learning. These studies provide unique insights into how teachers can use language to promote collaborative dialogue in the classroom during co-operative learning.
To explore what young people who self-harm think about online self-harm discussion forums. SharpTalk was set up to facilitate shared learning between health professionals and young people who self-harm. We extracted themes and illustrative statements from the online discussion and asked participants to rate statements.
Of 77 young people who participated in the forum, 47 completed the questionnaire. They said they learned more about mental health issues from online discussion forums than from information sites, found it easier to talk about self-harm to strangers than to family or friends, and preferred to talk online than face-to-face or on the telephone. They valued the anonymity the forums provided and reported feeling more able to disclose and less likely to be judged online than in ‘real life’.
Mental health professionals should be aware of the value of anonymous online discussion forums for some young people who self-harm, so that they can talk about them and assess their use with their patients.
Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS).
As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS.
We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced.
Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health.
For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.
Attention-deficit hyperactivity disorder (ADHD) is recognised as a
common, disabling condition. Little information is available regarding
the long-term outcomes for individuals with ADHD in the UK.
To examine the 5-year outcome for a UK cohort of children with diagnosed,
treated ADHD and identify whether maternal and social factors predict key
One hundred and twenty-six school-aged children (mean age 9.4 years, s.d.
= 1.7) diagnosed with ADHD were reassessed 5 years later during
adolescence (mean age 14.5 years, s.d. = 1.7) for ADHD, conduct disorder
and other antisocial behaviours.
Most adolescents (69.8%) continued to meet full criteria for ADHD, were
known to specialist services and exhibited high levels of antisocial
behaviour, criminal activity and substance use problems. Maternal
childhood conduct disorder predicted offspring ADHD continuity; maternal
childhood conduct disorder, lower child IQ and social class predicted
offspring conduct disorder symptoms.
The treatment and monitoring of ADHD need to be intensified as outcomes
are poor especially in offspring of mothers with childhood conduct