Perspectives on clinical guidelines for severe behavioural problems in children across Europe: a qualitative study with mental health clinicians

Multilevel barriers to guideline implementation: a nationwide multi-professional cross-sectional study within child and adolescent psychiatry

BACKGROUND

Despite efforts to promote guideline use, guideline adoption is often suboptimal due to failure to identify and address relevant barriers. Barriers vary not only between guidelines but also between settings, intended users, and targeted patients. Multi-professional guidelines are often used in child and adolescent mental health services (CAMHS), making the implementation process more difficult. Despite this, there is a lack of knowledge about which barriers to consider or if barriers vary by profession. The aim of this study was to address these gaps by examining barriers to adopting a multi-professional depression guideline in the context of a nationwide implementation study.

METHODS

440 CAMHS clinicians across Sweden (52%) completed the Barriers and Facilitators Assessment Instrument (BFAI) ahead of an implementation endeavour. BFAI is a widely used and validated measure of guideline implementation on four scales: Innovation, Provider, Context, and Patient. Barriers were calculated at scale and at item levels. ANOVA and chi-square tests were used to analyse differences by profession and effect sizes were calculated.

RESULTS

Overall, clinicians were optimistic about guideline uptake, particularly about guideline characteristics and their own adoption ability. Barriers were related to the patient and the context domains, as well as to individual clinician knowledge and training. Perceptions differed across professions; psychiatrists were most, and counsellors were least positive about guideline embeddedness.

CONCLUSION

This large-scale quantitative study suggests that CAMHS clinicians have an overall favourable attitude towards guideline adoption but highlights the need for adaptations to certain patient groups. Strategies to improve guideline use should primarily address these patient issues while securing proper support to the implementation. Implementation efforts, particularly those targeting staff knowledge, training, and involvement, may benefit from being tailored to different professional needs. These findings may inform implementation projects in CAMHS and future research.

Clinicians' Adherence to Guidelines When Initiating Methylphenidate Treatment

Aims: Between 2008 and 2012, the number of children and adolescents in the Netherlands who received methylphenidate prescriptions increased by 35.6%. We determined guideline adherence regarding the assessment of attention-deficit/hyperactivity disorder (ADHD) and rates of off-label use in those 2 years. We also compared adherence to guidelines between mental health and pediatrics settings. Methods: We conducted a medical file audit of 506 children or adolescents who had received a first methylphenidate prescription in 2008 (n = 208) or 2012 (n = 298) across mental health (n = 333) and pediatrics outpatient clinics (n = 173) in the Netherlands and assessed adherence to seven guideline recommendations. Results: We did not find significant differences between 2008 and 2012 regarding the mean adherence to the seven recommendations (43% vs. 45%) or the percentage of off-label use (35% vs. 30%). Best adherence rates (over the years 2008 and 2012 combined) concerned the assessment of comorbidities (89%) and the involvement of teachers in the diagnostic process (75%). Least frequently adhered to were assessing ADHD severity (1%), the use of a (semi-)structured parent interview (16%), and providing psycho-education to parents (42%) or teachers (1%). Mental health settings showed better adherence than pediatrics settings (over the years 2008 and 2012 combined) concerning the use of (semi-)structured parent interviews (22% vs. 3.1%), having a separate diagnostic session directed at the child (81% vs. 63%), assessment of comorbidities (95% vs. 76%), and providing psycho-education to parents (51% vs. 24%). Conclusions: There was neither a decrease in adherence to guidelines nor an increase in off-label use between 2008 and 2012. However, there is ample room for improvement regarding guideline adherence.

Behavioural difficulties in early childhood and risk of adolescent injury

OBJECTIVE

To evaluate long-term associations between early childhood hyperactivity and conduct problems (CP), measured using Strengths and Difficulties Questionnaire (SDQ) and risk of injury in early adolescence.

DESIGN

Data linkage between a longitudinal birth cohort and routinely collected electronic health records.

SETTING

Consenting Millennium Cohort Study (MCS) participants residing in Wales and Scotland.

PATIENTS

3119 children who participated in the age 5 MCS interview.

MAIN OUTCOME MEASURES

Children with parent-reported SDQ scores were linked with hospital admission and Accident & Emergency (A&E) department records for injuries between ages 9 and 14 years. Negative binomial regression models adjusting for number of people in the household, lone parent, residential area, household poverty, maternal age and academic qualification, child sex, physical activity level and country of interview were fitted in the models.

RESULTS

46% of children attended A&E or were admitted to hospital for injury, and 11% had high/abnormal scores for hyperactivity and CP. High/abnormal or borderline hyperactivity were not significantly associated with risk of injury, incidence rate ratio (IRR) with 95% CI of the high/abnormal and borderline were 0.92 (95% CI 0.74 to 1.14) and 1.16 (95% CI 0.88 to 1.52), respectively. Children with borderline CP had higher injury rates compared with those without CP (IRR 1.31, 95% CI 1.09 to 1.57).

CONCLUSIONS

Children with high/abnormal hyperactivity or CP scores were not at increased risk of injury; however, those with borderline CP had higher injury rates. Further research is needed to understand if those with difficulties receive treatment and support, which may reduce the likelihood of injuries.