Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data

Economic Evaluation of anti-epileptic Medicines for Autistic Children with Epilepsy

We examine the cost-effectiveness of treating epilepsy with anti-epileptic medicines in autistic children, looking at impacts on healthcare providers (in England, Ireland, Italy and Spain) and children's families (in Ireland). We find carbamazepine to be the most cost-effective drug to try first in children with newly diagnosed focal seizures. For England and Spain, oxcarbazepine is the most cost-effective treatment when taken as additional treatment for those children whose response to monotherapy is suboptimal. In Ireland and Italy, gabapentin is the most cost-effective option. Our additional scenario analysis presents the aggregate cost to families with autistic children who are being treated for epilepsy: this cost is considerably higher than healthcare provider expenditure.

Effects of mental health status during adolescence on primary care costs in adulthood across three British cohorts

PURPOSE

This study examines the association between mental health problems in adolescence and general practice (GP) costs during adulthood up to age 50 in the UK.

METHODS

We conducted secondary analyses of three British birth cohorts (individuals born in single weeks in 1946, 1958 and 1970). Data for the three cohorts were analysed separately. All respondents who participated in the cohort studies were included. Adolescent mental health status was assessed in each cohort using the Rutter scale (or, for one cohort, a forerunner of that scale) completed in interviews with parents and teachers when cohort members were aged around 16. Presence and severity of conduct and emotional problems were modelled as independent variables in two-part regression models in which the dependent variable was costs of GP services from data collection sweeps up to mid-adulthood. All analyses were adjusted for covariates (cognitive ability, mother's education, housing tenure, father's social class and childhood physical disability).

RESULTS

Adolescent conduct and emotional problems, particularly when coexisting, were associated with relatively high GP costs in adulthood up to age 50. Associations were generally stronger in females than males.

CONCLUSION

Associations between adolescent mental health problems and annual GP cost were evident decades later, to age 50, suggesting that there could be significant future savings to healthcare budgets if rates of adolescent conduct and emotional problems could be reduced.

TRIAL REGISTRATION

Not applicable.

The Efficacy of Parent Management Training With or Without Involving the Child in the Treatment Among Children with Clinical Levels of Disruptive Behavior: A Meta-analysis

A systematic review and meta-analysis was conducted where we evaluated the effects of Parent Management Training (PMT), Parent-Child Interaction Therapy (PCIT) and PMT combined with child cognitive behavioral therapy (CBT) using data from 25 RCTs on children with clinical levels of disruptive behavior (age range 2-13 years). Results showed that PMT (g = 0.64 [95% CI 0.42, 0.86]) and PCIT (g = 1.22 [95% CI 0.75, 1.69]) were more effective than waiting-list (WL) in reducing parent-rated disruptive behavior, and PMT also in improving parental skills (g = 0.83 [95% CI 0.67, 0.98]) and child social skills (g = 0.49 [95% CI 0.30, 0.68]). PCIT versus WL had larger effects in reducing disruptive behavior than PMT versus WL. In the few studies found, the addition of child CBT to PMT did not yield larger effects than PMT or WL. These results support offering PMT to children with clinical levels of disruptive behavior and highlight the additional benefits of PCIT for younger ages.

Mental Health Conditions Among Children and Adolescents With Congenital Heart Disease: A Danish Population-Based Cohort Study

BACKGROUND

Despite the known mental health burden among children with congenital heart disease (CHD), the literature is constrained by a lack of comparison cohorts and population-based follow-up data. We examined the incidence of mental health conditions among children with CHD, relative to 3 comparison cohorts.

METHODS

This population-based cohort study identified all children with CHD (<18 years of age; n=16 473) in Denmark from 1996 to 2017, through linkage of individual-level data across national registries. This allowed for complete follow-up of the population. Comparison cohorts included children from the general population (n=162 204), siblings of children with CHD (n=20 079), and children with non-CHD major congenital anomalies (n=47 799). Mental health conditions were identified using inpatient and outpatient hospital discharge codes, prescription data, and data on use of community-based psychology, psychiatry, and psychotherapy services. We computed cumulative incidence by 18 years of age, incidence rates, and adjusted hazard ratios (aHRs) using Cox regression. aHRs accounted for sex, year of CHD diagnosis, parental mental health, and socioeconomic status. All estimates were stratified by age, sex, and CHD complexity.

RESULTS

The cumulative incidence of mental health conditions by 18 years of age in the CHD cohort was 35.1% (95% CI, 34.0%-36.1%), corresponding to aHRs of 1.64 (95% CI, 1.58-1.71), 1.41 (95% CI, 1.30-1.52), and 1.02 (95% CI, 0.98-1.07) compared with the general population, sibling, and major congenital anomaly cohorts, respectively. Mental health incidence rates showed prominent peaks in early childhood and adolescence. Males and children with severe or single-ventricle CHD demonstrated higher incidence rates of mental health conditions relative to females and children with mild or moderate CHD, respectively. Compared with the general population and sibling cohorts, incidence rates and aHRs in the CHD cohort were highest for severe stress reactions, attention deficit/hyperactivity disorder, intellectual disability, and autism spectrum disorder. Compared with children in the major congenital anomaly cohort, the aHRs were close to 1.

CONCLUSIONS

More than one-third of children with CHD were diagnosed or treated for a mental health condition by 18 years of age. Mental health conditions began early in life and were most prominent among males and children with severe or single-ventricle heart disease.

Knowledge and attitudes about conduct disorder of professionals working with young people: The influence of occupation and direct and indirect experience

BACKGROUND

Knowledge and attitudes of professionals both pose a potential barrier to diagnosis and treatment of mental disorders. However, knowledge and attitudes about conduct disorder in professionals working with young people are poorly understood. Little is known about the impact of occupation, direct and indirect (training and education) experience, or the interrelationship between knowledge and attitudes.

METHODS

We conducted an online survey of 58 participants, including Psychology Staff, Teaching Staff, Care Staff, and Other Non-Clinical Staff. A questionnaire comprising three subscales (causes, treatments, and characteristics) measured knowledge. A thermometer scale measured global attitudes. Open-ended response measures were used to measure four attitude components: stereotypic beliefs (about characteristics), symbolic beliefs (about the holder's traditions), affect, and past behaviour. Primary analysis explored the impact of occupation, direct experience, and indirect experience on outcome measures. A secondary exploratory analysis was conducted to explore the relationship between knowledge and attitudes.

RESULTS

Psychology Staff had significantly more favourable global attitudes (F = 0.49, p = 0.01) and symbolic beliefs (F = 0.57, p = 0.02) towards those with conduct disorder than Teaching Staff; there were no other significant group differences in attitudes. Psychology staff had more knowledge about conduct disorder than other groups, though the differences were not significant. Direct and indirect experience were associated with greater knowledge (direct: d = 0.97, p = 0.002; indirect d = 0.86, p = 0.004) and favourable global attitudes (direct: d = 1.12, p < 0.001; indirect: d = 0.68, p = 0.02). Secondary exploratory analyses revealed significant positive correlations between: all knowledge variables with global attitudes; total knowledge with past behaviour; and affect and knowledge of causes with past behaviour.

CONCLUSIONS

Psychology-based staff may have more favourable attitudes towards children with conduct disorder than teachers, primarily due to direct and indirect experience with the disorder. Our sample may have been too small to detect overall or within-group effects of knowledge or attitudes, however exploratory analyses showing a positive correlation between knowledge and attitudes suggest education may be critical in supporting teachers and other groups in their approaches to this challenging group of young people.

Influence of stigma, sociodemographic and clinical characteristics on mental health-related service use and associated costs among young people in the United Kingdom

This study examined the influence of stigma, psychopathology, and sociodemographic characteristics on mental health-related service use and costs related to service use in a cohort of young people in the UK. Using data from a community sample of young people aged 9-17 years and their caregivers, we assessed 407 young people's use of services due to mental health problems, young people's psychopathology, demographic characteristics, maternal education and caregivers' stigma-related beliefs. Unit costs related to services were gathered from national annual compendia and other widely used sources. We assessed predictors of service use through logistic regression analysis and developed generalised linear models to identify factors associated with costs of mental health-related service utilisation. Persistent psychopathology, socioeconomic disadvantage, and low caregiver intended stigma-related behaviour were associated with increased likelihood of service use among young people. Older age and socioeconomic disadvantage were associated with increased costs. Different factors influenced contact with services and the cost associated with their use - persistent psychopathology and socioeconomic disadvantage increased, and caregivers' intended stigma-related behaviour decreased the likelihood of using services, whereas socioeconomic disadvantage and older age were associated with increased costs. Social determinants of mental health problems play an important role in the use and costs of different types of mental health-related services for young people. Discordance between drivers of service use and costs implies that young people who are more likely to access services due to mental health problems do not necessarily receive care at the intensity they need.

Can we challenge attention and interpretation threat biases in rescued child labourers with a history of physical abuse using a computerised cognitive training task? Data on feasibility, acceptability and target engagement

Child labourers are more likely to have experienced physical victimisation, which may increase risk for anxiety/depression, by shaping threat biases in information-processing. To target threat biases and vulnerability for anxiety/depression, we evaluated whether Cognitive Bias Modification (CBM) training could be feasibly and acceptably delivered to rescued youth labourers. Seventy-six physically abused rescued labourers aged 14-17 (40 from Nepal, 36 from India) in out-of-home care institutions received either multi-session computerised CBM or control training. Training targeted attention away from threat to positive cues and the endorsement of benign over threat interpretations. Feasibility and acceptability data were gathered along with pre and post intervention measures of attention and interpretation bias and emotional and behavioural symptoms. In terms of feasibility, uptake (proportion of those who completed the pre-intervention assessment from those who consented) and retention (proportion of those who completed the post-intervention assessment from those who completed the pre-intervention assessment) were above 75% in both countries. Average acceptability ratings were mostly 'moderate' on most indices for both countries, and none of the participants reported experiencing serious adverse events or reactions in response to or during the trial. Secondarily, CBM participants showed increased attention to positive and decreased attention to threatening stimuli, as well as increased endorsement of benign interpretation and decreased endorsement in negative interpretations of ambiguous social situations. Symptom changes were less clear. Delivering CBM to former child labourers in out-of-home care institutions has interventive potential. ClinicalTrials.gov Identifier: NCT03625206, Date of registration: August 10, 2018.

Association between type 1 diabetes and neurodevelopmental disorders in children and adolescents: A systematic review and meta-analysis

Type 1 diabetes and neurodevelopmental disorders are common chronic conditions in childhood and adolescence, and having one may lead to an increased chance of developing the other. Type 1 diabetes mellitus is mainly manifested by elevated blood glucose, while neurodevelopmental diseases are composed of a variety of diseases, which are relatively complex. The purpose of this meta-analysis was to find out the prevalence of type 1 diabetes-related neurodevelopmental disorders in children and adolescents and to explore the potential association between neurodevelopmental disorders and type 1 diabetes. PubMed, Embase and Web of science databases were searched from the inception to May 22, 2022 to identify relevant studies, Finally, 24 original studies were included in the meta-analysis. Prevalence estimates for neurodevelopmental disorders in the type 1 diabetes adolescent and their 95% confidence intervals were pooled using random effects models. The pooled estimates for autism spectrum disorders (ASD) and attention deficit hyperactivity disorder (ADHD) in the type 1 diabetes population were 1.2 and 5.3%, respectively, both of which are higher than the 2019 global prevalence of ASD and ADHD in the general population. The results of the subgroup analysis showed that the prevalence of ASD and ADHD in the T1DM population tended to increase with age. In conclusion, there may be a potential link between the occurrence of type 1 diabetes mellitus and the development of neurodevelopmental disorders in children and adolescents, but more relevant studies are needed to understand the link between the underlying pathogenesis of type 1 diabetes and neurodevelopmental disorders.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CDR42022333443].

Pilot evaluation to assess the effectiveness of youth peer community support via the Kooth online mental wellbeing website

BACKGROUND

Mental health problems among young people are of growing concern globally. UK adolescent mental health services are increasingly restricted to those with the most severe needs. Many young people turn to the internet for advice and support, but little is known about the effectiveness, and potential harms, of online support. Kooth is a widely-used, anonymised and moderated online platform offering access to professional and peer support. This pilot evaluation sought to assess changes in the wellbeing and mental health of Kooth users, and changes in their use of formal services, over one month. We explored how community aspects of the site were used, and we considered the economic implications for commissioners making Kooth available to young people.

METHODS

We surveyed young people when they first accessed Kooth and again one month later (n = 302). Respondents completed measures of mental health and wellbeing, including family relationships and pandemic-related anxiety, and reported on their use of services and, at follow-up, their perceptions of whether and how they had benefitted. We carried out qualitative interviews with ten participants, exploring perceptions of the Kooth community and its impact.

RESULTS

We found improvements across nearly all measures, including reductions in psychological distress, suicidal ideation and loneliness. Subsample analyses suggested similar benefits for those who used only the community/peer parts of Kooth as for those who engaged with Kooth's counsellors. Participants reported learning from peers' suggestions and experiences, described as different from the advice given by professionals. Helping others gave users a sense of purpose; participants learnt self-help strategies and became more confident in social interactions. Service use and opinion data suggested Kooth experiences may help users make more appropriate and effective use of formal services.

CONCLUSION

This pilot evaluation suggests that Kooth is likely to be a cost-effective way of providing preventative support to young people with concerns about their mental health, with possible benefits across a range of domains which could be investigated in a future controlled trial.

The health care cost of comorbidity in individuals with mental disorders: A Danish register-based study

AIM

The aim of the study was to estimate the annual health care cost by number of comorbid mental and somatic disorders in persons with a mental disorder.

METHODS

All persons living in Denmark between 2004 and 2017 with a hospital diagnosis of a mental disorder were identified. We investigated the cost of different health care services: psychiatric hospitals, somatic hospitals, primary health care (e.g. general practitioners, psychologists and so on) and subsidised prescriptions. Within those with at least one mental disorder, we examined the costs for people with (a) counts of different types of mental disorders (e.g. exactly 1, exactly 2 and so on up to 8 or more) and (b) counts of different types of somatic disorders (e.g. no somatic disorders, exactly 1, exactly 2 and so on up to 15 or more). The estimates are reported in average cost per case and nationwide annual cost in Euro 2017.

RESULTS

In total, 447,209 persons (238,659 females and 208,550 males) were diagnosed with at least one mental disorder in the study period. The average annual health care cost per case and nationwide cost was 4471 Euros and 786 million Euro, respectively, for persons with exactly one mental disorder, and 33,273 Euro and 3.6 million Euro for persons with eight or more mental disorders. The annual health care cost was 4613 Euro per case and 386 million Euro for persons without any somatic disorders, while the cost per case was 16,344 Euro and 0.7 million Euro in nationwide cost for persons with 15 or more disorders. The amount and proportion of the different health care costs varied by type of comorbidity and count of disorders.

CONCLUSIONS

The annual health care cost per case was higher with increasing number of comorbid mental and somatic disorders, while the nationwide annual health care cost was lower with increasing number of comorbid disorders for persons with a mental disorder in Denmark.

Cost-effectiveness of a transdiagnostic psychotherapy program for youth with common mental health problems

OBJECTIVES

Our objective was to evaluate the cost-effectiveness of the transdiagnostic psychotherapy program Mind My Mind (MMM) for youth with common mental health problems using a cost-utility analysis (CUA) framework and data from a randomized controlled trial. Furthermore, we analyzed the impact of the choice of informant for both quality-of-life reporting and preference weights on the Incremental Cost-Effectiveness Ratio (ICER).

METHODS

A total of 396 school-aged (6-16 years) youth took part in the 6-month trial carried out in Denmark. CUAs were carried out for the trial period and four one-year extrapolation scenarios. Costs were based on a combination of budget and self-reported costs. Youths and parents were asked to report on the youth's quality-of-life three times during the trial using the Child Health Utility 9D (CHU9D). Parental-reported CHU9D was used in the base case together with preference weights of a youth population. Analyses using self-reported CHU9D and preference weights of an adult population were also carried out.

RESULTS

The analysis of the trial period resulted in an ICER of €170,465. The analyses of the one-year scenarios resulted in ICERs between €23,653 and €50,480. The ICER increased by 24% and 71% compared to the base case when using self-reported CHU9D and adult preference weights, respectively.

CONCLUSION

The MMM intervention has the potential to be cost-effective, but the ICER is dependent on the duration of the treatment effects. Results varied significantly with the choice of informant and the choice of preference weights indicating that both factors should be considered when assessing CUA involving youth.

The cost of mental disorders in Denmark: a register-based study

The aim of the study was to undertake a detailed analysis of healthcare cost, public transfer payments, and income loss associated with a broad range of mental disorders in Denmark. Based on all persons living in Denmark, we identified those with a hospital diagnosis of one of 18 types of mental disorders and 10 age- and sex-matched controls per case. For each mental disorder, the outcomes were nationwide totals, cost per case, and cost per capita, investigated by sex, age strata, and the number of years after diagnosis. We found a substantial annual income loss of 5 billion Euros and excess healthcare cost of 1 billion Euros for persons with any mental disorder. Each mental disorder was associated with an income loss, excess healthcare cost, and excess public transfer payments compared to matched controls. An interactive data visualisation site with summary data is available at https://nbepi.com/cost .

Parent Management Training Combined with Group-CBT Compared to Parent Management Training Only for Oppositional Defiant Disorder Symptoms: 2-Year Follow-Up of a Randomized Controlled Trial

Parent management training (PMT) is recommended treatment for children with oppositional defiant disorder (ODD) and child-directed cognitive behavior therapy (CBT) is also recommended for school-aged children. The current study examined 2-year follow-up effects of parent management training (PMT) combined with the CBT based group intervention Coping Power Program (CPP) compared to PMT only. Results showed long-term effectiveness of both PMT and PMT combined with CPP in reduced disruptive behavior problems and harsh parenting strategies, and increased emotion regulation- and social communication skills. The earlier reported increase in emotion regulation- and social communication skills in the PMT with CPP condition during treatment remained stable while the PMT condition showed continued improvement during the follow-up period. To conclude, PMT with CPP did generally not provide significant benefits at the 2-year follow-up compared to PMT, apart from an improvement earlier in time regarding emotion regulation- and social communication skills.Trial registration number ISRCTN10834473, date of registration: 23/12/2015.

The economic costs of child maltreatment in UK

Child maltreatment is a major public health problem with significant consequences for individual victims and for society. In this paper, we quantify for the first time the economic costs of fatal and nonfatal child maltreatment in the UK in relation to several short-, medium-, and long-term outcomes ranging from physical and mental health problems to labor market outcomes and welfare use. We combine novel regression analysis of rich data from the National Child Development Study and the English Longitudinal Study of Aging with secondary evidence to produce an incidence-based estimate of the lifetime costs of child maltreatment from a societal perspective. The discounted average lifetime incidence cost of nonfatal child maltreatment by a primary caregiver is estimated at £89,390 (95% uncertainty interval £44,896 to £145,508); the largest contributors to this are costs from social care, short-term health, and long-term labor market outcomes. The discounted lifetime cost per death from child maltreatment is estimated at £940,758, comprising health care and lost productivity costs. Our estimates provide the first comprehensive benchmark to quantify the costs of child maltreatment in the UK and the benefits of interventions aimed at reducing or preventing it.

Impact of counselling provision in primary schools on child and adolescent mental health service referral rates: a longitudinal observational cohort study

BACKGROUND

In the United Kingdom, schools play an increasingly important role in supporting young peoples' mental health. While there is a growing evidence base to support the effectiveness of school-based interventions, less is known about how these provisions impact on local Child and Adolescent Mental Health Service (CAMHS) referral rates. There is a concern that an increase in school-based provision might lead to an increase in CAMHS referrals and overwhelm services. We aimed to examine the longitudinal association between Place2Be counselling provision in primary schools on CAMHS referral rates in South London.

METHOD

This was a retrospective cohort study using linked data from the National Pupil Database (NPD) and CAMHS referrals to the South London and Maudsley's NHS Foundation Trust (SLaM) identified through the Clinical Record Interactive Search (CRIS) tool. The cohort included a total of 285 state-maintained primary schools in four London boroughs for the academic years of 2007-2012. During the study period, 23 of these schools received school-based mental health provision from Place2Be. The primary outcome was the incident rate ratio (IRR) of school-level accepted CAMHS referrals in 2012/13 in schools with, or without, Place2Be provision.

RESULTS

There was no significant association between elevated rates of CAMHS referral and Place2Be provision, even after comprehensive adjustment for school-level and pupil characteristics (IRR 0.91 (0.67-1.23)). School-level characteristics, including higher proportion of white-British pupils (IRR 1.009 (1.002-1.02)), medical staff ratio (IRR 6.49 (2.05-20.6)) and poorer Ofsted school inspection ratings (e.g. IRR 1.58 (1.06-2.34) for 'Requires Improvement' vs. 'Outstanding') were associated with increased CAMHS referral rates.

CONCLUSIONS

Place2Be provision did not result in increased specialist mental health referrals; however, other school-level characteristics did. Future research should investigate pupils' Place2Be clinical outcomes, as well the outcomes of individuals referred to CAMHS to better understand which needs are being met by which services.

Referral patterns to outpatient child and adolescent mental health services and factors associated with referrals being rejected. A cross-sectional observational study

BACKGROUND

Outpatient child and adolescent mental health services (CAMHS) are faced with the challenge of balancing increasing demands with limited resources. An additional challenge is high rejection rates of referrals which causes frustration for referring agents and families. In order to effectively plan and allocate available resources within CAMHS there is a need for up-to-date knowledge on referral patterns and factors associated with rejection of referrals.

METHODS

In this cross-sectional observational study we did a retrospective review of all referrals (n = 1825) for children (0-18) referred for assessment at the outpatient CAMHS of the North Denmark Region in 2018.

RESULTS

The most common referral reasons to CAMHS were attention deficit disorder (ADHD/ADD) (27.9%), autism spectrum disorder (22.4%), affective disorders (14.0%) and anxiety disorders (11.6%). The majority of referrals came from general practitioners, but for neurodevelopmental disorders educational psychologists were the primary referral source. Re-referrals constituted more than a third of all referrals (35.9%). Children in care were overrepresented in this clinical sample and had an increased risk (Adj. OR 2.54) of having their referrals rejected by CAMHS. Referrals from general practitioners were also associated with an increased risk of rejection (Adj. OR 3.29).

CONCLUSIONS

A high proportion of children with mental disorders have a repeated need for assessment by CAMHS. There is a need for future research on predictors of re-referral to outpatient services to identify potential targets for reducing re-referral rates as well as research on how to optimize service provision for children with a repeated need for assessment. General practitioners are the main gatekeepers to CAMHS and research on interventions to improve the referral process should be aimed towards general practitioners.

Feasibility of School-Based Identification of Children and Adolescents Experiencing, or At-risk of Developing, Mental Health Difficulties: a Systematic Review

Under-identification of mental health difficulties (MHD) in children and young people contributes to the significant unmet need for mental health care. School-based programmes have the potential to improve identification rates. This systematic review aimed to determine the feasibility of various models of school-based identification of MHD. We conducted systematic searches in Medline, Embase, PsycINFO, ERIC, British Education Index, and ASSIA using terms for mental health combined with terms for school-based identification. We included studies that assessed feasibility of school-based identification of students in formal education aged 3-18 with MHD, symptomatology of MHD, or exposed to risks for MHD. Feasibility was defined in terms of (1) intervention fit, (2) cost and resource implications, (3) intervention complexity, flexibility, manualisation, and time concerns, and (4) adverse events. Thirty-three studies met inclusion criteria. The majority focused on behavioural and socioemotional problems or suicide risk, examined universal screening models, and used cross-sectional designs. In general, school-based programmes for identifying MHD aligned with schools' priorities, but their appropriateness for students varied by condition. Time, resource, and cost concerns were the most common barriers to feasibility across models and conditions. The evidence base regarding feasibility is limited, and study heterogeneity prohibits definitive conclusions about the feasibility of different identification models. Education, health, and government agencies must determine how to allocate available resources to make the widespread adoption of school-based identification programmes more feasible. Furthermore, the definition and measurement of feasibility must be standardised to promote any future comparison between models and conditions.

mHealth: Potentials and Risks for Addressing Mental Health and Well-Being Issues Among Nepali Adolescents

Adolescents are slowly being recognized as a generation, worldwide, that may require different policy approaches to improve staggering statistics on their failing well-being, including mental health. By providing the support to allow the next generation to achieve better mental health outcomes, they are going to be more economically successful and the future economic growth of nations can be better assured. Adoption of mobile-based health interventions (e.g., mHealth) has garnered a lot of attention toward this end. While mHealth interventions are growing in popularity, many researchers/policy-makers appear to have neglected assessing potential (indirect) costs/negative consequences from their use. Evidence from the developed world shows strong associations between extensive cell phone use and negative mental health outcomes, but similar research is minimal in developing world contexts. Additionally, the bulk of work on the outcomes of mobile phone use is studied using a unidirectional approach with blinders to front-end motivations. Using primary data from a large-scale, school-based survey of older adolescents in southwestern Nepal (N = 539), this work investigates such a tension between mobile/smartphone usage as a true mobile health (mHealth) opportunity in Nepal or as a potential problem, introducing additional deleterious well-being effects from over-use. Founded in Basic Psychological Needs Theory (BPNT), robust results of analyses using full structural modeling approaches (and traditional regression-based sensitivity analyses) indicate support for the BPNT framework in explaining statistically significant positive associations between bullying and anxiety, as well as, negative associations between bullying and grit, including evidence to support the mediating role of problematic mobile phone use in these relationships. More than 56% of the sample showed indicators of mild to moderate anxiety and over 10% claim experiences of bullying, coupled with over 75% of the sample scoring above the midline of a problematic mobile phone use scale, all of which motivates the relevance of our findings. Potential policy implications of these findings, and mention of other intriguing avenues for future work are further discussed.

Humanistic counselling plus pastoral care as usual versus pastoral care as usual for the treatment of psychological distress in adolescents in UK state schools (ETHOS): a randomised controlled trial

BACKGROUND

About one in seven adolescents have a mental health disorder in England, UK. School counselling is one of the most common means of trying to address such a problem. We aimed to determine the effectiveness and cost-effectiveness of school-based humanistic counselling (SBHC) for the treatment of psychological distress in young people in England, UK.

METHODS

We did a two-arm, individually randomised trial in 18 secondary state-funded schools across the Greater London area of the UK. Participants were randomly assigned (1:1) using a centrally secure randomisation procedure with random permuted blocks to either SBHC plus schools' pastoral care as usual (PCAU), or PCAU alone. Participants were pupils aged 13-16 years who had moderate-to-severe levels of emotional symptoms (measured by a score of ≥5 on the Strengths and Difficulties Questionnaire Emotional Symptoms scale) and were assessed as competent to consent to participate in the trial. Participants, providers, and assessors (who initially assessed and enrolled participants) were not masked but testers (who measured outcomes) were masked to treatment allocation. The primary outcome was psychological distress at 12 weeks (Young Person's Clinical Outcomes in Routine Evaluation measure [YP-CORE]; range 0-40), analysed on an intention-to-treat basis (with missing data imputed). Costs were assessed at 24 weeks (Client Service Receipt Inventory and service logs). The trial was registered with ISRCTN, number ISRCTN10460622.

FINDINGS

329 participants were recruited between Sept 29, 2016, and Feb 8, 2018, with 167 (51%) randomly assigned to SBHC plus PCAU and 162 (49%) to PCAU. 315 (96%) of 329 participants provided data at 12 weeks and scores were imputed for 14 participants (4%). At baseline, the mean YP-CORE scores were 20·86 (SD 6·38) for the SBHC plus PCAU group and 20·98 (6·41) for the PCAU group. Mean YP-CORE scores at 12 weeks were 16·41 (SD 7·59) for the SBHC plus PCAU group and 18·34 (7·84) for the PCAU group (difference 1·87, 95% CI 0·37-3·36; p=0·015), with a small effect size (0·25, 0·03-0·47). Overall costs at 24 weeks were £995·20 (SD 769·86) per pupil for the SBHC plus PCAU group and £612·89 (1224·56) for the PCAU group (unadjusted difference £382·31, 95% CI £148·18-616·44; p=0·0015). The probability of SBHC being more cost-effective reached 80% at a willingness to pay of £390 for a 1-point improvement on the YP-CORE. Five serious adverse events occurred for four participants in the SBHC plus PCAU group, all involving suicidal intent. Two serious adverse events occurred for two participants in the PCAU group, one involving suicidal intent.

INTERPRETATION

The addition of SBHC to PCAU leads to small reductions in psychological distress, but at an additional economic cost. SBHC is a viable treatment option but there is a need for equally rigorous evaluation of alternative interventions.

FUNDING

This work was supported by the Economic and Social Research Council (grant reference ES/M011933/1).

Economic Return on Investment of Parent Training Programmes for the Prevention of Child Externalising Behaviour Problems

Economic models to inform decision-making are gaining popularity, especially for preventive interventions. However, there are few estimates of the long-term returns to parenting interventions used to prevent mental health problems in children. Using data from a randomised controlled trial evaluating five indicated parenting interventions for parents of children aged 5-12, we modeled the economic returns resulting from reduced costs in the health care and education sector, and increased long-term productivity in a Swedish setting. Analyses done on the original trial population, and on various sized local community populations indicated positive benefit-cost ratios. Even smaller local authorities would financially break-even, thus interventions were of good value-for-money. Benefit-cost analyses of such interventions may improve the basis for resource allocation within local decision-making.

Healthcare Costs, School Performance, and Health-related Quality of Life in Adolescence Following Psychotic Experiences in Preadolescence: A Longitudinal Cohort Study

Psychotic experiences (PEs) are common in the general population in preadolescence. The implications of PEs on socioeconomic outcomes, including educational attainment, are scarcely described. We aimed to estimate how preadolescent PEs were associated with later healthcare costs, school performance, and health-related quality of life (HRQoL) in adolescence. A total of 1607 preadolescents from the general population Copenhagen Child Cohort 2000 were assessed for PEs at age 11-12 years and followed up over 5 years using register-based data on mental and somatic healthcare costs, and school performance at age 16. Furthermore, HRQoL was assessed for a subsample of the children at age 16-17. We adjusted for perinatal and family sociodemographic adversities, prior parental mental illness and healthcare use, child IQ-estimate at age 11-12, and parent-rated general psychopathology of their child. PEs were associated with slightly poorer school performance. However, preadolescents with PEs more often reported HRQoL within the lowest 10th percentile (OR = 2.74 [95% CI 1.71-4.37]). Preadolescents who reported PEs had higher average total healthcare costs over the following 5 years. The costs for individuals with PEs were higher for mental healthcare services across primary to tertiary care, but not for somatic care. After adjustments, PEs remained independently associated with higher costs and poorer HRQoL, but not with poorer school performance. In conclusion, PEs are important in mental health screening of preadolescents and identify a group of young people with increased healthcare service-use throughout adolescence and who report poorer HRQoL in adolescence, over and above parent-rated general psychopathology of their child.

Psychological Correlates of Sedentary Screen Time Behaviour Among Children and Adolescents: a Narrative Review

PURPOSE OF REVIEW

The aims of this narrative review were to (1) synthesise the literature on the relationship between screen time and important mental health outcomes and (2) examine the underpinning factors that can influence this association.

RECENT FINDINGS

Paralleling the rise of mental health issues in children and adolescents is the ubiquitous overuse of screens, but it is unclear how screen time is related to important mental health outcomes and whether this association differs by gender, age and screen type.

METHODS

Medline/PubMed, PsychINFO and Google Scholar databases were searched on December 2019 for articles published mainly in the last 5 years. The search focused on two main concepts: (i) screen time and (ii) mental health outcomes including anxiety, depression, psychological and psychosocial well-being and body image concerns.

RESULTS

Sixty studies were included in the review. Higher levels of screen time were associated with more severe depressive symptoms. We found moderate evidence for an association between screen time and poor psychological well-being and body dissatisfaction especially among females. Relationships between screen time and anxiety were inconsistent and somewhat gender specific. Social media use was consistently associated with poorer mental health. Higher levels of screen time are generally associated with poorer mental health outcomes, but associations are influenced by screen type, gender and age. Practitioners, parents, policy makers and researchers should collectively identify and evaluate strategies to reduce screen time, or to use screens more adaptively, as a means of promoting better mental health among children and adolescents.

Child and adolescent mental health trajectories in relation to exclusion from school from the Avon Longitudinal Study of Parents and Children

BACKGROUND

As the prevalence of childhood mental health conditions varies by age and gender, we explored whether there were similar variations in the relationship between psychopathology and exclusion from school in a prospective UK population-based birth cohort.

METHOD

The Avon Longitudinal Study of Parents and Children collected reports of exclusion at 8 years and 16 years. Mental health was assessed at repeated time points using the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

Using adjusted linear mixed effects models, we detected a nonlinear interaction between exclusion and age related to poor mental health for boys [adjusted coefficient 1.13 (95% confidence interval 0.55-1.71)] excluded by age 8, but not for girls. The SDQ scores of boys who were excluded in primary school were higher than their peers from age 3, and increasingly diverged over time. As teenagers, these interactions appeared for both genders [boys' adjusted coefficient 0.18 (0.10-0.27); girls 0.29 (0.17-0.40)]. For teenage girls, exclusion by 16 was followed by deteriorating mental health. Family adversity predicted exclusion in all analyses.

CONCLUSION

Prompt access to effective intervention for children in poor mental health may improve both mental health and access to education.

KEY PRACTITIONER MESSAGE

Children who were subsequently excluded from school often faced family adversity and had poor mental health, which suggests the need for an interdisciplinary response and a multiagency approach. Poor mental health may contribute to and result from exclusion from school, so both mental health and education practitioners have a key role to play. Boys who enter school with poor mental health are at high risk of exclusion in primary school, which prompt assessment and intervention may prevent. Both boys and girls who are excluded between the ages of 15 and 16 years may have poor, and in the case of girls, deteriorating, mental health.

Sugar consumption, sugar sweetened beverages and Attention Deficit Hyperactivity Disorder: A systematic review and meta-analysis

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a significant neurobehavioral disorder in children and adolescence which may be affected by diet.

OBJECTIVE

To evaluate the possible relationship between sugar consumption and the development of symptoms of ADHD.

METHODS

In March 2020, an exhaustive systematic literature search was conducted using Google Scholar, PubMed, and Scopus. In this meta-analysis of observational studies, odds ratios, relative risks, hazard ratios, and their 95% confidence intervals, which was reported for ADHD regarding SSBS, soft drink consumption, and dietary sugars, were used to calculate ORs and standard errors. At first, a fixed-effects model was used to drive the overall effect sizes using log ORs and SEs. If there was any significant between-studies heterogeneity, the random-effects model was conducted. Cochran's Q test and I² were used to measure potential sources of heterogeneity across studies. The Newcastle-Ottawa scale was used to assess the quality of the included articles.

RESULTS

Seven studies, two cross-sectional, two case-control, and three prospective with a total of 25,945 individuals were eligible to include in the current meta-analysis. The association between sugar and soft drink consumption and the risk of ADHD symptoms were provided based on the random-effects model (pooled effect size: 1.22, 95%CI: 1.04-1.42, P = 0.01) (I² = 81.9%, P _{heterogeneity}< 0.0001).

CONCLUSION

This meta-analysis indicated a positive relationship between overall sugar and sugar-sweetened beverages consumption and symptoms of ADHD; however, there was heterogeneity among included studies. Future well-designed studies that can account for confounds are necessary to confirm the effect of sugar on ADHD.

eMental Health Literacy and Knowledge of Common Child Mental Health Disorders among Parents of Preschoolers

The purpose of the study was to assess the eMental health literacy of parents of preschool children and explore the relationships between their eMental health literacy skills and their knowledge of common child mental health disorders and their child difficulties. Online survey data were collected using Mechanical Turk (MTurk). Parents of preschool children completed questionnaires related to internet-based mental health information seeking behavior, knowledge of common child mental health disorders using case vignettes, and child difficulties. Data were analyzed using descriptive statistical methods. eMental health literacy of parents was high but knowledge of the child mental health disorders was low. Only 14% of parents correctly identified all three disorders; 41.1% identified attention deficit hyperactivity disorder (ADHD), 64.9% recognized autism spectrum disorder (ASD), and 19.1% identified separation anxiety disorder (SAD). Parents with high eMental health literacy (≥30) were more likely to endorse professional help and seek information on how to manage problem behaviors for all three disorders. Parents with low eMental health literacy (<30) were more likely to have a child with a high risk of a mental health disorder. The findings will be used to inform educational initiatives on the use of online resources and recognition of child mental health disorders to promote early intervention and appropriate help seeking.

Effectiveness of Video-Feedback with Cognitive Preparation in Improving Social Performance and Anxiety through Super Skills for Life Programme Implemented in a School Setting

Effectiveness of video-feedback with cognitive preparation to treat anxiety problems (especially social anxiety) has been scarcely explored on children. Super Skills for Life (SSL) is a CBT-based intervention to reduce anxiety and comorbid problems that, apart from social skills training and behavioural activation, integrates video-feedback with cognitive preparation. This study aimed to evaluate SSL effects, implemented in a school setting, on social performance and to test self-concept and social skills as potential mediators of pre- and post-test changes in social anxiety and generalized anxiety. Sample comprised 57 children aged 8-11 years with emotional symptoms. Children were video recorded in the first and last session to assess social performance. Anxiety and self-concept measures were completed by children pre-test and post-test. Participants reduced anxiety behaviours and improved social and communication skills after treatment. In general, girls showed better social performance than boys, but SSL impact was greater in males. Social self-concept was the only mediator of change in pre- to post-treatment social anxiety. This study provides evidence of SSL to improve children's social performance and reduce anxiety through video-feedback with cognitive preparation. Improving social concept seems essential to reduce social anxiety. An SSL programme is an ideal prevention protocol for anxious children.

Counselling for young people and young adults in the voluntary and community sector: An overview of the demographic profile of clients and outcomes

OBJECTIVES

To determine the demographic profile of clients accessing voluntary and community sector (VCS) counselling services for young people and young adults, and to undertake the first systematic evaluation of outcomes.

DESIGN

Naturalistic, non-experimental study design.

METHODS

A total of 2,144 clients were recruited from nine services in England. Data on gender, age, ethnicity, number of sessions, problem descriptions, and initial levels of psychological distress were collected from clients. Calculations of reliable and clinically significant change, repeated measures t-tests, effect size estimates, and moderation analyses were undertaken to determine whether pre-post change, over an average of 5.1 (SD = 5.3) sessions, was significant and which variables predicted outcomes. Levels of service satisfaction were also recorded.

RESULTS

The demographic profile of clients accessing VCS services was distinct to those accessing statutory and school-based counselling services, with a greater representation of females, 'older' clients, and clients from Black and Minority Ethnic (BME) groups. Clients accessing VCS counselling services presented with multiple and complex needs. Statistically significant reductions in psychological distress were observed with effect sizes ranging from .64 to .80. High levels of service satisfaction were expressed by clients.

CONCLUSIONS

This study establishes that clinical outcomes in the VCS are comparable to those reported in school-based and statutory mental health services in the United Kingdom. VCS services were perceived as being highly accessible and appear able to reach marginalized groups who may not be accessing other services.

PRACTITIONER POINTS

VCS services in the United Kingdom may be more accessible to young people from marginalized groups, such as those from BME backgrounds, compared to statutory and school-based counselling services. Counselling in VCS services is associated with significant short-term reductions in psychological distress, at a level comparable with the statutory and educational sectors. Clients accessing counselling in VCS services report relatively high levels of service satisfaction.

Economics and mental health: the current scenario

Economics and mental health are intertwined. Apart from the accumulating evidence of the huge economic impacts of mental ill-health, and the growing recognition of the effects that economic circumstances can exert on mental health, governments and other budget-holders are putting increasing emphasis on economic data to support their decisions. Here we consider how economic evaluation (including cost-effectiveness analysis, cost-utility analysis and related techniques) can contribute evidence to inform the development of mental health policy strategies, and to identify some consequences at the treatment or care level that are of relevance to service providers and funding bodies. We provide an update and reflection on economic evidence relating to mental health using a lifespan perspective, analyzing costs and outcomes to shed light on a range of pressing issues. The past 30 years have witnessed a rapid growth in mental health economics, but major knowledge gaps remain. Across the lifespan, clearer evidence exists in the areas of perinatal depression identification-plus-treatment; risk-reduction of mental health problems in childhood and adolescence; scaling up treatment, particularly psychotherapy, for depression; community-based early intervention and employment support for psychosis; and cognitive stimulation and multicomponent carer interventions for dementia. From this discussion, we pull out the main challenges that are faced when trying to take evidence from research and translating it into policy or practice recommendations, and from there to actual implementation in terms of better treatment and care.

A Randomized Controlled Trial of Attention Bias Modification Treatment in Youth With Treatment-Resistant Anxiety Disorders

OBJECTIVE

Randomized clinical trials of augmentation strategies for youth with treatment-resistant anxiety disorders do not exist. This report presents findings from an efficacy trial of attention bias modification treatment (ABMT) as an augment for this population compared with attention control training (ACT).

METHOD

Sixty-four youths (34 boys; mean age 11.7 years) who continued to meet for anxiety diagnoses after completing cognitive-behavioral therapy were randomized to ABMT or ACT. ABMT and ACT consisted of dot-probe attention training trials presenting angry and neutral faces; probes appeared in the location of neutral faces on 100% of trials in ABMT and 50% of trials in ACT. Independent evaluators, youths, and parents completed ratings of youth anxiety severity, and youths completed measures of attention bias to threat and attention control at pretreatment, post-treatment, and 2-month follow-up.

RESULTS

The 2 arms showed significant decreases in anxiety severity, with no differences between arms. Specifically, across informants, anxiety severity was significantly decreased at post-treatment and decreases were maintained at follow-up. Primary anxiety disorder diagnostic recovery combined across arms was 50% at post-treatment and 58% at follow-up. Attention control, but not attention bias to threat, was significantly improved at post-treatment in the 2 arms.

CONCLUSION

This is the first study to show anxiety can be decreased in youth who did not respond to cognitive-behaviorial therapy, and that the anxiety-decreasing effect is found using these 2 attention training contingency schedules. These findings and increases in attention control in the 2 arms raise intriguing questions about mechanisms of decreasing anxiety in treatment-resistant youth with attention training that require further research.

CLINICAL TRIAL REGISTRATION INFORMATION

Attention Bias Modification Training for Child Anxiety CBT Nonresponders; https://clinicaltrials.gov/; NCT01819311.

Cost-effectiveness analysis of parenting interventions for the prevention of behaviour problems in children

BACKGROUND

Behavior problems are common among children and place a high disease and financial burden on individuals and society. Parenting interventions are commonly used to prevent such problems, but little is known about their possible longer-term economic benefits. This study modelled the longer-term cost-effectiveness of five parenting interventions delivered in a Swedish context: Comet, Connect, the Incredible Years (IY), COPE, bibliotherapy, and a waitlist control, for the prevention of persistent behavior problems.

METHODS

A decision analytic model was developed and used to forecast the cost per averted disability-adjusted life-year (DALY) by each parenting intervention and the waitlist control, for children aged 5-12 years. Age-specific cohorts were modelled until the age of 18. Educational and health care sector costs related to behavior problems were included. Active interventions were compared to the waitlist control as well as to each other.

RESULTS

Intervention costs ranged between US$ 14 (bibliotherapy) to US$ 1,300 (IY) per child, with effects of up to 0.23 averted DALYs per child (IY). All parenting interventions were cost-effective at a threshold of US$ 15,000 per DALY in relation to the waitlist control. COPE and bibliotherapy strongly dominated the other options, and an additional US$ 2,629 would have to be invested in COPE to avert one extra DALY, in comparison to bibliotherapy.

CONCLUSIONS

Parenting interventions are cost-effective in the longer run in comparison to a waitlist control. Bibliotherapy or COPE are the most efficient options when comparing interventions to one another. Optimal decision for investment should to be based on budget considerations and priority settings.

Evaluating a Web-Based Health-Promoting Dialogue Tool in School Health Services: Feasibility and User Experiences

Adolescence is a sensitive period in life and a time to redefine and learn new skills. In Norway, school health services provide individual health-promoting consultations with all eighth-grade students. As an aid to support these consultations, a dialogue tool called SchoolHealth was developed using a co-creation approach. SchoolHealth consists of a web-based health information form designed to be completed by the students and generates individual feedback reports to help the school nurses to prepare for the consultation and tailor it to the individual student's need. Our aims were to evaluate the feasibility and user experiences of SchoolHealth among students and school nurses using a mixed methods approach. A total of 79 eighth-grade students (69% of those invited) and four school nurses from three schools participated. Analyses indicated that SchoolHealth was feasible, promoted reflection among students, and helped prepare students and school nurses for the consultation.

Evaluating the real-world effectiveness of a cognitive behavior therapy-based transdiagnostic program for emotional problems in children in a regular school setting

BACKGROUND

The present study examined the real-world effectiveness of a transdiagnostic prevention program, Super Skills for Life (SSL), among children with emotional problems in regular school settings. SSL is based on the principles of Cognitive Behavior Therapy (CBT), behavioral activation, and social skills training.

METHODS

Participants were 205 children, aged 8-12 years, who were referred by their teachers as having significant emotional problems. All the children completed measures of emotional and behavioral problems and self-esteem, both before and after participating in SSL, and at six months after the intervention. The children's parents and class teachers also completed a questionnaire that measures children's general difficulties and positive attributes. Children also gave a 2-minute speech task in front of the video in sessions 1 and 8.

RESULTS

There was agreement among self, parent, and teacher report, showing significant decreases of emotional symptoms from pretest to posttest and pretest to follow-up. Main effect of gender was significant for anxiety symptoms, emotional symptoms peer problems, and prosocial behavior. Video analysis of the 2-minute speech task showed significant improvement in length of eye gaze, vocal quality, length of speech, manifestation of comfort, and conversational flow. However, hypothesized increases in self-esteem did not act as a mediator of change in pre- to post-anxiety symptoms or social phobia subscale scores.

LIMITATIONS

The present study used an open clinical trial design.

CONCLUSIONS

This study provides initial support for the effectiveness of the manual-guided CBT for emotional problems in regular school settings when delivered by school services staff.

Prevention of Anxiety and Depression in Swedish School Children: a Cluster-Randomized Effectiveness Study

Our study aimed at evaluating FRIENDS for Life, an intervention to prevent anxiety and depression in Swedish school children. A total of 695 children between the ages of 8 and 11 were recruited from 17 schools in Stockholm, Sweden, and cluster-randomized to either the intervention or control group. Teachers in the intervention group received a full day of training and administered FRIENDS for Life in their classrooms. We assessed the children’s anxiety and depressive symptoms, general mental health, and academic performance at pre- and post-intervention as well as at the 12-month follow-up. A multi-informant approach was used with data collected from children, parents, and teachers. Assessment was done with the Spence Children’s Anxiety Scale, Children’s Depression Inventory, and the Strengths and Difficulties Questionnaire. Children’s baseline symptoms, gender, and age as well as their teacher’s use of supervision were examined as moderators of effect. Our study found no short- or long-term effects of the intervention for any outcome with regard to the entire sample. We found an enhanced effect of the intervention regarding children with elevated depressive symptoms at baseline. We found a decrease in anxiety symptoms among children whose teachers attended a larger number of supervision sessions, compared to children whose teachers attended fewer supervised sessions or the control group. Mediation analyses showed that this effect was driven by change in the last phase of the intervention, suggesting that supervision might play an important role in enhancing teachers’ ability to administer the intervention effectively.

A Systematic Review of Risk and Protective Factors for Externalizing Problems in Children Exposed to Intimate Partner Violence

Intimate partner violence (IPV) is a serious public health issue with innumerable costs to the victims, children, and families affected as well as society at large. The evidence is conclusive regarding a strong association between exposure to IPV and children's externalizing problems. Moving forward, the next step is to enhance our understanding of risk and protective factors associated with these outcomes in order to tailor treatments to meet the needs of both parents and children. The databases Medline, PubMed, and PsyINFO were searched combining variations of the key words such as parent*, child*, mother, partner abuse, domestic abuse, spousal abuse, interpersonal violence, domestic violence, or intimate partner violence. This search were combined with child externalizing behaviors specifically conduct*, oppositional defiant disorder, externaliz*, aggress*, hyperactivity, and ADHD. A total of 31 studies from all three databases were reviewed following application of inclusion and exclusion criteria. The main findings were that child age and gender, callous-unemotional traits, cognitive appraisals, maternal mental health, and quality of parenting emerged as key mediating and moderating factors of the relationship between IPV exposure and child externalizing problems. These findings suggest that interventions provided to families exposed to IPV need to target both maternal and child risk factors in order to successfully reduce child externalizing problems.

Association between chronic somatic conditions and depression in children and adolescents: A retrospective study of 13,326 patients

AIMS

The goal of this study was to analyze the association between chronic somatic conditions and depression diagnosis in children and adolescents.

METHODS

The present case-control study included 13,326 children and adolescents with depression as well as controls without depression followed in 243 pediatric practices between 2010 and 2015. Cases and controls were matched by age, gender, index year, and physician. The effect of several chronic disorders in terms of the risk of developing depression was estimated using logistic regression models.

RESULTS

Depression was diagnosed in 0.7% of the population. The prevalence of depression increased with age from 0.2% in individuals aged 7 years to 2.0% in those aged 15 years. Depression was significantly associated with anorexia nervosa (OR = 6.69), ADHD (OR = 2.32), chronic sinusitis (OR = 1.82), short stature due to endocrine disorder (OR = 1.70), obesity (OR = 1.57), disorders of the thyroid gland (OR = 1.53) and certain disorders involving the immune mechanism (OR = 1.42). The risk of a depression diagnosis also increased with the number of chronic conditions (one condition: OR = 1.69; two conditions: OR = 1.81; more than two conditions: OR = 2.03).

CONCLUSIONS

Depression was associated with several chronic disorders and the number of such conditions in pediatric practices in Germany. Therefore, depression should be regularly assessed in young patients affected by chronic disorders.

Long-Term Outcome of a Cluster-Randomized Universal Prevention Trial Targeting Anxiety and Depression in School Children

The present study concerns a 3-year follow-up of a universal prevention trial targeting anxiety and depressive symptoms in school children. In addition to evaluating the long-term effect of the prevention program, we also examined attrition and its effect on the outcome. High rates of attrition have commonly been observed in studies in the field. However, the role of attrition is not sufficiently understood regarding internal and external validity biases. The current study comprised 695 children (aged 8-11 at baseline) from 17 schools in Sweden. Schools were cluster-randomized to either the intervention or control condition. Children completed measures of anxiety and depressive symptoms and parents completed measures of their child's anxiety and general mental health. We found no evidence of long-term effects of the prevention program, except for a small effect regarding parent reports of child anxiety. However, that effect was not found to be of clinical significance. Regarding attrition, children with missing data at the 3-year follow-up displayed higher levels of psychiatric symptoms at baseline and increasing symptoms across time. Furthermore, children in the control condition with missing follow-up data were found to be significantly deteriorated across time compared to the corresponding children in the intervention condition regarding depressive symptoms and total difficulties. In other words, attrition served as a moderator of the effect, which suggests that the overall result was biased toward a null-result. Our study highlights that large and nonrandom attrition severely limits the validity of the results. Further, given the common problem of retaining participants in long-term evaluations of school-based prevention trials, previous studies may suffer from the same limitations as the current study.

Honest, Open, Proud for adolescents with mental illness: pilot randomized controlled trial

BACKGROUND

Due to public stigma or self-stigma and shame, many adolescents with mental illness (MI) struggle with the decision whether to disclose their MI to others. Both disclosure and nondisclosure are associated with risks and benefits. Honest, Open, Proud (HOP) is a peer-led group program that supports participants with disclosure decisions in order to reduce stigma's impact. Previously, HOP had only been evaluated among adults with MI.

METHODS

This two-arm pilot randomized controlled trial included 98 adolescents with MI. Participants were randomly assigned to HOP and treatment as usual (TAU) or to TAU alone. Outcomes were assessed pre (T0/baseline), post (T1/after the HOP program), and at 3-week follow-up (T2/6 weeks after T0). Primary endpoints were stigma stress at T1 and quality of life at T2. Secondary outcomes included self-stigma, disclosure-related distress, empowerment, help-seeking intentions, recovery, and depressive symptoms. The trial is registered on ClinicalTrials (NCT02751229; http://www.clinicaltrials.gov).

RESULTS

Compared to TAU, adolescents in the HOP program showed significantly reduced stigma stress at T1 (d = .92, p < .001) and increased quality of life at T2 (d = .60, p = .004). In a longitudinal mediation model, the latter effect was fully mediated by stigma stress reduction at T1. HOP further showed significant positive effects on self-stigma, disclosure-related distress, secrecy, help-seeking intentions, attitudes to disclosure, recovery, and depressive symptoms. Effects at T1 remained stable or improved further at follow-up. In a limited economic evaluation HOP was cost-efficient in relation to gains in quality of life.

CONCLUSIONS

As HOP is a compact three-session program and showed positive effects on stigma and disclosure variables as well as on symptoms and quality of life, it could help to reduce stigma's negative impact among adolescents with MI.

Crossing the divide: a longitudinal study of effective treatments for people with autism and attention deficit hyperactivity disorder across the lifespan

Background

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) frequently persist into adolescence and young adulthood. However, there are few clinical services that support those with these disorders through adulthood.

Objective

Our aim was to determine if clinical services meet the needs of people with ASD and ADHD, who are ‘at transition’ from childhood to adulthood.

Design

A longitudinal study of individuals with ASD and ADHD, the impact of services and treatments.

Methods

Our research methods included (1) interviewing > 180 affected individuals (and their families) with a confirmed diagnosis of ASD and/or ADHD, (2) screening for ASD and ADHD in approximately 1600 patients and (3) surveying general practitioner prescribing to 5651 ASD individuals across the UK. In addition, we tested the effectiveness of (1) new ASD diagnostic interview measures in 169 twins, 145 familes and 150 non-twins, (2) a magnetic resonance imaging-based diagnostic aid in 40 ASD individuals, (3) psychological treatments in 46 ASD individuals and (4) the feasability of e-learning in 28 clinicians.

Setting

NHS clinical services and prisons.

Participants

Focus – young people with ASD and ADHD as they ‘transition’ from childhood and adolescence into early adulthood.

Interventions

Testing the utility of diagnostic measures and services, web-based learning interventions, pharmacological prescribing and cognitive–behavioural treatments.

Main outcome measures

Symptom severity, service provision and met/unmet need.

Results

People with ASD and ADHD have very significant unmet needs as they transition through adolescence and young adulthood. A major contributor to this is the presence of associated mental health symptoms. However, these are mostly undiagnosed (and untreated) by clinical services. Furthermore, the largest determinant of service provision was age and not severity of symptoms. We provide new tools to help diagnose both the core disorders and their associated symptoms. We also provide proof of concept for the effectiveness of simple psychological interventions to treat obsessional symptoms, the potential to run treatment trials in prisons and training interventions.

Limitations

Our findings only apply to clinical service settings.

Conclusions

As individuals ‘transition’ their contact with treatment and support services reduces significantly. Needs-led services are required, which can both identify individuals with the ‘core symptoms’ of ASD and ADHD and treat their residual symptoms and associated conditions.

Future work

To test our new diagnostic measures and treatment approaches in larger controlled trials.

Trial registration

Current Controlled Trials ISRCTN87114880.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Societal costs of multiple sclerosis in Ireland

AIMS

This paper evaluates the impact of multiple sclerosis (MS) in Ireland, and estimates the associated direct, indirect, and intangible costs to society based on a large nationally representative sample.

MATERIALS AND METHODS

A questionnaire was developed to capture the demographics, disease characteristics, healthcare use, informal care, employment, and wellbeing. Referencing international studies, standardized survey instruments were included (e.g. CSRI, MFIS-5, EQ-5D) or adapted (EDSS) for inclusion in an online survey platform. Recruitment was directed at people with MS via the MS Society mailing list and social media platforms, as well as in traditional media. The economic costing was primarily conducted using a 'bottom-up' methodology, and national estimates were achieved using 'prevalence-based' extrapolation.

RESULTS

A total of 594 people completed the survey in full. The sample had geographic, disease, and demographic characteristics indicating good representativeness. At an individual level, average societal cost was estimated at €47,683; the average annual costs for those with mild, moderate, and severe MS were calculated as €34,942, €57,857, and €100,554, respectively. For a total Irish MS population of 9,000, the total societal costs of MS amounted to €429m. Direct costs accounted for just 30% of the total societal costs, indirect costs amounted to 50% of the total, and intangible or QoL costs represented 20%. The societal cost associated with a relapse in the sample is estimated as €2,438.

LIMITATIONS AND CONCLUSIONS

The findings highlight that up to 70% of the total costs associated with MS are not routinely counted. These "hidden" costs are higher in Ireland than the rest of Europe, due in part to significantly lower levels of workforce participation, a higher likelihood of permanent workforce withdrawal, and higher levels of informal care needs. The relationship between disease progression and costs emphasize the societal importance of managing and slowing the progression of the illness.

Setting the Boundaries for Economic Evaluation: Investigating Time Horizon and Family Effects in the Case of Postnatal Depression

OBJECTIVES

This study investigates the impact of varying the boundaries of economic evaluation: time horizon and inclusion of family effects. The context is postnatal mental health, where although advocates for investment often include longer-term and family problems in describing the burden of postnatal depression, economic evaluations are usually limited to mothers' effects with a relatively short time horizon. This discrepancy may lead to suboptimal allocation of healthcare resources.

METHODS

The question of whether such boundary extensions could make a difference to decision-making is explored using decision analytic models, populated with data from the literature, to estimate the cost-effectiveness of a hypothetical preventive intervention under alternate boundary-setting approaches.

RESULTS

The results suggest that broader boundaries, particularly extension of the time horizon, could make substantial differences to estimated cost-effectiveness. Inclusion of family effects without extension of the time horizon had little impact, but where a longer time horizon was used, family effects could make a significant difference to the conclusions drawn from cost-effectiveness analysis.

CONCLUSIONS

Considerations in applying broader boundaries include the substantial resource requirements for evaluation, potential equity implications, relevance to decision-makers, methods for inclusion, and the interpretation and use of such results in decision-making. However, this context underscores the importance of considering not only caregiving but also family health effects, and illustrates the need for consistency between the arguments presented to decision-makers and the analytical approach taken in economic evaluation.

The relationship between exclusion from school and mental health: a secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007

BACKGROUND

Children with poor mental health often struggle at school. The relationship between childhood psychiatric disorder and exclusion from school has not been frequently studied, but both are associated with poor adult outcomes. We undertook a secondary analysis of the British Child and Adolescent Mental Health Surveys from 2004 and its follow-up in 2007 to explore the relationship between exclusion from school and psychopathology. We predicted poorer mental health among those excluded.

METHOD

Psychopathology was measured using the Strengths and Difficulties Questionnaire, while psychiatric disorder was assessed using the Development and Well-Being Assessment and applying Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM IV) criteria. Exclusion from school and socio-demographic characteristics were reported by parents. Multi-variable regression models were used to examine the impact of individual factors on exclusion from school or psychological distress.

RESULTS

Exclusion from school was commoner among boys, secondary school pupils and those living in socio-economically deprived circumstances. Poor general health and learning disability among children and poor parental mental health were also associated with exclusion. There were consistently high levels of psychological distress among those who had experienced exclusion at baseline and follow-up.

CONCLUSIONS

We detected a bi-directional association between psychological distress and exclusion. Efforts to identify and support children who struggle with school may therefore prevent both future exclusion and future psychiatric disorder.

Which children and young people are excluded from school? Findings from a large British birth cohort study, the Avon Longitudinal Study of Parents and Children (ALSPAC)

BACKGROUND

Exclusion from school is increasingly recognized as pertinent to child health. National educational data reveal that boys, children who are looked-after, living in poverty, have special educational needs, or from certain ethnic minorities, are disproportionately excluded from school. As population-based data on the wider characteristics of excluded children are scarce, we aimed to describe predictors of school exclusion in the Avon Longitudinal Study of Parents and Children.

METHOD

Avon Longitudinal Study of Parents and Children, a prospective U.K. population-based birth cohort study, collected parent reports of permanent school exclusions by 8 years and parent and self-reports of permanent and fixed-term exclusions in the preceding 12 months at 16 years. Potential risk factors were examined for associations with exclusion using logistic regression, with a focus on child mental health and neurodevelopment.

RESULTS

Analyses were based on all available data on 53/8,245 (0.6%) pupils excluded from school by 8 years and 390/4,482 (8.7%) at 16 years. Key factors associated with exclusion at both time points included male gender, lower socio-economic status, maternal psychopathology, mental health and behavioural difficulties, psychiatric disorder, social communication difficulties, language difficulties, antisocial activities, bullying/being bulled, lower parental engagement with education, low school engagement, poor relationship with teacher, low educational attainment, and special educational needs (all p < .05).

CONCLUSION

Exclusion from school was associated with child, family and school-related factors identifiable at, or prior to, primary school age. Child health professionals have an important role in the holistic, multidisciplinary assessment of children who are at risk of exclusion from school. Mental health and neurodevelopmental difficulties should be recognized and supported, to improve the health and educational outcomes among this vulnerable group.

ADHD in children and young people: prevalence, care pathways, and service provision

Attention-deficit hyperactivity disorder (ADHD) is a common childhood behavioural disorder. Systematic reviews indicate that the community prevalence globally is between 2% and 7%, with an average of around 5%. At least a further 5% of children have substantial difficulties with overactivity, inattention, and impulsivity that are just under the threshold to meet full diagnostic criteria for ADHD. Estimates of the administrative prevalence (clinically diagnosed or recorded) vary worldwide, and have been increasing over time. However, ADHD is still relatively under-recognised and underdiagnosed in most countries, particularly in girls and older children. ADHD often persists into adulthood and is a risk factor for other mental health disorders and negative outcomes, including educational underachievement, difficulties with employment and relationships, and criminality. The timely recognition and treatment of children with ADHD-type difficulties provides an opportunity to improve long-term outcomes. This Review includes a systematic review of the community and administrative prevalence of ADHD in children and adolescents, an overview of barriers to accessing care, a description of associated costs, and a discussion of evidence-based pathways for the delivery of clinical care, including a focus on key issues for two specific age groups-younger children (aged ≤6 years) and adolescents requiring transition of care from child to adult services.