Measuring outcome in child and adolescent mental health services: consumers' views of measures

Talking 'Bout Better outcomes for Adolescent Depression: Youth and Caregiver Perspectives on an Integrated Care Pathway for Depression

BACKGROUND

Depression is a common condition among adolescents, with rates continuing to rise. A gap exists between evidence-based recommendations for the treatment of depression and clinical practice. Integrated Care Pathways (ICPs) can help address this gap, but to date no study has examined how young people and their caregivers experience ICPs and whether these pathways are an acceptable form of care. This study used focus groups with adolescents, caregivers, and service providers to examine experiences of an ICP.

METHODS

Six individual interviews with service providers, four focus groups with youth, and two focus groups with caregivers were completed. Data was analyzed consistent with Braun & Clarke's Thematic Analysis Framework within an interpretivist paradigm.

RESULTS AND CONCLUSION

The study demonstrated that ICPs are acceptable to youth and their caregivers and that ICPs facilitate shared decision making between youth/caregivers and care providers. Findings also indicated that youth are willing to engage with ICPs particularly when there is a trusted clinician involved who helps interpret and tailor the ICP to the young person's experience. Further questions include how to best integrate these into the overall system and how to further tailor these pathways to support youth with diagnostic complexity and treatment resistance.

Patient-reported outcome measures used to improve youth mental health services: a systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) are standardized and validated self-administered questionnaires that assess whether healthcare interventions and practices improve patients' health and quality of life. PROMs are commonly implemented in children and youth mental health services, as they increasingly emphasize patient-centered care. The objective of this study was to identify and describe the PROMs that are currently in use with children and youth living with mental health conditions (MHCs).

METHODS

Three databases (MEDLINE, EMBASE, and PsycINFO) were systematically searched that used PROMs with children and youth < 18 years of age living with at least one diagnosed MHC. All methods were noted according to Preferred Reporting Items for Systematic reviews and Meta-Analysis. Four independent reviewers extracted data, which included study characteristics (country, year), setting, the type of MHC under investigation, how the PROMs were used, type of respondent, number of items, domain descriptors, and the psychometric properties.

RESULTS

Of the 5004 articles returned by the electronic search, 34 full-texts were included in this review. This review identified both generic and disease-specific PROMs, and of the 28 measures identified, 13 were generic, two were generic preference-based, and 13 were disease-specific.

CONCLUSION

This review shows there is a diverse array of PROMs used in children and youth living with MHCs. Integrating PROMs into the routine clinical care of youth living with MHCs could improve the mental health of youth. Further research on how relevant these PROMs are children and youth with mental health conditions will help establish more uniformity in the use of PROMs for this population.

How much is enough? Considering minimally important change in youth mental health outcomes

To make decisions in mental health care, service users, clinicians, and administrators need to make sense of research findings. Unfortunately, study results are often presented as raw questionnaire scores at different time points and regression coefficients, which are difficult to interpret with regards to their clinical meaning. Other commonly reported treatment outcome indicators in clinical trials or meta-analyses do not convey whether a given change score would make a noticeable difference to service users. There is an urgent need to improve the interpretability and relevance of outcome indicators in youth mental health (aged 12-24 years), in which shared decision making and person-centred care are cornerstones of an ongoing global transformation of care. In this Personal View, we make a case for considering minimally important change (MIC) as a meaningful, accessible, and user-centred outcome indicator. We discuss what the MIC represents, how it is calculated, and how it can be implemented in dialogues between clinician and researcher, and between youth and clinician. We outline how use of the MIC could enhance reporting in clinical trials, meta-analyses, clinical practice guidelines, and measurement-based care. Finally, we identify current methodological challenges around estimating the MIC and areas for future research. Efforts to select outcome domains and valid measurement instruments that resonate with youth, families, and clinicians have increased in the past 5 years. In this context, now is the time to define demarcations of changes in outcome scores that are clinically relevant, and meaningful to youth and families. Through the use of MIC, youth-centred outcome measurement, analysis, and reporting would support youth-centred therapeutic decision making.

Music, families and interaction (MUFASA): a protocol article for an RCT study

Background

General mental health and interpersonal skills of families are crucial to children's development and future. Research suggests a link between participation in music activities and individuals' own sense of mental health, as well as an effect in objective measures of health such as quality of life, social skills, and rehabilitation of various kinds. However, in Denmark there are not many services for families with school-aged children (7–12 years) that focus on prevention and strengthening family interaction hereby minimising the risk of children not thriving and developing optimally in terms of social and emotional skills and competences. The purpose of this study is to investigate the effect of shared music activities on family interaction, parental stress, and child well-being.

Methods

The study is a controlled effect study where 40 family dyads from Aalborg and Aarhus are randomized into 4 different groups including music therapy activities, community music, family concerts and a control group. Measurements of family interaction (Assessment of Parent Child Interaction, APCI) and mental health (Parental Stress Scale, PSS, and the Strengths and Difficulties Questionnaire, SDQ) will be made at baseline/pre intervention, at post intervention and a follow-up measurement 12 month after baseline (month 1, 3 and 12) 3 times in total. Furthermore, data about the family dyad’s regular participation in music events as part of every-day life at the same measure points (month 1, 3 and 12). Since this is a planned prospective study, results are not yet available, but clinical experience from a feasibility study in 2021 were promising and expected challenges and changes are discussed in the article.

Discussion

Findings of this study will be relevant for all fields where music is applied for families, such as education, mental health, social work and for basic research on the study of music and interaction. Music used as a resource for families is crucial in understanding how different modalities can influence the family interaction including emotional communication and attachment.

Trial registration: ISRCTN, ISRCTN17290015, Registered 03 March 2022, https://www.isrctn.com/ISRCTN17290015

Date and protocol version

July 2022, version 1. Protocol is planned to be updated after finalized recruitment during second data collection point and again after the third and last data collection point (see Additional file 1: SPIRIT Checklist).

Are We Comparing Apples with Oranges? Assessing Improvement Across Symptoms, Functioning, and Goal Progress for Adolescent Anxiety and Depression

Strategies for comparing routinely collected outcome data across services or systems include focusing on a common indicator (e.g., symptom change) or aggregating results from different measures or outcomes into a comparable core metric. The implications of either approach for judging treatment success are not fully understood. This study drew on naturalistic outcome data from 1641 adolescents with moderate or severe anxiety and/or depression symptoms who received routine specialist care across 60 mental health services in England. The study compared rates of meaningful improvement between the domains of internalizing symptoms, functioning, and progress towards self-defined goals. Consistent cross-domain improvement was observed in only 15.6% of cases. Close to one in four (24.0%) young people with reliably improved symptoms reported no reliable improvement in functioning. Inversely, one in three (34.8%) young people reported meaningful goal progress but no reliable symptom improvement. Monitoring systems that focus exclusively on symptom change risk over- or under-estimating actual impact, while aggregating different outcomes into a single metric can mask informative differences in the number and type of outcomes showing improvement. A move towards harmonized outcome measurement approaches across multiple domains is needed to ensure fair and meaningful comparisons.

The effective delivery of digital CBT: a service evaluation exploring the outcomes of young people who completed video conferencing therapy in 2020

Despite its impressive evidence base, there is a widening access gap to receiving cognitive behavioural therapy (CBT). Video conferencing therapy (VCT) offers an effective solution for logistical barriers to treatment, which has been salient throughout the Coronavirus pandemic. However, research concerning the delivery of CBT via VCT for children and young people (CYP) is in its infancy, and clinical outcome data are limited. The aim of this service evaluation was to explore the effectiveness of a VCT CBT intervention for CYP referred from Child and Adolescent Mental Health Services (CAMHS) in the UK. A total of 989 records of CYP who had completed CBT via VCT in 2020 with Healios, a digital mental health company commissioned by the National Health Service (NHS), were examined to determine changes in anxiety, depression and progress towards personalised goals. Routine outcome measures (ROMs) were completed at baseline and endpoint, as well as session by session. Feedback was collected from CYP and their families at the end of treatment. There was a significant reduction in symptoms of anxiety and depression and significant progress towards goals, with pre- to post-effect sizes (Cohen’s d) demonstrating medium to large effects (d=.45 to d=−1.39). Reliable improvement ranged from 31 to 80%, clinical improvement ranged from 33 to 50%, and 25% clinically and reliably improved on at least one measure; 92% reported that they would recommend Healios. This service evaluation demonstrates that Healios’ CBT delivered via VCT is effective for CYP receiving it as part of routine mental health care.

Key learning aims

(1)

A comprehensive mapping of outcomes following psychotherapy for adolescent depression: The perspectives of young people, their parents and therapists

As mental health systems move towards person-centred care, outcome measurement in clinical research and practice should track changes that matter to young people and their families. This study mapped the types of change described by three key stakeholder groups following psychotherapy for depression, and compared the salience of these outcomes with the frequency of their measurement in recent quantitative treatment effectiveness studies for adolescent depression.Using qualitative content analysis, this study identified and categorized outcomes across 102 semi-structured interviews that were conducted with depressed adolescents, their parents, and therapists, as part of a randomized superiority trial. Adolescents had been allocated to Cognitive-Behavioral Therapy, Short-Term Psychoanalytic Psychotherapy, or a Brief Psychosocial Intervention.The study mapped seven high-level outcome domains and 29 outcome categories. On average, participants discussed change in four domains and six outcome categories. The most frequently discussed outcome was an improvement in mood and affect (i.e., core depressive symptoms), but close to half of the participants also described changes in family functioning, coping and resilience, academic functioning, or social functioning. Coping had specific importance for adolescents, while parents and therapists showed particular interest in academic functioning. There was some variation in the outcomes discussed beyond these core themes, across stakeholder groups and treatment arms.Of the outcomes that were frequently discussed in stakeholder narratives, only symptomatic change has been commonly reported in recent treatment studies for adolescent depression. A shift towards considering multiple outcome domains and perspectives is needed to reflect stakeholder priorities and enable more nuanced insights into change processes.

Attitudes Towards the Use of Routine Outcome Monitoring of Psychological Therapies Among Mental Health Providers: The EBPAS-ROM

Implementation of routine outcome monitoring (ROM) in mental health care is progressing slowly. Knowledge about factors influencing ROM implementation, including health providers' attitudes towards ROM, is necessary. Based on a survey of 662 psychologists and nurses, this article describes (1) the development of a short instrument measuring provider attitudes towards ROM, derived from the Evidence-based Practice Attitude Scale (EBPAS), and (2) how attitudinal domains relate to clinicians' current use of standardized instruments for treatment evaluation. The EBPAS-ROM showed concurrent validity in predicting aspects important for the implementation of ROM, including perceived limitations and the value of organizational support.

Complexity and potentials of clinical feedback in mental health: an in-depth study of patient processes

Purpose

Routine outcome monitoring (ROM) and clinical feedback systems (CFS) are becoming increasingly prevalent in mental health services. Their overall efficacy is unclear, but quantitative evidence suggests they can be useful tools for preventing treatment failure and enhancing therapeutic outcomes, especially for patients who are not progressing in therapy. The body of qualitative material, however, is smaller and less refined. We need to know more about how ROM/CFS is used in psychotherapy, and why it is helpful for some patients, but not others.

Methods

We recorded therapy sessions of 12 patients who were using a CFS as part of their therapies at an outpatient clinic in Norway. We then conducted video-assisted interviews and follow-up interviews with patients. Data were analyzed with systematic text condensation.

Results

Analysis revealed three themes: (1) triggering reflections, emotions, and self-awareness, (2) Ambivalent and ambiguous self-presentation, and (3) potential for feeling understood and talking about what matters.

Conclusion

Answering questions in a CFS is an interpretative and intentional process of self-presentation and the results from ROM/CFS must be interpreted and explored in conversation to be clinically useful. When they are, they have potential for enhancing the therapeutic process by stimulating self-awareness, reflexivity, and allowing access to new therapeutic topics. Further research should explore this how-to aspect of ROM/CFS with different CFS and different types of patients. Integrating clinical feedback in therapeutic practice can be conceptualized as a clinical skill, which should be a part of training programs for therapists.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02550-1) contains supplementary material, which is available to authorized users.

Review: What Outcomes Count? A Review of Outcomes Measured for Adolescent Depression Between 2007 and 2017

OBJECTIVE

Measurement of treatment outcomes in childhood depression has traditionally focused on assessing symptoms from the clinician's perspective, without exploring other outcome domains or considering young people's perspectives. This systematic review explored the extent to which multidimensional and multi-informant outcome measurements have been used in clinical research for adolescent depression in the past decade and how patterns have evolved over time.

METHOD

Embase, Medline, and PsycINFO were searched, and studies that were published from 2007 through 2017 and assessed the effectiveness of treatments or service provision for adolescent depression were included. Of 7,483 studies screened, 95 met the inclusion criteria and were included for data extraction and analysis.

RESULTS

Ten outcomes domains were identified, 2 of which were assessed on average using 4 outcome measures. Most studies (94%) measured symptoms, followed by functioning (52%). Other domains such as personal growth, relationships, quality of life, and service satisfaction were each considered by less than 1 in 10 studies. Youth self-report was considered by 54% but tended to focus on secondary outcomes. Multidimensional and multi-informant measurements were more frequent in studies published since 2015.

CONCLUSION

Recent clinical research continues to prioritize symptoms measurement based on clinician report and has not yet fully embraced multidimensional and multi-informant approaches. In the context of significant policy shifts toward patient-centered and evidence-based care, measuring what matters most to patients has become a priority, but this is not yet widely reflected in clinical research.

How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis

BACKGROUND

In this paper, we report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. We tested two overarching programme theories: (1) PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians and (2) PROMs scores raise clinicians' awareness of patients' problems and prompts discussion and action. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes.

RESULTS

PROMs completion prompts patients to reflect on their health and gives them permission to raise issues with clinicians. However, clinicians found standardised PROMs completion during patient assessments sometimes constrained rather than supported communication. In response, clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships. Individualised PROMs supported dialogue by enabling the patient to tell their story. In oncology, PROMs completion outside of the consultation enabled clinicians to identify problematic symptoms when the PROM acted as a substitute rather than addition to the clinical encounter and when the PROM focused on symptoms and side effects, rather than health related quality of life (HRQoL). Patients did not always feel it was appropriate to discuss emotional, functional or HRQoL issues with doctors and doctors did not perceive this was within their remit.

CONCLUSIONS

This paper makes two important contributions to the literature. First, our findings show that PROMs completion is not a neutral act of information retrieval but can change how patients think about their condition. Second, our findings reveal that the ways in which clinicians use PROMs is shaped by their relationships with patients and professional roles and boundaries. Future research should examine how PROMs completion and feedback shapes and is influenced by the process of building relationships with patients, rather than just their impact on information exchange and decision making.

Routine Outcome Monitoring in CAMHS: How Can We Enable Implementation in Practice?

BACKGROUND

Many CAMHS teams across the UK are now required to use Routine Outcome Monitoring (ROM). However, some clinicians hold negative attitudes towards ROM and various practical implementation issues have been identified.

METHOD

The aim of this study was to explore clinician experiences of using ROM in the context of an 'enforced' initial implementation initiative. Twenty clinicians were surveyed at the beginning (T1) and end (T2) of the six-month period in a large UK CAMHS network adopting CYP-IAPT practice. Changes in the use of and attitudes towards ROM were investigated, as well as barriers to implementation.

RESULTS

Overall, a small but significant increase in clinician use of ROM was observed from T1 to T2, but attitudes towards ROM did not change significantly. On the whole, clinicians were more positive than negative about ROM during the implementation period, but key implementation challenges included clinician concerns about the value and (mis)use of ROM data, poor technological support and additional workload demands.

CONCLUSIONS

CAMHS clinicians will not necessarily become more receptive to ROM simply as a by-product of being asked to use it more. Seeking clinician feedback at the early stages of implementation can help provide a focus for improvement efforts. Ideas for future research and important limitations of the study are discussed.

Validation of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) in New Zealand help-seeking adolescents

OBJECTIVE

This study examines the reliability and validity of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) for measuring depression in New Zealand help-seeking adolescents.

METHOD

A sample of 183 adolescents completed the 33-item MFQ, which includes all 13 items on the SMFQ, at three time points during a trial of a computerized intervention for depression.

RESULTS

Both the MFQ and SMFQ demonstrated good to excellent Cronbach's alphas, moderate to strong item-total score correlations, moderate to strong correlations with quality of life and anxiety measures, and strong correlations with the clinician-rated Children's Depression Rating Scale-Revised and the Reynolds Adolescent Depression Scale 2 at all time points, indicating good reliability and content, convergent, and concurrent validities, respectively. Favoring sensitivity over specificity, the optimal cut-off value for differentiating depressed from nondepressed cases for the MFQ was ≥28 and for the SMFQ was ≥12. Both instruments demonstrated satisfactory diagnostic accuracy and sensitivity to change.

CONCLUSION

The MFQ and SMFQ are free and simple instruments that can be used to identify depression and measure symptom change in New Zealand help-seeking adolescents.

The young adult Strengths and Difficulties Questionnaire (SDQ) in routine clinical practice

Expansion of the youth mental health sector has exposed a need for an outcome measure for young adults accessing services. The Strengths and Difficulties Questionnaire (SDQ) is a widely used consumer and carer outcome measure for children and adolescents. The aim of this study was to evaluate the psychometric properties of a young adult SDQ. The young adult SDQ was introduced for routine clinical practice at Eastern Health Child and Youth Mental Health Service (EH-CYMHS), complementing the well-established adolescent and child versions. Data for adolescents (aged 12-17) and young adults (aged 18-25) where both self-report and parent SDQs had been completed at entry point to the service were extracted from a two-year period. Overall, paired cases involved 532 adolescents and 125 young adults. Across both self-report and parent SDQs, a similar pattern of results was found between adolescents and young adults on mean scores, inter-scale correlations, internal consistency, and inter-rater agreement. The findings of the current study support the use of the young adult SDQ in public mental health as an instrument whose psychometric properties, to date, appear consistent with those of the adolescent version. Further investigation is warranted.

Patterns of referral and waiting times for specialist Child and Adolescent Mental Health Services

BACKGROUND

During 12-month period (2012/13) around 21,480 children and young people (CYP) were referred to Child and Adolescent Mental Health Service (CAMHS) in Scotland (NHS Scotland, 2013, Child and Adolescent Mental Health Services waiting times in Scotland). At the end of September 2012, there were 3,602 CYP still waiting for 'start of treatment' or 'removal from the waiting list', 375 (10%) CYP had waited over 26 weeks and 1,204 (33%) CYP had waited over 18 weeks (NHS Scotland, 2013, Child and Adolescent Mental Health Services waiting times in Scotland). Referral source, referral reason and the sociodemographic characteristics of CYP are not routinely collected, and therefore, associations between these factors and wait times for 'start of treatment' or 'removal from the waiting list' (i.e. the referral outcome) are unknown.

METHOD

In this exploratory study, a retrospective analysis of referral data was conducted in one CAMHS. Data for 476 referrals between 1st May 2013 and 31st May 2014 were initially analysed to define categories for each of the following key variables: referral source, referral reason and referral outcome. Data on CYP sociodemographic characteristics were extracted from referral records, including age, gender and postcode, from which Scottish Index of Multiple Deprivation quintile of residence was derived. Descriptive statistics were calculated for referral source, referral reason and CYP sociodemographic characteristics. Regression models were then built to determine predictors of a referral being rejected by CAMHS and waiting time for referrals accepted by CAMHS. Data were analysed in SPSS (Version 20).

RESULTS

Of the 476 referrals, 72% (n = 342) were accepted and 12% (n = 59) were rejected. Most referrals were made by general practitioners. Just under a third of referrals to CAMHS (31%) were for CYP with emotional and behavioural difficulties. The odds of being rejected by CAMHS were significantly higher if referred by teachers and for CYP with emotional and behavioural difficulties. Age and referral reason were significant independent predictors of waiting time after referral to CAMHS, with CYP referred for hyperactivity/inattention waiting significantly longer.

CONCLUSIONS

Policymakers should consider ways to foster dialogue and collaboration between different groups of professionals making and accepting referrals to CAMHS in order to improve timely access to appropriate mental health support services for CYP. Research is urgently needed to investigate the experiences of CYP who are either rejected by CAMHS or wait lengthy periods of time before starting their treatment with CAMHS.

The Challenges of Using Self-Report Measures with People with Severe Mental Illness: Four Participants' Experiences of the Research Process

This study aimed to explore four mental health consumers' experiences of completing self-report outcome measures in a research project. Participants were recruited from a community mental health organisation in Melbourne and were interviewed upon completion of a mixed methods research study where they were asked to complete a series of self-report outcome measures. Descriptive phenomenological micro-analysis was used to analyse interview data and is presented along with the researchers' observations during the data collection process. Results revealed that participants found the outcome measures cognitively challenging and the language used in the measures did not support the empowering intentions of mental health recovery. The authors suggest that the value of completing surveys for people with severe mental illness needs to be carefully considered so that the research process does not diminish other benefits of participation.

Patients' experiences with routine outcome monitoring and clinical feedback systems: A systematic review and synthesis of qualitative empirical literature

Routine outcome monitoring (ROM) and clinical feedback (CF) systems have become important tools for psychological therapies, but there are challenges for their successful implementation.

OBJECTIVE

To overcome these challenges, a greater understanding is needed about how patients experience the use of ROM/CF.

METHOD

We conducted a systematic literature search of qualitative studies on patient experiences with the use of ROM/CF in mental health services.

RESULTS

The findings from 16 studies were synthesized, resulting in four meta-themes: (1) Suspicion towards service providers, (2) Flexibility and support to capture complexity, (3) Empowering patients, and (4) Developing collaborative practice.

CONCLUSIONS

We discuss the implications of these meta-themes for further development and implementation of ROM/CF into clinical practice, acknowledging the limitations of our review and suggesting avenues for further research. Clinical or methodological significance of this article: This article provides useful and actionable knowledge about the patient perspective on ROM/CF, an important discussion on the current state of research in this area, and useful and concrete suggestions for further avenues of research.

A qualitative exploration of attitudes towards the use of outcome measures in child and adolescent mental health services

The aim of the present research was to explore clinician attitudes to outcome measures and, in particular, the facilitators and barriers to implementing outcome measures. An up-to-date exploration of clinician attitudes is especially needed in the context of recent policies on the implementation of outcome measures in child and adolescent mental health services (CAMHS), and because evidence suggests that there is a disparity between policy recommendations and the use of outcome measures in clinical practice. Semi-structured interviews were conducted with nine CAMHS clinicians from a Mental Health Trust in South London. Two levels of implementation emerged from the analysis: (1) the service level, regarding the implementation of outcome measures across a service to inform service improvement and (2) the session level, regarding the implementation of outcome measures within individual clinical sessions. The present research described training and ongoing support as a crucial facilitator of use at both service and session levels. This included help overcoming local contextual barriers, such as resources, information systems and administrative processes. The research showed that a balance is needed between a mandatory and uniform approach across a service and providing clinicians with support to use outcome measures with all service users for whom they are appropriate.

A Qualitative Exploration of Patient and Clinician Views on Patient Reported Outcome Measures in Child Mental Health and Diabetes Services

Patient Reported Outcome Measures (PROMs) are increasingly being recommended for use in both mental and physical health services. The present study is a qualitative exploration of the views of young people, mothers, and clinicians on PROMs. Semi-structured interviews were conducted with a sample of n = 10 participants (6 young people, 4 clinicians) from mental health services and n = 14 participants (4 young people, 7 mothers, 3 clinicians) from a diabetes service. For different reasons, young people, mothers, and clinicians saw feedback from PROMs as having the potential to alter the scope of clinical discussions.

When is Sessional Monitoring More Likely in Child and Adolescent Mental Health Services?

Sessional monitoring of patient progress or experience of therapy is an evidence-based intervention recommended by healthcare systems internationally. It is being rolled out across child and adolescent mental health services (CAMHS) in England to inform clinical practice and service evaluation. We explored whether patient demographic and case characteristics were associated with the likelihood of using sessional monitoring. Multilevel regressions were conducted on N = 2609 youths from a routinely collected dataset from 10 CAMHS. Girls (odds ratio, OR 1.26), older youths (OR 1.10), White youths (OR 1.35), and youths presenting with mood (OR 1.46) or anxiety problems (OR 1.59) were more likely to have sessional monitoring. In contrast, youths under state care (OR 0.20) or in need of social service input (OR 0.39) were less likely to have sessional monitoring. Findings of the present research may suggest that sessional monitoring is more likely with common problems such as mood and anxiety problems but less likely with more complex cases, such as those involving youths under state care or those in need of social service input.

Patient reported outcome measures in child and adolescent mental health services: associations between clinician demographic characteristics, attitudes and efficacy

BACKGROUND

Policy recommends using patient reported outcome measures (PROMs), yet their use is persistently low. Our aim was to examine the association between PROM use and clinician demographic characteristics, attitudes and efficacy.

METHOD

A sample of N = 109 clinicians completed an online survey.

RESULTS

Clinicians who reported higher levels of use of cognitive behaviour or humanistic approaches had higher levels of PROM use than clinicians who reported lower levels of use of these approaches. Clinicians who reported having received training had higher levels of self-efficacy regarding PROMs than clinicians who reported not having received training, but the effects of training on PROM attitudes and use were not significant. Still, clinicians with more positive attitudes or self-efficacy regarding PROMs had higher levels of PROM use than clinicians with less positive attitudes or self-efficacy regarding PROMs.

CONCLUSION

Clinicians should be supported to have the knowledge, skills and confidence to effectively use PROMs in their clinical practice.

Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care

Background

The feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.

Objectives

To (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.

Design

Two separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.

Interventions

Aggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.

Main outcome measures

Aggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.

Data sources

Searches of electronic databases and forwards and backwards citation tracking.

Review methods

Realist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.

Results

Providers were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.

Strengths and limitations

There was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.

Conclusions

PROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.

Future work

Future research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.

Study registration

This study is registered as PROSPERO CRD42013005938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Game for health: How eHealth approaches might address the psychological needs of children and young people with long-term physical conditions

AIM

The aim of this study was to describe the psychological experiences of children and young people with long term physical conditions, their families and clinicians and to explore if these may be improved using eHealth interventions, including online information, support and e-therapy.

METHODS

Totally 11 children (7-12 years), 11 young people (13-18 years), 7 parents, 11 paediatricians and 10 general practitioners participated in a series of seven semi-structured digitally recorded focus groups. A general inductive approach was used to analyse interview data.

RESULTS

Feedback consisted of five main themes: (i) the experience of long-term physical conditions as an anxiety-provoking journey, (ii) limited access to information and eHealth-related interventions to support this journey, (iii) desires for interventions that assist with multiple aspects of the illness experience, (iv) diversity of preferences regarding the format and vehicle of such interventions, (v) the importance of trust regarding the source of interventions for children, young people and families and the sustainability of new interventions for clinicians.

CONCLUSIONS

eHealth interventions are currently being used in a limited manner by children and young people with long-term physical conditions and their families. Despite some concern expressed mainly by clinicians, there is overall support from all groups for the future development of eHealth interventions to address psychological issues for this audience, particularly anxiety. Relatable content, technological appeal and ease of access/referral to such interventions are likely to improve the uptake of these relatively new interventions.

Cross-cultural acceptability and utility of the strengths and difficulties questionnaire: views of families

BACKGROUND

Screening children for behavioural difficulties requires the use of a tool that is culturally valid. We explored the cross-cultural acceptability and utility of the Strengths and Difficulties Questionnaire for pre-school children (aged 3-5) as perceived by families in New Zealand.

METHODS

A qualitative interpretive descriptive study (focus groups and interviews) in which 65 participants from five key ethnic groups (New Zealand European, Māori, Pacific, Asian and other immigrant parents) took part. Thematic analysis using an inductive approach, in which the themes identified are strongly linked to the data, was employed.

RESULTS

Many parents reported they were unclear about the purpose of the tool, affecting its perceived value. Participants reported not understanding the context in which they should consider the questions and had difficulty understanding some questions and response options. Māori parents generally did not support the questionnaire based approach, preferring face to face interaction. Parents from Māori, Pacific Island, Asian, and new immigrant groups reported the tool lacked explicit consideration of children in their cultural context. Parents discussed the importance of timing and multiple perspectives when interpreting scores from the tool.

CONCLUSIONS

In summary, this study posed a number of challenges to the use of the Strengths and Difficulties Questionnaire in New Zealand. Further work is required to develop a tool that is culturally appropriate with good content validity.

A critical interpretive synthesis of the most commonly used self-report measures in Australian mental health research

OBJECTIVE

To critically examine the self-report measures most commonly used in Australian mental health research in the last 10 years.

METHOD

A critical interpretive synthesis was conducted using seven outcome measures that were identified as most popular in 43 studies from three mental health journals.

RESULTS

Results suggest that the amount and type of language used in outcome measures is important in both increasing the accuracy of the data collected and fostering positive experiences of data collection for participants.

CONCLUSIONS

Results indicate that many of the measures most often used in Australian mental health research may not align with the current contemporary philosophy of mental health clinical practice in Australia.

Feasibility of the Strengths and Difficulties Questionnaire in assessing children's mental health in primary care: Finnish parents', teachers' and public health nurses' experiences with the SDQ

BACKGROUND

The aim of the study was to evaluate the feasibility of the Strengths and Difficulties Questionnaire (SDQ).

METHOD

Following the administration of the SDQ in medical check-ups of 4-9 year-old children (n = 2 682) the involved parents, teachers and public health nurses were asked to complete a feedback questionnaire of the SDQ.

RESULTS

Parents took a maximum of 10-15 minutes to complete the SDQ, and only the public health nurses reported that its use was rather burdensome. The SDQ was an age-appropriate method and it was helpful in increasing information and agreement about the child's mental health and need for support. Using the SDQ was a positive experience for parents, but they expected more dialogue with the professionals about the child's situation. The respondents criticised the questionnaire somewhat for being difficult to interpret and complete.

CONCLUSIONS

The SDQ was found to be a feasible method for screening children's mental health in primary health care together with parents, teachers and public health nurses. Using the SDQ was a positive experience for parents. However, they reminded the professionals of the importance of sensitive dialogue when assessing the mental health of the child.