M.I.C.E-Mental Health Intervention for Children with Epilepsy: a randomised controlled, multi-centre clinical trial evaluating the clinical and cost-effectiveness of MATCH-ADTC in addition to usual care compared to usual care alone for children and young people with common mental health disorders and epilepsy-study protocol

Training and supervision of physical health professionals to implement mental health care in paediatric epilepsy clinics

BACKGROUND

Children and young people with epilepsy are more likely to experience multiple mental health problems than those without chronic physical health conditions, yet they often do not receive evidence-based (or indeed any) psychological interventions. Integrated healthcare is recommended as a solution to address these inequalities, but remains limited in the United Kingdom. This is partly due to the lack of training and availability of ongoing supervision for clinicians to ensure the safe and effective delivery of treatments. This study aimed to train and provide supervision for health professionals to deliver a modular cognitive-behavioural intervention for common mental health problems, optimised for use in paediatric epilepsy. Specifically, this study aimed to measure therapist competence and evaluate the acceptability of training and supervision.

METHODS

Fifteen health professionals working in paediatric epilepsy services were trained over a six-month period. Training included face-to-face training workshops and completing at least one training case of a young person with epilepsy and anxiety, depression and/or behavioural problems under close clinical supervision. Throughout the training, health professionals were offered weekly one-hour supervisions with an experienced Clinical Psychologist. Clinical competence was assessed using a widely used measure of therapist competence in cognitive-behavioural therapy. Rates of attendance at supervision sessions and therapist ratings of satisfaction were recorded.

RESULTS

At the end of the six-month training, 14 health professionals reached clinical competence in delivering the mental health intervention. One person left the service and therefore did not complete the training. Overall, health professionals were satisfied with the training and supervision. However, 14 % of supervision sessions were cancelled and a further 11 % were not attended. Supervision sessions were also often shorter than the standard hour used in mental health settings (M = 41.18 min, SD = 10.30).

CONCLUSIONS

Our findings suggest that health professionals working in paediatric epilepsy services can be trained to deliver a psychological intervention with proficiency. However, the supervision model typically used in mental health may need adaptation to be sustainable in physical health settings. Future research is needed to evaluate the impact of training and supervision on patient outcomes and to ensure that ethical delivery of psychological interventions by health professionals without a mental health background.

Clinical effectiveness of the psychological therapy Mental Health Intervention for Children with Epilepsy in addition to usual care compared with assessment-enhanced usual care alone: a multicentre, randomised controlled clinical trial in the UK

BACKGROUND

Mental health difficulties are common in children and young people with chronic health conditions, but many of those in need do not access evidence-based psychological treatments. The study aim was to evaluate the clinical effectiveness of integrated mental health treatment for children and young people with epilepsy, a common chronic health condition known to be associated with a particularly high rate of co-occurring mental health difficulties.

METHODS

We conducted a parallel group, multicentre, open-label, randomised controlled trial of participants aged 3-18 years, attending epilepsy clinics across England and Northern Ireland who met diagnostic criteria for a common mental health disorder. Participants were randomised (1:1; using an independent web-based system) to receive the Mental Health Intervention for Children with Epilepsy (MICE) in addition to usual care, or assessment-enhanced usual care alone (control). Children and young people in both groups received a full diagnostic mental health assessment. MICE was a modular psychological intervention designed to treat common mental health conditions in children and young people using evidence-based approaches such as cognitive behaviour therapy and behavioural parenting strategies. Usual care for mental health disorders varied by site but typically included referral to appropriate services. Participants, along with their caregivers, and clinicians were not masked to treatment allocation but statisticians were masked until the point of analysis. The primary outcome, analysed by modified intention-to-treat, was the parent-report Strengths and Difficulties Questionnaire (SDQ) at 6 months post-randomisation. The study is complete and registered with ISRCTN (57823197).

FINDINGS

1401 young people were potentially deemed eligible for study inclusion. Following the exclusion of 531 young people, 870 participants were assessed for eligibility and completed the SDQ, and 480 caregivers provided consent for study inclusion between May 20, 2019, and Jan 31, 2022. Between Aug 28, 2019, and Feb 21, 2022, 334 participants (mean ages 10·5 years [SD 3·6] in the MICE group vs 10·3 [4·0] in control group at baseline) were randomly assigned to an intervention using minimisation balanced by age, primary mental health disorder, diagnosis of intellectual disability, and autistic spectrum disorder at baseline. 168 (50%) of the participants were female and 166 (50%) were male. 166 participants were randomly assigned to the MICE group and 168 were randomly assigned to the control group. At 6 months, the mean SDQ difficulties for the 148 participants in the MICE group was 17·6 (SD 6·3) and 19·6 (6·1) for the 148 participants in the control group. The adjusted effect of MICE was -1·7 (95% CI -2·8 to -0·5; p=0·0040; Cohen's d, 0·3). 14 (8%) patients in the MICE group experienced at least one serious adverse event compared with 24 (14%) in the control group. 68% percent of serious adverse events (50 events) were admission due to seizures.

INTERPRETATION

MICE was superior to assessment-enhanced usual care in improving symptoms of emotional and behavioural difficulties in young people with epilepsy and common mental health disorders. The trial therefore shows that mental health comorbidities can be effectively and safely treated by a variety of clinicians, utilising an integrated intervention across ages and in the context of intellectual disability and autism. The evidence from this trial suggests that such a model should be fully embedded in epilepsy services and serves as a model for other chronic health conditions in young people.

FUNDING

UK National Institute for Health Research Programme Grants for Applied Research programme and Epilepsy Research UK Endeavour Project Grant.

Group-based parent training programme for children with neurological conditions: a feasibility study

OBJECTIVE AND DESIGN

This study aimed to determine the feasibility and effectiveness of a parent training programme for parents of children with neurological conditions and behaviours that challenge.

SETTING

Child and adolescent mental health service within a specialist children's hospital.

PARTICIPANTS

Parents of 31 children with neurological conditions and behaviours that challenge.

INTERVENTIONS

Parents attended a 6-week evidence-based behavioural parenting programme delivered in a group format, either face-to-face or remote.

MAIN OUTCOME MEASURES

Feasibility was determined by attendance rates. Effectiveness was analysed primarily using parent-reported measures of child behaviour (Strengths and Difficulties Questionnaire, Paediatric Quality of Life and Goal-Based Outcomes). Secondary measures of parental well-being were also reported (Brief Parental Self-Efficacy Scale, Depression Anxiety Stress Scale Short Form and Parental Sense of Competence). Paired t-tests or Wilcoxon rank-sum tests were conducted to analyse differences preintervention and postintervention.

RESULTS

The attendance rates for the face-to-face and remote groups were 80% and 79%, respectively. Medium to large effect sizes were reported for most measures of child behaviour and parental well-being. There were statistically significant improvements found postintervention in children's behaviour (p=0.014), quality of life (p<0.001), goal-based outcomes (p<0.001), parental self-efficacy (p<0.001) and parental anxiety (p=0.030). Anecdotal feedback showed that parents indicated the group format was acceptable.

CONCLUSIONS

The group parenting intervention for parents of children with heterogeneous neurological conditions and behaviours that challenge appears feasible and effective in improving child behaviour and parental well-being.

The Influence of Comorbidity and Perceived Complexity on Outcomes of Referrals to Children and Young Person Mental Health Services (UK): A Mixed Methods Vignette Study

Children and young people (CYP) with long-term physical conditions (LTCs) are four times more likely to develop mental health disorders yet many cannot access Children and Young People's Mental Health Services (CYPMHS) or evidence-based interventions. This study aimed to understand the reasons for this; presence of an LTC neurodevelopmental disorder, or service requirements. 79 CYP mental health practitioners were randomly assigned to read vignettes depicting a hypothetical referral letter for a child with a mental health condition alone (n = 27), mental health condition and LTC (n = 25), or mental health condition and neurodevelopmental disorder (Autism Spectrum Disorder-ASD) (n = 27), answering questions about their likelihood of accepting the referral and proposed treatment plan. There were no significant differences between accessing CYPMHS or being offered first line evidence-based interventions in those with a LTC or ASD compared to those without. However, additional perceived complexity was frequently provided as a reason for rejecting referrals and not offering evidence-based intervention, with clinicians' predicted success of intervention significantly lower for these CYP. Clinicians were significantly more likely to suggest adapting the intervention in the LTC and the ASD groups to account for additional perceived complexity. The research suggests a need for additional services for CYP with LTCs and those with neurodevelopmental disorders, as well as training/awareness for clinicians.

Comprehensive nursing program for children with epilepsy: A randomized controlled trial

Background

Epilepsy is a relatively common childhood neurological disease. Children with epilepsy need to take precautions to minimize seizure damage in order to adapt to seizures and manage them.

Aim

The current study aimed to evaluate the feasibility and effects of a comprehensive nursing program for children with epilepsy to reduce children's symptoms of epilepsy.

Subject and Methods

Participants were children suffering from epilepsy between 2019 and 2021 at Ningbo Women and Children's Hospital. Seventy children were included in a randomized controlled trial with a comprehensive nursing group (CNG) and an active control group (ACG). Measurements were assessed pre- and post-intervention and at a one- and three-month follow-ups. Children in the CNG learned and practiced the strategies related to the comprehensive nursing intervention. The outcomes were anxiety and depression.

Results

The results showed that anxiety and depression scores were significantly lower in the CNG than the ACG at 1 and 3 months after intervention (P < 0.05). According to the feasibility results, whereas most participants believed that the program was informative and meaningful, a minority reported that it was time-consuming.

Conclusion

The intervention has the potential to support children with epilepsy. The program is easily accessible, cost-effective and could be implemented in epilepsy care rehabilitation.

Advancing cluster randomised trials in children’s therapy: a survey of the acceptability of trial behaviours to therapists and parents

Background

Randomised controlled trials of non-pharmacological interventions in children’s therapy are rare. This is, in part, due to the challenges of the acceptability of common trial designs to therapists and service users. This study investigated the acceptability of participation in cluster randomised controlled trials to therapists and service users.

Methods

A national electronic survey of UK occupational therapists, physiotherapists, speech and language therapists, service managers, and parents of children who use their services. Participants were recruited by NHS Trusts sharing a link to an online questionnaire with children’s therapists in their Trust and with parents via Trust social media channels. National professional and parent networks also recruited to the survey. We aimed for a sample size of 325 therapists, 30 service managers, and 60 parents. Trial participation was operationalised as three behaviours undertaken by both therapists and parents: agreeing to take part in a trial, discussing a trial, and sharing information with a research team. Acceptability of the behaviours was measured using an online questionnaire based on the Theoretical Framework of Acceptability constructs: affective attitude, self-efficacy, and burden. The general acceptability of trials was measured using the acceptability constructs of intervention coherence and perceived effectiveness. Data were collected from June to September 2020. Numerical data were analysed using descriptive statistics and textual data by descriptive summary.

Results

A total of 345 survey responses were recorded. Following exclusions, 249 therapists and 40 parents provided data which was 69.6% (289/415) of the target sample size. It was not possible to track the number of people invited to take the survey nor those who viewed, but did not complete, the online questionnaire for calculation of response rates. A completion rate (participants who completed the last page of the survey divided by the participants who completed the first, mandatory, page of the survey) of 42.9% was achieved. Of the three specified trial behaviours, 140/249 (56.2%) therapists were least confident about agreeing to take part in a trial. Therapists (135/249, 52.6%) reported some confidence they could discuss a trial with a parent and child at an appointment. One hundred twenty of 249 (48.2%) therapists reported confidence in sharing information with a research team through questionnaires and interviews or sharing routine health data. Therapists (140/249, 56.2%) felt that taking part in the trial would take a lot of effort and resources. Support and resources, confidence with intervention allocation, and sense of control and professional autonomy over clinical practice were factors that positively affected the acceptability of trials. Of the 40 parents, twelve provided complete data. Most parents (18/40, 45%) agreed that it was clear how trials improve children’s therapies and outcomes and that a cluster randomised trial made sense to them in their therapy situation (12/29, 30%).

Conclusions

Using trials to evaluate therapy interventions is, in principle, acceptable to therapists, but their willingness to participate in trials is variable. The willingness to participate may be particularly influenced by their views related to the burden associated with trials, intervention allocation, and professional autonomy.

Impact of epilepsy on learning and behaviour and needed supports: Views of children, parents and school staff

BACKGROUND

There is limited data on the views of young people with epilepsy, their parents and school staff regarding the impact of epilepsy on learning and behaviour in school. The purpose of the study was to gain an understanding of the impact of epilepsy on learning and behaviour and needed supports according to children with epilepsy, their parents and supporting school staff.

METHODS

School-aged children (n = 20) with 'active epilepsy' (taking anti-seizure Medications (ASMs) for epilepsy), their parents (n = 68) and school staff (n = 56) were interviewed or completed surveys. The quantitative data was analysed using descriptive statistics and responses were compared for children attending mainstream and special schools using chi-square analyses. The answers to open questions were answered using thematic analyses.

RESULTS

The majority (53%) of children with epilepsy felt that epilepsy affected their learning including aspects such as memory, attention and concentration but also physical and emotional wellbeing including increased tiredness and lowered self-confidence. In addition, children brought up possible negative aspects of taking ASMs including increased irritability and emotional reactivity. The children also mentioned that epilepsy in school was associated with stigma and restrictions. The majority (85%) of parents agreed that epilepsy affects the child's learning/behaviour while more staff agreed that epilepsy affects learning (61%) than behaviour (45%). Most parents agreed that that their child's school provided the appropriate resources to support their child's learning (79%) and 72% agreed that they were satisfied overall with the support their child received at school. However, parents of children attending special schools were more likely to agree that the child's school provided appropriate resources to support their child's learning (p = 0.034) and be satisfied with the support their child received in school (p = 0.02), than parents of children attending mainstream schools. With respect to current or desired supports, analysis of the children's responses indicated that they want access to supportive environments outside the classroom, accommodations in tests/exams and increased support from trusted adults. Parent responses included approaches that promote child wellbeing, environmental accommodations, a high ratio of adult support and a consideration of the child's communication needs. Staff views regarding optimal strategies included a high level of adult support for the child, environmental accommodations, use of multimodal learning, adapting communication and approaches that promote psychological wellbeing.

CONCLUSIONS

The majority of children perceived that epilepsy affected their learning and behaviour in school including leading to specific learning difficulties, but also negative impacts on emotional and physical wellbeing. Levels of parental satisfaction with supports were significantly higher in special schools compared with mainstream schools. Children, parents and staff highlighted a number of supports which they felt can support the child with epilepsy's learning but also emotional wellbeing.