REACH-ASD: a UK randomised controlled trial of a new post-diagnostic psycho-education and acceptance and commitment therapy programme against treatment-as-usual for improving the mental health and adjustment of caregivers of children recently diagnosed with autism spectrum disorder.

BACKGROUND: Autism is a neurodevelopmental disability affecting over 1% of UK children. The period following a child's autism diagnosis can present real challenges in adaptation for families. Twenty to 50% of caregivers show clinically significant levels of mental health need within the post-diagnostic period and on an ongoing basis. Best practice guidelines recommend timely post-diagnostic family support. Current provision is patchy, largely unevidenced, and a source of dissatisfaction for both families and professionals. There is a pressing need for an evidenced programme of post-diagnostic support focusing on caregiver mental health and adjustment, alongside autism psycho-education. This trial tests the clinical and cost-effectiveness of a new brief manualised psychosocial intervention designed to address this gap. METHODS: This is a multi-centre two-parallel-group single (researcher)-blinded randomised controlled trial of the Empower-Autism programme plus treatment-as-usual versus usual local post-diagnostic offer plus treatment-as-usual. Caregivers of children aged 2-15 years with a recent autism diagnosis will be recruited from North West England NHS or local authority centres. Randomisation is individually by child, with one "index" caregiver per child, stratified by centre, using 2:1 randomisation ratio to assist recruitment and timely intervention. Empower-Autism is a group-based, manualised, post-diagnostic programme that combines autism psycho-education and psychotherapeutic components based on Acceptance and Commitment Therapy to support caregiver mental health, stress management and adjustment to their child's diagnosis. The comparator is any usual local group-based post-diagnostic psycho-education offer. Receipt of services will be specified through health economic data. PRIMARY OUTCOME: caregiver mental health (General Health Questionnaire-30) at 52-week follow-up. SECONDARY OUTCOMES: key caregiver measures (wellbeing, self-efficacy, adjustment, autism knowledge) at 12-, 26- and 52-week follow-up and family and child outcomes (wellbeing and functioning) at 52-week endpoint. SAMPLE: N=380 (approximately 253 intervention/127 treatment-as-usual). Primary analysis will follow intention-to-treat principles using linear mixed models with random intercepts for group membership and repeated measures. Cost-effectiveness acceptability analyses will be over 52 weeks, with decision modelling to extrapolate to longer time periods. DISCUSSION: If effective, this new approach will fill a key gap in the provision of evidence-based care pathways for autistic children and their families. TRIAL REGISTRATION: ISRCTN 45412843 . Prospectively registered on 11 September 2019.

Virtual clinical examinations: are they the new ‘normal'?

Aims The North West School of Psychiatry run a yearly structured clinical examination to help Core Psychiatry Trainees develop their training competencies and prepare for the MRCPsych Clinical Assessment of Skills and Competencies (CASC). Historically, this has been face-to-face with logistical difficulties, high cost, low trainee uptake and challenging in recruiting examiners. Following the COVID-19 pandemic and the subsequent shift to virtual consultations and examinations, the team implemented an innovative virtual Skills test. The main aims were to improve the test's quality and the trainee uptake, adapt the test delivery to a Health Education England (HEE) online platform, and establish cost-effectiveness in the post-COVID world. Method A working group was formed to develop the Skills test, and in May 2019, the test was delivered face-to-face, implementing 5 cycles of 8 stations over 3 days. The same group adapted the test for online delivery, and in August 2020, 3 cycles of 8 stations were delivered. Feedback was collected, with adaptations made for a second Skills Test in December 2020. Result 96.4% of trainees rated their overall experience and the test organisation in the 2019 test as excellent or good (82.1% and 85.7 excellent, respectively). 93.5% of examiners rated their overall experience and the test organisation as excellent or good (45.1% excellent for both). In the August test, 95.8% of trainees rated their overall experience as excellent or good (58.3% excellent). 100% of trainees rated the test organisation and the online format as excellent or good (70.8% and 50% excellent, respectively). Although 100% of examiners rated the overall experience, the test organisation and online format as excellent or good, some felt the stations were not long enough to allow for technical issues. In the December test, higher proportions of trainees rated the overall experience (80%), organisation of the test (80%) and online format (70%) as excellent. Conclusion The virtual test is shown to be a viable and successful alternative to the face-to-face test in preparing trainees for their CASC, and trainees felt it was excellent preparation for the new online CASC format. It had some clear advantages, such as saving on consumables, reducing the financial costs of running the test, improving the test quality, and increasing the trainee uptake. It is more eco-friendly and reduces fuel emission, raising the question of how the test should be delivered after the COVID-19 pandemic.