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

Clinical guidelines for severe behavioural problems (SBPs) in children have recently been developed in several European countries. However, questions emerged regarding their applicability to practice. Our study aimed to provide a first European insight into guidelines' fitness-for-purpose by exploring mental health clinicians' familiarity with, use and perceived value of guidelines for SBPs in children. Participants included 161 clinicians, primarily psychiatrists, from 24 countries. Clinicians completed a semi-structured qualitative questionnaire on existing SBPs guidelines and development of new guidelines where not available. Clinicians' responses were mapped against academic experts' perceptions on SBPs guidelines highlighted in a previous study (Gatej et al. in Eur Psychiatry 57:1-9, 2019). Under half of the clinicians reported being unaware of guidelines. Of these, 37.6% represented countries where guidelines were available according to experts. The remaining half of clinicians who were aware of guidelines on average reported being moderately familiar with their content, perceiving them as moderately useful and using them some of the time. Additionally, 60.8% clinicians agreed that SBPs guidelines need to be developed, as these would create a shared scientific knowledge base and common practice. Guideline improvements included taking a multifactorial approach, creating specific case recommendations, and dissemination efforts. The modest familiarity with and use of guidelines amongst practitioners may highlight guidelines poor fitness-for-purpose, or, alternatively, an underlying confusion around the meaning and purpose of guidelines. Moving forward, efforts should be directed at disseminating clearer definitions of guidelines, addressing existing challenges, and unifying efforts to further develop and audit application of international guidelines for SBPs.

Awareness and perceptions of clinical guidelines for the diagnostics and treatment of severe behavioural problems in children across Europe: A qualitative survey with academic experts.

BACKGROUND: Severe behavioural problems (SBPs1) in childhood are highly prevalent, impair functioning, and predict negative outcomes later in life. Over the last decade, clinical practice guidelines for SBPs have been developed across Europe to facilitate the translation of scientific evidence into clinical practice. This study outlines the results of an investigation into academic experts' perspectives on the current prevalence, implementation, and utility of clinical guidelines for SBPs in children aged 6-12 across Europe. METHODS: An online semi-structured questionnaire was completed by 28 psychiatry and psychology experts from 23 countries. RESULTS: Experts indicated that approximately two thirds of the included European countries use at least an unofficial clinical document such as textbooks, while nearly half possess official guidelines for SBPs. Experts believed that, although useful for practice, guidelines' benefits would be maximised if they included more specific recommendations and were implemented more conscientiously. Similarly, experts suggested that unofficial clinical documents offer a wide range of treatment options to individualise treatment from. However, they stressed the need for more consistent, evidence-based clinical practices, by means of developing national and European clinical guidelines for SBPs. CONCLUSIONS: This study offers a preliminary insight into the current successes and challenges perceived by experts around Europe associated with guidelines and documents for SBPs, acting as a stepping stone for future systematic, in-depth investigations of guidelines. Additionally, it establishes experts' consensus for the need to develop official guidelines better tailored to clinical practice, creating a momentum for a transition towards European clinical guidelines for this population.

Childhood aggression and the co-occurrence of behavioural and emotional problems: results across ages 3-16 years from multiple raters in six cohorts in the EU-ACTION project.

Childhood aggression and its resulting consequences inflict a huge burden on affected children, their relatives, teachers, peers and society as a whole. Aggression during childhood rarely occurs in isolation and is correlated with other symptoms of childhood psychopathology. In this paper, we aim to describe and improve the understanding of the co-occurrence of aggression with other forms of childhood psychopathology. We focus on the co-occurrence of aggression and other childhood behavioural and emotional problems, including other externalising problems, attention problems and anxiety-depression. The data were brought together within the EU-ACTION (Aggression in Children: unravelling gene-environment interplay to inform Treatment and InterventiON strategies) project. We analysed the co-occurrence of aggression and other childhood behavioural and emotional problems as a function of the child's age (ages 3 through 16 years), gender, the person rating the behaviour (father, mother or self) and assessment instrument. The data came from six large population-based European cohort studies from the Netherlands (2x), the UK, Finland and Sweden (2x). Multiple assessment instruments, including the Child Behaviour Checklist (CBCL), the Strengths and Difficulties Questionnaire (SDQ) and Multidimensional Peer Nomination Inventory (MPNI), were used. There was a good representation of boys and girls in each age category, with data for 30,523 3- to 4-year-olds (49.5% boys), 20,958 5- to 6-year-olds (49.6% boys), 18,291 7- to 8-year-olds (49.0% boys), 27,218 9- to 10-year-olds (49.4% boys), 18,543 12- to 13-year-olds (48.9% boys) and 10,088 15- to 16-year-olds (46.6% boys). We replicated the well-established gender differences in average aggression scores at most ages for parental ratings. The gender differences decreased with age and were not present for self-reports. Aggression co-occurred with the majority of other behavioural and social problems, from both externalising and internalising domains. At each age, the co-occurrence was particularly prevalent for aggression and oppositional and ADHD-related problems, with correlations of around 0.5 in general. Aggression also showed substantial associations with anxiety-depression and other internalizing symptoms (correlations around 0.4). Co-occurrence for self-reported problems was somewhat higher than for parental reports, but we found neither rater differences, nor differences across assessment instruments in co-occurrence patterns. There were large similarities in co-occurrence patterns across the different European countries. Finally, co-occurrence was generally stable across age and sex, and if any change was observed, it indicated stronger correlations when children grew older. We present an online tool to visualise these associations as a function of rater, gender, instrument and cohort. In addition, we present a description of the full EU-ACTION projects, its first results and the future perspectives.

Longitudinal results of strengthening the parent-team alliance in child semi-residential psychiatry: does team investment make a difference?

BACKGROUND: In a semi-residential setting where children switch daily between treatment and home, establishment of a strong parent-team alliance can be a challenge. The development of alliance with parents and the symptoms of the child might be strengthened by a structured investment of treatment team members. METHODS: Participants were caregivers and treatment team members of 46 children (6-12 years) who received semi-residential psychiatric treatment. An A-B design was applied, in which the first 22 children were assigned to the comparison group receiving treatment as usual and the next 24 to the experimental group, where treatment team members used additional alliance-building strategies. Alliance and symptom questionnaires were filled out at three-month intervals during both treatment conditions. Parent-treatment team interactions, assessed on DVD, were coded according to members' adherence to these strategies. RESULTS: Multilevel analyses (using MLwiN) showed that based on reports of primary caregivers and a case manager, the alliance-building strategies had a statistically significant effect on the strength of the therapeutic alliance between treatment team members and parents. In addition, primary caregivers in the experimental group reported significant less hyperactivity symptoms of their children. CONCLUSIONS: Despite the methodological challenge of examining therapeutic processes in this complex treatment setting, this study supports the benefits of structured investment in the parent-team alliance.

A Measure of the Parent-Team Alliance in Youth Residential Psychiatry: The Revised Short Working Alliance Inventory.

BACKGROUND: The therapeutic alliance between multidisciplinary teams and parents within youth (semi) residential psychiatry is essential for the treatment process and forms a promising process variable for Routine Outcome Monitoring (ROM). No short evaluative instrument, however, is currently available to assess parent-team alliance. OBJECTIVE: In this study, the Working Alliance Inventory-Short Version (WAV-12), a widely used alliance questionnaire, was adjusted to assess parent-team alliance from both a parent and team perspective within a youth residential setting. Psychometric properties, including factor structure and validity of the subscales, were explored. METHODS: A sample of youth with mainly complex developmental disorders admitted to 11 inpatient and day patient units of a child and adolescent psychiatric institute participated in this study. The case manager involved with the youth and the primary caregiver of 87 youth completed the revised WAV-12 (WAV-12R). RESULTS: The team version of the WAV-12R showed a good fit to the original conceptualized model, and distinguished Bond, Task and Goal scales. For the parents' version an adjusted model with Insight, Bond and combined Task/Goal scales had the best fit. The reliability and validity of the scales were shown to be good. CONCLUSIONS: This paper presents preliminary evidence that the parent and treatment team versions of the WAV-12R are psychometrically sound for assessing parent-team alliance within youth (semi) residential psychiatry in the Netherlands. The team and parents' versions of the WAV-12R are recommended instruments to complement outcome measures in ROM.

The use of routine outcome monitoring in child semi-residential psychiatry: predicting parents' completion rates.

BACKGROUND: Parents' perspectives on their children's treatment process and outcomes are valuable to treatment development and improvement. Participants' engagement in Routine Outcome Monitoring (ROM) has, however, been difficult and may particularly be so in specialized settings, such as semi-residential psychiatry. In this paper, the use of a web-based ROM system implemented in a child semi-residential psychiatric setting is described and predictors associated with low completion rates of questionnaires by parents are identified. METHODS: Parents and the multidisciplinary team of 46 children admitted to semi-residential psychiatric treatment participated in this study and completed a battery of questionnaires in three month intervals. RESULTS: The overall completion rate of both parents during ROM assessment was 77 % compared to 83 % of all clinicians involved. Completion of questionnaires by parents was higher around first assessments and declined after a year treatment. For eight clients at least one of the parents stopped filling out questionnaires during ROM measuring. Logistic multilevel analyses revealed initial treatment factors associated with a low completion of questionnaires by parents during ROM: high comorbidity of the child on DSM Axis I, single parenthood, a higher parental educational level and having a weaker therapeutic alliance regarding goal setting. CONCLUSIONS: The findings in this paper demonstrate relatively high completion of questionnaires by clinicians and parents when using ROM in child semi-residential psychiatry. Strong administrative and electronic support undoubtedly contributed to this result. Clinicians are encouraged to motivate parents to mutually invest in ROM, and to take into account factors indicating a possible lower completion of questionnaires by parents.

Assessment of the therapeutic alliance of youth and parents with team members in youth residential psychiatry.

Although therapeutic alliance is widely acknowledged as a key component for therapeutic change, its role is almost unknown in youth residential psychiatry. A likely reason for the lack of research is the absence of assessment tools and procedures for youth residential settings. This study assesses the psychometric properties of the Dutch version of the Family Engagement Questionnaire (FEQ), an alliance measure completed by team members. In addition, agreement among team members is explored. Eleven youth psychiatric day and inpatient units participated. Parent counsellors and case managers of 86 patients from 6 to 17 years old reported on the therapeutic alliance. Exploratory factor analysis of team members' reports resulted in meaningful structures, with child and parent alliance scales primarily corresponding to the conceptualization of the developers and earlier factor analysis. Internal reliability and validity were good for most of the subscales. The hypothesis that team members would show low levels of agreement in their reports of the therapeutic alliance was confirmed, demonstrating the need to include multiple team members in assessment procedures. Overall, this study underscores the psychometric properties of the Dutch version of the FEQ. Team members in residential youth psychiatric settings are encouraged to reflect regularly with their colleagues on the youth and parent therapeutic alliance.