Outcomes for Adaptive Mentalization Based Integrative Treatment informed care for adolescents using a deployment-based approach.

PURPOSE: Adolescent mentalisation-based integrative therapy (AMBIT) is a whole-systems approach designed to enhance the effectiveness and coordination of care for clients experiencing severe and pervasive difficulties in social and health care settings, who have not responded to traditional clinical approaches. AMBIT is a team-based manualised method that primarily aims to bolster mental state understanding and discourse focused on the client within and between teams. Over 300 teams worldwide have been trained in and adhere to AMBIT principles. METHOD: In this paper, we review and summarise the outcomes reported by eight AMBIT-informed teams that have published their findings with young people. Each report is discussed, and limitations of the data provided are identified. RESULTS: A synthesis of the findings across the studies suggests a generally positive impact of teams informed by AMBIT with moderate to large effect sizes on reducing symptoms and improving functionality. CONCLUSIONS: This study suggests that AMBIT may be a promising approach for young people with multiple problems but further research is needed to identify the active mechanisms of change in complex helping systems.

Kailo: a systemic approach to addressing the social determinants of young people's mental health and wellbeing at the local level.

The mental health and wellbeing of children and young people is deteriorating. It is increasingly recognised that mental health is a systemic issue, with a wide range of contributing and interacting factors. However, the vast majority of attention and resources are focused on the identification and treatment of mental health disorders, with relatively scant attention on the social determinants of mental health and wellbeing and investment in preventative approaches. Furthermore, there is little attention on how the social determinants manifest or may be influenced at the local level, impeding the design of contextually nuanced preventative approaches. This paper describes a major research and design initiative called Kailo that aims to support the design and implementation of local and contextually nuanced preventative strategies to improve children's and young people's mental health and wellbeing. The Kailo Framework involves structured engagement with a wide range of local partners and stakeholders - including young people, community partners, practitioners and local system leaders - to better understand local systemic influences and support programmes of youth-centred and evidence-informed co-design, prototyping and testing. It is hypothesised that integrating different sources of knowledge, experience, insight and evidence will result in better embedded, more sustainable and more impactful strategies that address the social determinants of young people's mental health and wellbeing at the local level.

A Mixed-Methods Realist Evaluation of the Implementation and Impact of Community Forensic CAMHS to Manage Risk for Young People With Forensic and Mental Health Needs: Study Protocol.

Introduction: Young people in contact with forensic child and adolescent mental health services present with more complex needs than young people in the general population. Recent policy has led to the implementation of new workstreams and programmes to improve service provision for this cohort. This paper aims to present the protocol for a national study examining the impact and implementation of Community Forensic Child and Adolescent Mental Health Services (F:CAMHS). Methods and analysis: The study will use a mixed-methods Realist Evaluation design. Quantitative service activity and feedback data will be collected from all 13 sites, as well as questionnaires from staff. Non-participant observations and qualitative interviews will be conducted with staff, young people and parents/guardians from four focus study sites. An economic evaluation will examine whether Community F:CAMHS provides good value for money. The results will be triangulated to gain an in-depth understanding of young people's, parents/guardians' and staff experiences of the service. Ethics and dissemination: Ethical approval was granted by the Health Research Association and UCL Ethics. The results will be disseminated via project reports, feedback to sites, peer-reviewed journal publications and conference presentations.

Realist Process Evaluation of the implementation and impact of an organisational cultural transformation programme in the Children and Young People's Secure Estate (CYPSE) in England: study protocol.

INTRODUCTION: Young people in contact with the youth justice system are more likely to present with complex ongoing needs than young people in the general population. To address this, the Framework for Integrated Care (SECURE STAIRS) is being implemented in the Children and Young People's Secure Estate: a 'whole systems' approach to support secure settings to develop trauma-informed and relationally based environments, supporting staff to provide consistent, therapeutic care. This paper aims to present the protocol for a national cohort study examining the impact and implementation of this cultural transformation programme. METHODS AND ANALYSIS: A mixed-methods realist evaluation will be conducted. Data collection will take place between August 2018 and December 2020. Eighteen sites will collect routine service activity data and questionnaires completed by young people, parents/guardians and staff. Semi-structured interviews and non-participant observations will be conducted across five qualitative focus sites with young people and staff. An economic evaluation will examine value for money. The results will be triangulated at the analysis stage to gain an in-depth understanding of experiences. ETHICS AND DISSEMINATION: Ethical approval was granted by the Health Research Authority, Her Majesty's Prison and Probation Service and UCL Ethics Committee. Findings will be disseminated via project reports, site feedback, peer-reviewed journal publications and conference presentations.

Improving lives not just saying no to substances: Evaluating outcomes for a young people's substance use team trained in the AMBIT approach.

Adaptive Mentalization Based Integrative Therapy (AMBIT) is a systemic, mentalization based intervention designed for young people with multiple problems including mental health problems. The purpose of this paper is to examine the impact of this approach both on clinical and functional outcomes for young people seen by a specialist young people's substance use service between 2015 and 2018. About 499 cases were seen by the service during this period. Substance use outcomes were obtained for 383 cases using the Treatment Outcome Profile (TOP). Cannabis and alcohol use were the key substance use problems for 81% and 63% respectively. Functional outcomes using the AMBIT Integrative Measure (AIM) were obtained for 100 cases covering domains of daily living, socio-economic context, peer relationships and mental health. At treatment end, cannabis use reduced significantly (t = 10.78; df = 311; p = .00; Cohen's d ES.61 as did alcohol use (t = 6.938; df = 242; p = .000; ES 0.44). Functional improvements were shown in five out of seven domains with highly significant total functional improvements on key problems selected by the client (t = 14.01; df = 99; p = .000; ES1.34). Measuring functional as well as clinical outcomes appears to reflect more accurately the overall benefit of the service to clients.

Debate: Mentalising remotely - The AFNCCF's adaptations to the coronavirus crisis.

An overview of the work the approach taken by the Anna Freud National Centre for Children and Families in the rapid transition to remote working in response to the coronavirus lockdown. We outline some of the challenges of remote working and how we are seeking to mitigate them, informed by the over-riding principle that individual relationships and the experiences of the child, young person and family must remain the central concern. The importance of maintaining a mentalising stance in remote working is discussed. We argue that a mentalising relationship which generates epistemic trust is possible in remote working, but this will require particular thought and effort on the part of the therapist. In particular, it is suggested that mentalising processes can be supported in remote working through, in the absence of the more implicit communications that are possible in face-to-face work, more explicit communications about mental states.

Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): 5-year follow-up of a pragmatic, randomised, controlled, superiority trial.

BACKGROUND: Multisystemic therapy is a manualised treatment programme for young people aged 11-17 years who exhibit antisocial behaviour. To our knowledge, the Systemic Therapy for At Risk Teens (START) trial is the first large-scale randomised controlled trial of multisystemic therapy in the UK. Previous findings reported to 18 months after baseline (START-I study) did not indicate superiority of multisystemic therapy compared with management as usual. Here, we report outcomes of the trial to 60 months (START-II study). METHODS: In this pragmatic, randomised, controlled, superiority trial, young people (aged 11-17 years) with moderate-to-severe antisocial behaviour were recruited from social services, youth offending teams, schools, child and adolescent mental health services, and voluntary services across England, UK. Participants were eligible if they had at least three severity criteria indicating past difficulties across several settings and one of five general inclusion criteria for antisocial behaviour. Eligible families were randomly assigned (1:1), using stochastic minimisation and stratifying for treatment centre, sex, age at enrolment, and age at onset of antisocial behaviour, to management as usual or 3-5 months of multisystemic therapy followed by management as usual. Research assistants and investigators were masked to treatment allocation; the participants could not be masked. For this extension study, the primary outcome was the proportion of participants with offences with convictions in each group at 60 months after randomisation. This study is registered with ISRCTN, ISRCTN77132214, and is closed to accrual. FINDINGS: Between Feb 4, 2010, and Sept 1, 2012, 1076 young people and families were assessed for eligibility and 684 were randomly assigned to management as usual (n=342) or multisystemic therapy (n=342). By 60 months' of follow-up, 188 (55%) of 342 people in the multisystemic therapy group had at least one offence with a criminal conviction, compared with 180 (53%) of 341 in the management-as-usual group (odds ratio 1·13, 95% CI 0·82-1·56; p=0·44). INTERPRETATION: The results of the 5-year follow-up show no evidence of longer-term superiority for multisystemic therapy compared with management as usual. FUNDING: National Institute for Health Research Health Services and Delivery Research programme.

Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): a pragmatic, randomised controlled, superiority trial.

BACKGROUND: Adolescent antisocial behaviour is a major health and social problem. Studies in the USA have shown that multisystemic therapy reduces such behaviour and the number of criminal offences committed by this group. However, findings outside the USA are equivocal. We aimed to assess the effectiveness and cost-effectiveness of multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour. METHODS: We did an 18 month, multisite, pragmatic, randomised controlled, superiority trial in England. Eligible participants aged 11-17 years with moderate-to-severe antisocial behaviour had at least three severity criteria indicating past difficulties across several settings and one of five general inclusion criteria for antisocial behaviour. We randomly assigned families (1:1) using stochastic minimisation, stratifying for treatment centre, sex, age at enrolment to study, and age at onset of antisocial behaviour, to receive either management as usual or 3-5 months of multisystemic therapy followed by management as usual. Research assistants and investigators were masked to treatment allocation; the participants could not be masked. The primary outcome was out-of-home placement at 18 months. The primary analysis included all randomised participants for whom data were available. This trial is registered, number ISRCTN77132214. Follow-up of the trial is still ongoing. FINDINGS: Between Feb 4, 2010, and Sept 1, 2012, 1076 families were referred to nine multi-agency panels, 684 of whom were assigned to management as usual (n=342) or multisystemic therapy followed by management as usual (n=342). At 18 months, the proportion of participants in out-of-home placement was not significantly different between the groups (13% [43/340] in the multisystemic therapy group vs 11% [36/335] in the management-as-usual group; odds ratio 1·25, 95% CI 0·77-2·05; p=0·37). INTERPRETATION: The findings do not support that multisystemic therapy should be used over management as usual as the intervention of choice for adolescents with moderate-to-severe antisocial behaviour. FUNDING: Department for Children, Schools and Families, Department of Health.

Innovations in Practice: Using clinician-rated outcomes to support improved service decision making in a Child and Adolescent Mental Health Service.

BACKGROUND: Clinical outcomes are now routinely collected in most services. However, there is a need to make full use of the information collected in order to improve the use of limited Child and Adolescent Mental Health Service (CAMHS) resources. This paper describes a method of improving service decision making by making the interpretation of outcomes data accessible to frontline staff. METHOD: Clinician ratings of child outcomes for 2876 cases were routinely collected between 2009 and 2013 in a single CAMHS service. These outcomes were assessed against seven 'point of entry' and 'treatment' variables. RESULTS: Older children, referred by social care and presenting with multiple problems were associated with worse treatment outcomes than other service users. These findings were used to create an accessible Service Evaluation Chart of outcomes, to support discussion and decision making within the service. This process enabled the identification of a group who had particularly poor outcomes and resulted in consideration about service changes to try to improve outcomes for this specific group. CONCLUSIONS: Providing clinicians with accessible information about outcomes promotes the likelihood of outcomes being used in service decision making.

Can we improve service efficiency in CAMHS using the CAPA approach without reducing treatment effectiveness?

Health-care systems are under increasing pressure to deliver more care with similar or even less resources and there is concern that this may be achieved at the cost of reduced clinical effectiveness. In Child and Adolescent Mental Health Services (CAMHS), the Choice and Partnership Approach (CAPA) has been widely adopted as a way of increasing the efficient use of limited service resources. Some evaluations have reported increased patient flow and reduced waiting times, but it remains unknown whether such changes have been achieved at a cost of clinical effectiveness. This article describes a pragmatic multi-method evaluation of a CAMHS service reporting service outcomes (client satisfaction, waiting times, and patient flow) and clinical outcomes (clinician-rated clinical outcomes and goals achieved by families). Results showed improved service outcomes (high levels of client satisfaction and reduced waiting times) and an increase in patient flow (49 cases increased to 72 cases over an equivalent time period). Clinical outcomes showed no reduction in effectiveness and a significant improvement against the agreed goals of the intervention. The evaluation suggested that a well-structured goal-focused patient flow system may improve services by increasing patient flow while maintaining high satisfaction levels, without negatively impacting clinical effectiveness.

Are clinician ratings useful in evaluating outcomes in Child and Adolescent Mental Health Services (CAMHS)? A study of a continuous series of 1446 cases from an inner city CAMHS.

RATIONALE, AIMS AND OBJECTIVES: Routine outcome evaluation in Child and Adolescent Mental Health Services is an essential part of effective service delivery but it has been hard for services to obtain client-rated outcomes on more than 50% of cases. Clinician-rated outcomes are examined whether this would provide a valid and reliable way of contributing to addressing this difficulty. METHOD: This paper will evaluate the pragmatic utility, reliability and validity of a method of measuring clinical outcomes using clinician ratings using an adapted form of the Clinical Global Impressions scale with additional items based on the Every Child Matters framework on a continuous case series of 1446 cases. RESULTS: A rating of clinical outcome was obtained on 93% of cases. Approximately 55% of cases were rated as improved and about 30% as showing no change with about 5% reported as being worse. Test-retest reliability was acceptable (Pearson r = 0.94; P < 0.001) and criterion validity, comparing clinician and parent ratings, showed a significant correlation of 0.42 on severity of problem (Kendall's tau; t = 2.321, P = 0.02) and 0.36 on the degree of improvement (t = 2.637, P = 0.008). Rates of clinical improvement in studies of usual care suggested similar rates to those reported in this study. CONCLUSIONS: Clinician ratings were obtained for a high proportion of cases and the burden on clinicians was extremely low with negative outcomes similar to known rates of usual care. This high coverage may add value to the evaluation of service outcomes.

Computerised therapies for anxiety and depression in children and young people: a systematic review and meta-analysis.

One quarter of children and young people (CYP) experience anxiety and/or depression before adulthood, but treatment is sometimes unavailable or inadequate. Self-help interventions may have a role in augmenting treatment and this work aimed to systematically review the evidence for computerised anxiety and depression interventions in CYP aged 5-25 years old. Databases were searched for randomised controlled trials and 27 studies were identified. For young people (12-25 years) with risk of diagnosed anxiety disorders or depression, computerised CBT (cCBT) had positive effects for symptoms of anxiety (SMD -0.77, 95% CI -1.45 to -0.09, k = 6, N = 220) and depression (SMD -0.62, 95% CI -1.13 to -0.11, k = 7, N = 279). In a general population study of young people, there were small positive effects for anxiety (SMD -0.15, 95% CI -0.26 to -0.03; N = 1273) and depression (SMD -0.15, 95% CI -0.26 to -0.03; N = 1280). There was uncertainty around the effectiveness of cCBT in children (5-11 years). Evidence for other computerised interventions was sparse and inconclusive. Computerised CBT has potential for treating and preventing anxiety and depression in clinical and general populations of young people. Further program development and research is required to extend its use and establish its benefit in children.

Applying attachment theory to effective practice with hard-to-reach youth: the AMBIT approach.

Adolescent Mentalization-Based Integrative Treatment (AMBIT) is a developing approach to working with "hard-to-reach" youth burdened with multiple co-occurring morbidities. This article reviews the core features of AMBIT, exploring applications of attachment theory to understand what makes young people "hard to reach," and provide routes toward increased security in their attachment to a worker. Using the theory of the pedagogical stance and epistemic ("pertaining to knowledge") trust, we show how it is the therapeutic worker's accurate mentalizing of the adolescent that creates conditions for new learning, including the establishment of alternative (more secure) internal working models of helping relationships. This justifies an individual keyworker model focused on maintaining a mentalizing stance toward the adolescent, but simultaneously emphasizing the critical need for such keyworkers to remain well connected to their wider team, avoiding activation of their own attachment behaviors. We consider the role of AMBIT in developing a shared team culture (shared experiences, shared language, shared meanings), toward creating systemic contexts supportive of such relationships. We describe how team training may enhance the team's ability to serve as a secure base for keyworkers, and describe an innovative approach to treatment manualization, using a wiki format as one way of supporting this process.

The Adolescent Mentalization-based Integrative Treatment (AMBIT) approach to outcome evaluation and manualization: adopting a learning organization approach.

AMBIT (Adolescent Mentalization-Based Integrative Treatment) is a developing team approach to working with hard-to-reach adolescents. The approach applies the principle of mentalization to relationships with clients, team relationships and working across agencies. It places a high priority on the need for locally developed evidence-based practice, and proposes that outcome evaluation needs to be explicitly linked with processes of team learning using a learning organization framework. A number of innovative methods of team learning are incorporated into the AMBIT approach, particularly a system of web-based wiki-formatted AMBIT manuals individualized for each participating team. The paper describes early development work of the model and illustrates ways of establishing explicit links between outcome evaluation, team learning and manualization by describing these methods as applied to two AMBIT-trained teams; one team working with young people on the edge of care (AMASS - the Adolescent Multi-Agency Support Service) and another working with substance use (CASUS - Child and Adolescent Substance Use Service in Cambridgeshire). Measurement of the primary outcomes for each team (which were generally very positive) facilitated team learning and adaptations of methods of practice that were consolidated through manualization.

Evaluation of multisystemic therapy pilot services in the Systemic Therapy for At Risk Teens (START) trial: study protocol for a randomised controlled trial.

BACKGROUND: There is an urgent need for clinically effective and cost-effective methods to manage antisocial and criminal behaviour in adolescents. Youth conduct disorder is increasingly prevalent in the UK and is associated with a range of negative outcomes. Quantitative systematic reviews carried out for the National Institute for Health and Clinical Excellence have identified multisystemic therapy, an intensive, multimodal, home-based, family intervention for youth with serious antisocial behaviour, as one of the most promising interventions for reducing antisocial or offending behaviour and improving individual and family functioning. Previous international trials of multisystemic therapy have yielded mixed outcomes, and it is questionable to what extent positive US findings can be generalised to a wider UK mental health and juvenile justice context. This paper describes the protocol for the Systemic Therapy for At Risk Teens (START) trial, a multicentre UK-wide randomised controlled trial of multisystemic therapy in antisocial adolescents at high risk of out-of-home placement. METHODS/DESIGN: The trial is being conducted at 10 sites across the UK. Seven hundred participants and their families will be recruited and randomised on a 1:1 basis to multisystemic therapy or management as usual. Treatments are offered over a period of 3 to 5 months, with follow-up to 18 months post-randomisation. The primary outcome is out-of-home placement at 18 months. Secondary outcomes include offending rates, total service and criminal justice sector costs, and participant well-being and educational outcomes. Data will be gathered from police computer records, the National Pupil Database, and interview and self-report measures administered to adolescents, parents and teachers. Outcomes will be analysed on an intention-to-treat basis, using a logistic regression with random effects for the primary outcome and Cox regressions and linear mixed-effects models for secondary outcomes depending on whether the outcome is time-to-event or continuous. DISCUSSION: The START trial is a pragmatic national trial of sufficient size to evaluate multisystemic therapy, to inform policymakers, service commissioners, professionals, service users and their families about its potential in the UK. It will also provide data on the clinical and cost-effectiveness of usual services provided to youth with serious antisocial behaviour problems. TRIAL REGISTRATION: ISRCTN77132214.

Innovations in Practice: Adolescent Mentalization-Based Integrative Therapy (AMBIT) - a new integrated approach to working with the most hard to reach adolescents with severe complex mental health needs.

BACKGROUND: 'Hard to reach' young people are associated by virtue of their serious, multiple, and complex needs, the difficulty of delivering effective help to them, and their poor long-term outcomes. There is a lack of published evidence relating to the effectiveness of interventions directed at this group. METHOD: We review these concerns and the options available to service commissioners and clinicians seeking, if not an evidence-based approach then at least an evidence-oriented one. A mentalization-based multimodal intervention (AMBIT) is briefly described, proposing a new kind of specialist practitioner and taking a radically different approach to treatment manualization. RESULTS: A brief description is given of the different settings in which AMBIT is currently being developed, deployed, and evaluated, and of lessons learned. CONCLUSIONS: AMBIT offers promise as an evolving 'open source' framework supporting development of evidence-based local practice in chaotic complex settings.

Psychosocial and Neurocognitive Aspects of Sickle Cell Disease.

Sickle cell disease (SCD) comprises a group of recessively inherited blood disorders and is the most common genetic disorder in the world (Embury et al., 1994). It is a chronic condition of variable severity that mainly affects people of African and African-Caribbean heritage. Over the last 20 years life expectancy has increased significantly, particularly for patients receiving western healthcare so that increasing attention has been directed to the psychosocial adaptation and neurocognitive profile of children and adolescents with SCD. Previously, research suggested that, like children with other chronic health conditions, children and adolescents with SCD were at increased risk for emotional and behavioural disorders. More recent research has not demonstrated increased rates of such difficulties. Increasing evidence suggests that children with severe disease are, however, at significantly increased risk for cerebro-vascular events and neurocognitive difficulties. This paper reviews the literature regarding the psychological and neurocognitive functioning of children with SCD and outlines a number of ways that psychological input may significantly contribute to more effective health care for these children and their families.