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We report a Delphi Consensus modification and first validation study of the Autism Diagnostic Observation Schedule – 2 with deaf children and young people (ADOS-2 Deaf adaptation). Validation included 122 deaf participants (aged 2–18 years), 63 with an Autism Spectrum Disorder (ASD). This was compared to a National Institute for Health and Clinical Excellence (NICE) guideline standard clinical assessment by blinded independent specialist clinicians. Results showed overall sensitivity 73% (95%CI 60%, 83%); specificity 71% (95%CI 58%, 82%), and for the more common modules 1–3 (combined as in previous studies) sensitivity 79% (95% CI 65–89%); specificity 79% (95% CI 66–89%) suggesting this instrument will be a helpful addition for use with deaf children and young people.

A Delphi consensus methodology was used to adapt the Autism Diagnostic Interview–Revised for the assessment of deaf children with suspected autism spectrum disorder. Each Autism Diagnostic Interview–Revised item was considered by a panel of nine international experts in terms of relevance and acceptability. Modifications were proposed and agreed by the expert panel for 45% of items. The pre-specified criterion for agreement between experts was set at 80% for each item. A first validation of the revised version, adapted for deaf children (Autism Diagnostic Interview–Revised Deaf Adaptation), was undertaken with a UK sample of 78 parents/carers of deaf children with autism spectrum disorder and 126 parents/carers with deaf children without autism spectrum disorder. When compared to National Institute for Health and Care Excellence guideline standard clinical assessments, the Autism Diagnostic Interview–Revised Deaf Adaptation diagnostic algorithm cut-off/threshold scores achieved a sensitivity of 89% (79%–96%) and specificity of 81% (70%–89%) for autism spectrum disorder. The alpha coefficients for each algorithm symptom domain ranged from 0.80 to 0.91, suggesting that the items had high internal consistency. Our findings indicate that the Autism Diagnostic Interview–Revised Deaf Adaptation is likely to be a useful measure for the assessment of deaf children with suspected autism spectrum disorder, although further research is needed. Lay abstract Autism assessment processes need to improve for deaf children as they are currently being diagnosed later than their hearing counterparts and misdiagnosis can occur. We took one of the most commonly used parent developmental interviews for autism spectrum disorder the Autism Diagnostic Interview–Revised and adapted it using international expert advice. Modifications were proposed and agreed by the expert panel for 45% of items; the remaining 55% of items were unchanged. We then tested the revised version, adapted for deaf children (Autism Diagnostic Interview–Revised Deaf Adaptation), in a UK sample of 78 parents/carers of deaf children with autism spectrum disorder and 126 parents/carers with deaf children without autism spectrum disorder. When compared to National Institute for Health and Care Excellence guideline standard clinical assessments, the Autism Diagnostic Interview–Revised Deaf Adaptation diagnostic algorithm threshold scores could identify those deaf children with a definite diagnosis (true autism spectrum disorder positives) well (sensitivity of 89% (79%–96%)) and those deaf children who did not have autism spectrum disorder (true autism spectrum disorder negatives) well (specificity of 81% (70%–89%)). Our findings indicate that the Autism Diagnostic Interview–Revised Deaf Adaptation is likely to prove a useful measure for the assessment of deaf children with suspected autism spectrum disorder and that further research would be helpful.

Background In response to the growing prevalence of physical and emotional burnout amongst medical students and practicing physicians, we sought to find a new methodology to scope a five-year undergraduate curriculum in detail to assess for teaching, learning objectives and experiences that seek to promote resilience in medical students. This was undertaken to test whether this methodology would enable curriculum discussions to enhance training for future cohorts through the introduction of a curriculum dedicated to the development of resilience and resourcefulness. Methods Based on literature review, a rating-scale was devised to generate quantitative data in four key areas of resilience; internal resources, lifestyle factors, external resources (self-mediated) and external resources (agent mediated). This scale was used to evaluate the entire five-year undergraduate curriculum of a medical school in the north of England through systematic evaluation of learning outcomes and planned activities. The methodology used was a four-stage process including i) identifying the learning objectives, ii) mapping them onto the criteria outlined, iii) assessing them against clear objective standards (planned, explicit, universal and quantifiable), and iv) rating data collected. Results The evaluation provided a clear, quantitative overview of the curriculum in terms of resilience building. Strengths and gaps were identified and work was undertaken leading to suggestions for change. This facilitated helpful discussions with course leaders and planners, received universally positive feedback and led to new learning objectives, activities and experiences that have been identified and begun to be implemented. Conclusions “The HYMS CARE Criteria” and our methodology for assessing it in a medical school curriculum context, offers a valuable perspective to aid the planning of improvements in curricula. This model for scoping and structuring resilience related learning experiences is offered for consideration by other schools.

Socioeconomic disadvantage has been linked to mental health difficulties in children and adolescents, although many children appear to do well despite exposure to financial adversity in childhood. Our study looked at the effects of family financial difficulty on children’s mental health outcomes (n = 636) at 4–5 years in a multi-ethnic UK cohort, the Born in Bradford cohort. We considered potential parent and child variables promoting resilience in this population. Univariate linear regression was used to identify associations between family financial difficulty measured antenatally and child mental health difficulties measured by teacher-rated Strengths and Difficulties (SDQ) scores at 4–5 years. Hierarchical multivariate regression was used to test for potential moderating effects of parent and child factors. Mothers completed the General Health Questionnaire-28, Kessler-6 Questionnaire and questions related to parenting warmth, hostility and confidence. Parent-rated Infant Characteristic Questionnaires and teacher-rated Early Years Foundation Stage scores provided information on child temperament, literacy and physical development as potential moderators. Financial difficulty was associated with worse mental health outcomes in children. High parent warmth, high child literacy scores and physical development scores were all associated with positive child mental health outcomes at 4–5 years. In terms of protective effects, only maternal warmth was found to significantly moderate the relationship between financial difficulty and child mental health difficulties. The current study demonstrates that family financial difficulty is associated with poorer child mental health outcomes in a UK cohort of mothers and their school-aged children. It provides evidence of the positive relationships between warm parenting, child literacy and child physical development with mental health in young children. The study supports the finding that warm parenting moderates the relationship between family financial difficulty and interventions supporting this aspect of parenting may therefore provide particular benefit to children growing up in this context.

Background Depression is one of the leading causes of illness and disability in young people, with approximately 20% having experienced a depressive episode by the age of 18 years. Behavioral activation (BA), a National Institute for Health and Care Excellence–recommended treatment for adults with depression, has shown preliminary support for its use with young people. BA may have the potential to be adapted and delivered in a computerized format to address the barriers often associated with young people accessing support. Despite the benefits of adopting computerized therapy delivery, the limited effectiveness of some programs has been attributed to a failure to tailor interventions to patients and practices. Therefore, while developing new treatments, it is important that target users be involved in the intervention design. Objective This qualitative study aims to explore the views and preferences of young people and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression, to ensure that the therapy was suitable for the target user. Methods Semistructured focus groups and individual interviews were conducted with young people (those with experience in accessing support and those without) and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression. The data were analyzed using thematic analysis. Results A total of 27 individuals, comprising both health care professionals and young people, participated in this study. Vital information pertaining to the important components of a new therapy, including its presentation, delivery, and content, was collected. Conclusions Variations in perspectives highlighted the need to adopt a systemic approach in therapy development by considering the opinions of young people with and without experience in accessing mental health support and health care professionals.

Background Maternal iodine requirements increase during pregnancy to supply thyroid hormones essential for fetal brain development. Maternal iodine deficiency can lead to hypothyroxinemia, a reduced fetal supply of thyroid hormones which, in the first trimester, has been linked to an increased risk of autism spectrum disorder (ASD) in the child. No study to date has explored the direct link between maternal iodine deficiency and diagnosis of ASD in offspring. Methods Urinary iodine concentrations (UIC) and iodine/creatinine ratios (I:Cr) were measured in 6955 mothers at 26–28 weeks gestation participating in the Born in Bradford (BiB) cohort. Maternal iodine status was examined in relation to the probability of a Read (CTV3) code for autism being present in a child’s primary care records through a series of logistic regression models with restricted cubic splines. Results Median (inter-quartile range) UIC was 76 μg/L (46, 120) and I:Cr was 83 μg/g (59, 121) indicating a deficient population according to WHO guidelines. Ninety two children (1·3%) in our cohort had received a diagnosis of ASD by the census date. Overall, there was no evidence to support an association between I:Cr or UIC and ASD risk in children aged 8–12 years (p = 0·3). Conclusions There was no evidence of an increased clinical ASD risk in children born to mothers with mild-to-moderate iodine deficiency at 26 weeks gestation. Alternative functional biomarkers of exposure and a wider range of conditions may provide further insight., BMC Pediatrics, 20 (1), ISSN:1471-2431

Background Interventions designed to support children with a diagnosis of Autism Spectrum Conditions (ASC) can be time consuming, needing involvement of outside experts. Social Stories™ are a highly personalised intervention aiming to give children with ASC social information or describing an otherwise difficult situation or skill. This can be delivered daily by staff in education settings. Studies examining Social Story™ use have yielded mostly positive results but have largely been single case studies with a lack of randomised controlled trials (RCTs). Despite this numerous schools are utilising Social Stories™, and a fully powered RCT is timely. Methods A multi-site pragmatic cluster RCT comparing care as usual with Social Stories™ and care as usual. This study will recruit 278 participants (aged 4–11) with a clinical diagnosis of ASC, currently attending primary school in the North of England. Approximately 278 school based staff will be recruited to provide school based information about participating children with approximately 140 recruited to deliver the intervention. The study will be cluster randomised by school. Potential participants will be screened for eligibility prior to giving informed consent. Follow up data will be collected at 6 weeks and 6 months post randomisation and will assess changes in participants’ social responsiveness, goal based outcomes, social and emotional health. The primary outcome measure is the Social Responsiveness Scale Second Edition (SRS-2) completed by school based staff at 6 months. Approvals have been obtained from the University of York’s Research Governance Committee, Research Ethics Committee and the Health Research Authority. Study results will be submitted for publication in peer-reviewed journals and disseminated to participating families, educational staff, local authority representatives, community groups and Patient and Participant Involvement representatives. Suggestions will be made to NICE about treatment evidence dependent on findings. Discussion This study addresses a much used but currently under researched intervention and results will inform school based support for primary school children with a diagnosis of ASC. Trial registration The trial is registered on the ISRCTN registry (registration number: ISRCTN11634810). The trial was retrospectively registered on 23rd April 2019.

Background: There has been a recent reported rise in prevalence of mental health problems among children in the United Kingdom, alongside increased referrals into specialist services. There is a need for up-to-date information regarding changing trends of young people’s mental health to allow for improved understanding and service planning. Objectives: This article aims to provide an overview of the current mental health and well-being of years 8, 9 and 11 secondary school–aged pupils from two large regions in the North of England. Method: This was a cohort cross-sectional study. Measures including the Strengths and Difficulties questionnaire, the EQ-5D-Y, social media use questions, and a mental health service use questionnaire were completed by participants. Results: In total, 6328 questionnaires were returned from 21 secondary schools. One in 10 participating pupils scored ‘very high’ for total mental health difficulties. Significant differences on well-being scores were found between both gender and year groups. Conclusion: In recent years, the proportion of children facing mental health problems has increased. In particular, high levels of female pupils and year 11 pupils report facing difficulties. It is important to develop targeted, accessible interventions, and to continue to collect up-to-date measures for this population.

In a special issue that focuses on complex presentations related to Autism, we ask the question in this editorial whether an Autism Spectrum Condition without complexity is a disorder, or whether it represents human diversity? Much research into Autism Spectrum Conditions (ASCs) over the years has focused on comparisons between neuro-typical people and people with Autism Spectrum Conditions. These comparisons have tended to draw attention to ‘deficits’ in cognitive abilities and descriptions of behaviours that are characterised as unwanted. Not surprisingly, this is reflected in the classification systems from the World Health Organisation and the American Psychiatric Association. Public opinion about ASC may be influenced by presentations in the media of those with ASC who also have intellectual disability. Given that diagnostic systems are intended to help us better understand conditions in order to seek improved outcomes, we propose a more constructive approach to descriptions that uses more positive language, and balances descriptions of deficits with research finding of strengths and differences. We propose that this will be more helpful to individuals on the Autism Spectrum, both in terms of individual self-view, but also in terms of how society views Autism Spectrum Conditions more positively. Commentary has also been made on guidance that has been adjusted for people with ASC in relation to the current COVID-19 pandemic.

Background Computerised cognitive–behavioural therapy (CCBT) in the care pathway has the potential to improve access to psychological therapies and reduce waiting lists within Child and Adolescent Mental Health Services, however, more randomised controlled trials (RCTs) are needed to assess this. Aims This single-centre RCT pilot study compared a CCBT program (Stressbusters) with an attention control (self-help websites) for adolescent depression at referral to evaluate the clinical and cost-effectiveness of CCBT (trial registration: ISRCTN31219579). Method The trial ran within community and clinical settings. Adolescents (aged 12–18) presenting to their primary mental health worker service for low mood/depression support were assessed for eligibility at their initial appointment, 139 met inclusion criteria (a 33-item Mood and Feelings Questionnaire score of ≥20) and were randomised to Stressbusters (n = 70) or self-help websites (n = 69) using remote computerised single allocation. Participants completed mood, quality of life (QoL) and resource-use measures at intervention completion, and 4 and 12 months post-intervention. Changes in self-reported measures and completion rates were assessed by group. Results There was no significant difference between CCBT and the website group at 12 months. Both showed improvements on all measures. QoL measures in the intervention group showed earlier improvement compared with the website group. Costs were lower in the intervention group but the difference was not statistically significant. The cost-effectiveness analysis found just over a 65% chance of Stressbusters being cost-effective compared with websites. The 4-month follow-up results from the initial feasibility study are reported separately. Conclusions CCBT and self-help websites may both have a place in the care pathway for adolescents with depression.

Background: Having good access to information is crucial when attending an appointment with a health professional; for 5% of the world’s population, who have some degree of hearing loss, this is ch...

Traits in Upper Palaeolithic art which are also seen in the work of talented artists with autism, including most obviously an exceptional realism, remain to be explained. However any association between the famously evocative animal depictions created in the European Upper Palaeolithic and what is commonly seen as a ‘disorder’ has always been contentious. Debate over these similarities has been heated, with explanations ranging from famous works of Upper Palaeolithic art having been created by individuals with autism spectrum conditions, to being influenced by such individuals, to being a product of the use of psychotropic drugs. Here we argue that ‘autistic traits’ in art, such as extreme realism, have been created by individuals with a cognitive extreme of local processing bias, or detail focus. The significance of local processing bias, which is found both as a feature of autism spectrum conditions and in artists with exceptional talent at realistic depiction who aren’t autistic, has implications for our understanding of Upper Palaeolithic society in general, as well as of the roles played by individuals with autism spectrum conditions.

ObjectiveWe set out to test whether the early years foundation stage profile (EYFSP) score derived from 17 items assessed by teachers at the end of reception school year had any association with autism spectrum disorder (ASD) diagnosis in subsequent years. This study tested the feasibility of successfully linking education and health data.DesignA retrospective data linkage study.Setting and participantsThe Born in Bradford longitudinal cohort of 13, 857 children.Outcome measuresWe linked the EYFSP score at the end of reception year with subsequent diagnosis of an ASD, using all ASD general practitioner Read codes. We used the total EYFSP score and a subscore consisting of five key items in the EYFSP, prospectively identified using a panel of early years autism experts.ResultsThis study demonstrated the feasibility of linking education and health data using ASDs as an exemplar. A total of 8,935 children had linked primary care and education data with 20.7% scoring ConclusionsWe demonstrate the feasibility of linking education and health data. Performance on teacher ratings taken universally in school reception class can flag children at risk of ASDs. Further research is warranted to explore the utility of EYFSP as an initial screening tool for ASD in early school years.

BackgroundLeishmaniasis is a neglected tropical parasitic disease endemic in South Asia, East Africa, South America and the Middle East. It is associated with low socioeconomic status (SES) and responsible for considerable mortality and morbidity. Reports suggest that patients with leishmaniasis may have a higher risk of mental illness (MI), psychosocial morbidity (PM) and reduced quality of life (QoL), but this is not well characterised. The aim of this study was to conduct a systematic review to assess the reported impact of leishmaniasis on mental health and psychosocial wellbeing.MethodsA systematic review of the literature was carried out. Pre-specified criteria were applied to identify publications including observational quantitative studies or systematic reviews. Two reviewers screened all of the titles, abstracts and full-studies and a third reviewer was consulted for disagreements. Data was extracted from papers meeting the criteria and quality appraisal of the methods was performed using the Newcastle-Ottowa Scale or the Risk of Bias in Systematic Review tool.ResultsA total of 14 studies were identified from 12,517 records. Nine cross-sectional, three case-control, one cohort study and one systematic review were included. Eleven assessed MI outcomes and were measured with tools specifically designed for this; nine measured PM and 12 measured QoL using validated measurement tools. Quality appraisal of the studies showed that six were of good quality. Cutaneous leishmaniasis and post kala-azar dermal leishmaniasis showed evidence of associated MI and PM including depression, anxiety and stigma, while all forms of disease showed decreased QoL. The findings were used to inform a proposed model and conceptual framework to show the possible links between leishmaniasis and mental health outcomes.ConclusionThere is evidence that leishmaniasis has an impact on MI, PM or QoL of patients and their families and this occurs in all the main subtypes of the disease. There are however large gaps in the evidence. Further research is required to understand the full extent of this problem and its mechanistic basis.AUTHOR SUMMARYLeishmaniasis is a parasitic disease prevalent in many low-and middle-income countries worldwide. In this study the authors looked for evidence as to whether leishmaniasis affected the mental health and quality of life of patients. To conduct the review, a wide search of the literature was conducted, where a total of 14 full articles were included and analysed. It was found that different forms of leishmaniasis (visceral leishmaniasis, cutaneous leishmaniasis and post kala-azar dermal leishmaniasis) do cause a significant impact on patients’ mental health and quality of life through societal factors such as stigma, lack of knowledge, culture and low self-esteem among others. However, no evidence of biological mechanisms was found linking leishmaniasis to mental illness or decreased quality of life. Despite being a very incapacitating disease physically, leishmaniasis also leads to mental illness and decreased quality of life, and should therefore be a priority on the global health agenda for both researchers and policy makers.

An increase in urinary indolyl-3-acryloylglycine (IAG) has been reported in children with autism spectrum disorders (ASD) who suffer with bowel problems in comparison to ASD children without gastrointestinal (GI) problems. The case for dietary intervention for ASD children with GI symptoms might be strengthened were such a difference to be autism-specific. Quantitative analysis of urinary IAG levels was performed for 53 children on the autism spectrum and 146 age-matched controls. The parents of each child were asked to provide information on bowel symptoms experienced by the child and their eating habits over a period of 2 wk. We find no significant difference in urinary IAG levels between the ASD children with GI problems and ASD children without GI problems. Although we see some difference between ASD children with GI problems and controls in mainstream schools with GI problems, the difference between non-autistic children with other developmental disorders and controls in mainstream schools is more significant so that any difference is not autism-specific. We find a strong correlation between bowel symptoms and diet problems in ASD children, especially idiosyncratic feeding behavior and we show that ASD children suffering from multiple bowel symptoms tend to be those who also have dietary problems. We found no evidence to support the hypothesis that children with ASD who suffer with bowel problems have increased levels of urinary IAG in comparison to children with ASD who do not have gastrointestinal problems.

Selection pressures to better understand other’s thoughts and feelings are seen as a primary driving force in human cognitive evolution. Yet might the evolution of social cognition be more complex than we assume, with more than one strategy towards social understanding and developing a positive pro-social reputation? Here we argue that social buffering of vulnerabilities through the emergence of collaborative morality will have opened new niches for adaptive cognitive strategies and widened personality variation. Such strategies include those that that do not depend on astute social perception or abilities to think recursively about other’s thoughts and feelings. We particularly consider how a perceptual style based on logic and detail, bringing certain enhanced technical and social abilities which compensate for deficits in complex social understanding could be advantageous at low levels in certain ecological and cultural contexts. ‘Traits of autism’ may have promoted innovation in archaeological material culture during the late Palaeolithic in the context of the mutual interdependence of different social strategies, which in turn contributed to the rise of innovation and large scale social networks.

Purpose The purpose of this paper is to focus upon the challenges faced by a research team when conducting a computerised cognitive behaviour therapy (CCBT) trial for adolescents with low mood/depression and how solutions were sought to eliminate these difficulties in future child and adolescent mental health clinical research. Design/methodology/approach The authors have presented a number of problems faced by the research team when conducting a randomised controlled trial (RCT) concerning adolescents with low mood/depression. Findings From examining the problems faced by the research team, the authors have provided key pieces of advice for prospective adolescent mental health RCTs. This advice includes developing clear project plans, setting strategies to encourage and maintain study information in the community and support recruitment, and keeping your organisation appraised of study needs and network and involve governance departments, IT and finance departments in these discussions early. Originality/value RCTs, particularly those focusing on child and adolescent mental health, can face a number of difficulties throughout its stages of completion (from protocol development to follow-up analysis). Studies involving the use of technologies add a layer of complexity to this. This review will be of value to researchers aiming to run a high-quality RCT concerning child and adolescent mental health.

IntroductionSpecific phobias (intense, enduring fears of an object or situation that lead to avoidance and severe distress) are highly prevalent among children and young people. Cognitive–behavioural therapy (CBT) is a well-established, effective intervention, but it can be time consuming and costly because it is routinely delivered over multiple sessions during several months. Alternative methods of treating severe and debilitating phobias in children are needed, like one-session treatment (OST), to reduce time and cost, and to prevent therapeutic drift and help children recover quickly. Our study explores whether (1) outcomes with OST are ‘no worse’ than outcomes with multisession CBT, (2) OST is acceptable to children, their parents and the practitioners who use it and (3) OST offers good value for money to the National Health Service (NHS) and to society.MethodA pragmatic, non-inferiority, randomised controlled trial will compare OST with multisession CBT-based therapy on their clinical and cost-effectiveness. The primary clinical outcome is a standardised behavioural task of approaching the feared stimulus at 6 months postrandomisation. The outcomes for the within-trial cost-effectiveness analysis are quality-adjusted life years based on EQ-5D-Y, and individual-level costs based of the intervention and use of health and social service care. A nested qualitative evaluation will explore children’s, parents’ and practitioners’ perceptions and experiences of OST. A total of 286 children, 7–16 years old, with DSM-IV diagnoses of specific phobia will be recruited via gatekeepers in the NHS, schools and voluntary youth services, and via public adverts.Ethics and disseminationThe trial received ethical approval from North East and York Research Ethics Committee (Reference: 17/NE/0012). Dissemination plans include publications in peer-reviewed journals, presentations in relevant research conferences, local research symposia and seminars for children and their families, and for professionals and service managers.Trial registration numberISRCTN19883421;Pre-results.

Although autism has been characterised as a disorder certain selective advantages of autism have been identified which may represent a selective trade-off for reduced ‘folk psychology’ and provide a potential explanation for the incorporation of autism genes in the human evolutionary past. Such potential trade-off skills remain to be explored in terms of selectively advantageous or disadvantageous behaviours in the distant past however. Here we present the results of an analysis of the relationship between AQ (autism quotient) and attitudes to valued personal possessions on the basis of a study of 550 participants. We find that individuals with autism have a reduced tendency to value and preserve objects as reminders of relationships/attachment figures and place a greater value on the direct practical function of their personal possessions. The latter strategy may have been more selectively advantageous in certain contexts whilst less advantageous in others in the distant evolutionary past.

Autism assessments for children who are deaf are particularly complex for a number of reasons, including overlapping cultural and clinical factors. We capture this in an ethnographic study of National Health Service child and adolescent mental health services in the United Kingdom, drawing on theoretical perspectives from transcultural psychiatry, which help to understand these services as a cultural system. Our objective was to analyse how mental health services interact with Deaf culture, as a source of cultural-linguistic identity. We ground the study in the practices and perceptions of 16 professionals, who have conducted autism assessments for deaf children aged 0–18. We adopt a framework of intersectionality to capture the multiple, mutually enforcing factors involved in this diagnostic process. We observed that professionals working in specialist Deaf services, or with experience working with the Deaf community, had intersectional understandings of assessments: the ways in which cultural, linguistic, sensory, and social factors work together to produce diagnoses. Working with a diagnostic system that focuses heavily on ‘norms’ based on populations from a hearing culture was a key source of frustration for professionals. We conclude that recognising the intersectionality of mental health and Deaf culture helps professionals provide sensitive diagnoses that acknowledge the multiplicity of D/deaf experiences.

Background is provided on biofilms, including their formation, tolerance mechanisms, structure, and morphology within the context of chronic wounds. The features of biofilms in chronic wounds are discussed in detail, as is the impact of biofilm on wound chronicity. Difficulties associated with the use of standard susceptibility tests (minimum inhibitory concentrations or MICs) to determine appropriate treatment regimens for, or develop new treatments for use in, chronic wounds are discussed, with alternate test methods specific to biofilms being recommended. Animal models appropriate for evaluating biofilm treatments are also described. Current and potential future therapies for treatment of biofilm-containing chronic wounds, including probiotic therapy, virulence attenuation, biofilm phenotype expression attenuation, immune response suppression, and aggressive debridement combined with antimicrobial dressings, are described.

A new model for a community mental health service for children and young people aged 0-18 years is described. This has been formulated after multi-level consultation including extensive user/carer involvement. The proposed model is multidisciplinary and integrated with multiagency provision, with smooth access onto and through care pathways. This model brings voluntary and statutory agencies into an integrated collaboration. It reinforces that social and emotional development and psychological functioning is everybody’s business and creates conditions where a child’s needs can be addressed on a day-to-day basis rather than through a “clinic-based model”.

IntroductionSocial skills training interventions for children with autism spectrum disorder (ASD) typically focus on a skills deficit model rather than building on existing skills or encouraging the child to seek their own solutions. LEGO-based therapy is a child-oriented intervention to help improve social interactional skills and reduce isolation. The therapy is designed for school-age children with ASD and uses group-based play in a school setting to encourage peer relationships and social learning. Despite the reported potential benefits of LEGO-based therapy in a prior randomised controlled trial (RCT) and its adoption by many schools, the evidence to support its effectiveness on the social and emotional well-being of children with ASD is limited and includes no assessment of cost-effectiveness.Methods and analysisThis multicentre, pragmatic, cluster RCT will randomise 240 participants (aged 7–15 years) with a clinical diagnosis of ASD to receive usual care or LEGO-based therapy with usual care. Cluster randomisation will be conducted on a school level, randomising each school as opposed to each individual child within a school. All prospective participants will be screened for eligibility before assenting to the study (with parents giving informed consent on behalf of their child). All participants will be followed up at 20 and 52 weeks after randomisation to assess for social, emotional and behavioural changes. The primary outcome measure is the social skills subscale of the Social Skills Improvement System completed by a teacher or teaching assistant associated with participating children at the 20-week follow-up time point.Ethics and disseminationEthics approval has been obtained via the University of York Research Ethics Committee. The results of the trial will be submitted for publication in a peer-reviewed journal and will be disseminated to participating families, education practitioners and the third sector including voluntary and community organisations.Trial registration numberISRCTN64852382; Pre-results.

SummaryYoung people who cut themselves may do so for reasons that go beyond diagnosis. Relevant processes include responses to trauma, coping, emotion regulation and cultural identification. Some clinicians regard those who self-harm negatively or consider one therapeutic approach to be suitable for all. This article explores the possible mechanisms involved when young people cut themselves and discusses therapeutic approaches in the light of these. Clinicians and researchers are encouraged to refine, develop and research interventions for young people who self-harm by cutting.

Objective To determine whether preoperative psychological depression and/or serotonin transporter gene polymorphism are associated with poor outcomes after the common procedure of laparoscopic cholecystectomy. Design Patients undergoing laparoscopic cholecystectomy were genotyped for the serotonin transporter gene 5-HTTLPR polymorphism and assessed for psychological morbidity before and 6 weeks after surgery. The main outcome was postoperative depression; secondary outcomes included fatigue, perceived pain, quality of life and subjective perception about return to usual. Results Full genetic and psychological data were obtained from 273 out of 330 patients consented to the study (82% female). Significantly fewer people with preoperative depression (Beck Depression Inventory (BDI) score >5) had returned to employment (57% vs 86%, p

Increasing numbers of young people are coming forward for assessment of autism spectrum disorders (ASD). Staff from pediatrics and child health services need to work together closely with Local Authority staff and child and adolescent mental health services (CAMHS). This paper describes the functioning of an ASD Forum, which allows for careful use of resources whilst providing comprehensive assessment and intervention planning services in an integrated way.

BackgroundDisorganised attachment patterns in infants have been linked to later psychopathology. Services have variable practices for identifying and providing interventions for families of children with disorganised attachment patterns, which is the attachment pattern leading to most future psychopathology. Several recent government reports have highlighted the need for better parenting interventions in at risk groups.ObjectivesThe objective of this review and meta-analysis was to evaluate the clinical effectiveness of available parenting interventions for families of children at high risk of developing, or already showing, a disorganised pattern of attachment.MethodsPopulation: Studies were included if they involved parents or caregivers of young children with a mean age under 13 years who had a disorganised classification of attachment or were identified as at high risk of developing such problems. Included interventions were aimed at parents or caregivers (e.g. foster carers) seeking to improve attachment. Comparators included an alternative intervention, an attention control, treatment as usual or no intervention. The primary outcome was a disorganised pattern in childhood measured using a validated attachment instrument. Studies that did not use a true Randomised Controlled Trial (RCT) design were excluded from the review. Both published and unpublished papers were included, there were no restrictions on years since publication and foreign language papers were included where translation services could be accessed within necessary timescales.ResultsA comprehensive search of relevant databases yielded 15,298 papers. This paper reports a systematic review as part of an NIHR HTA study identifying studies pre-2012, updated to include all papers to October 2016. Two independent reviewers undertook two stage screening and data extraction of the included studies at all stages. A Cochrane quality assessment was carried out to assess the risk of bias. In total, fourteen studies were included in the review. In a meta-analysis of these fourteen studies the interventions saw less disorganised attachment at outcome compared to the control (OR = 0.50, (0.32, 0.77), p = 0.008). The majority of the interventions targeted maternal sensitivity. We carried out exploratory analyses to examine factors that may influence treatment outcome but these should be treated with caution given that we were limited by small numbers of studies.ConclusionsParenting interventions that target parental sensitivity show promise in reducing disorganised attachment. This is limited by few high quality studies and the fact that most studies are with mothers. More high quality randomised controlled trials are required to elucidate this further.

There is a large body of research showing that there is a much higher prevalence of psychiatric disorders in children and adolescents with learning disabilities than in those without ([Dykens, 2000][1]; [Stromme & Diseth, 2000][2]; [Tonge & Einfield, 2000][3]; [Emerson, 2003][4]; [Whitaker & Read

Family work is often provided when young people present with psychotic illness, either on an inpatient basis or before or after admission. Whilst it seems intuitively sensible, for example, to provide information, support for the family and plan family-based support on return home, there is little evidence base for such work in adolescents. The largely adult-based literature is the main source of published work. There is a paucity of randomized controlled research on family work in adolescent psychosis. This article reviews the literature in the light of the practice of one such unit that has for some years routinely embarked upon family work with psychotic young people. It sets out some of the goals of this work and the evidence (or lack of it) supporting those goals. By so doing it highlights the need for more research in this area.

Objectives Computer-administered cognitive–behavioural therapy (CCBT) may be a promising treatment for adolescents with depression, particularly due to its increased availability and accessibility. The feasibility of delivering a randomised controlled trial (RCT) comparing a CCBT program (Stressbusters) with an attention control (self-help websites) for adolescent depression was evaluated. Design Single centre RCT feasibility study. Setting The trial was run within community and clinical settings in York, UK. Participants Adolescents (aged 12–18) with low mood/depression were assessed for eligibility, 91 of whom met the inclusion criteria and were consented and randomised to Stressbusters (n=45) or websites (n=46) using remote computerised single allocation. Those with comorbid physical illness were included but those with psychosis, active suicidality or postnatal depression were not. Interventions An eight-session CCBT program (Stressbusters) designed for use with adolescents with low mood/depression was compared with an attention control (accessing low mood self-help websites). Primary and secondary outcome measures Participants completed mood and quality of life measures and a service Use Questionnaire throughout completion of the trial and 4 months post intervention. Measures included the Beck Depression Inventory (BDI) (primary outcome measure), Mood and Feelings Questionnaire (MFQ), Spence Children9s Anxiety Scale (SCAS), the EuroQol five dimensions questionnaire (youth) (EQ-5D-Y) and Health Utility Index Mark 2 (HUI-2). Changes in self-reported measures and completion rates were assessed by treatment group. Results From baseline to 4 months post intervention, BDI scores and MFQ scores decreased for the Stressbusters group but increased in the website group. Quality of life, as measured by the EQ-5D-Y, increased for both groups while costs at 4 months were similar to baseline. Good feasibility outcomes were found, suggesting the trial process to be feasible and acceptable for adolescents with depression. Conclusions With modifications, a fully powered RCT is achievable to investigate a promising treatment for adolescent depression in a climate where child mental health service resources are limited. Trial registration number ISRCTN31219579.

Aims and MethodWe discuss the development of a service for children with learning disabilities within a child and adolescent mental health team using the Health Advisory Service Together We Stand tier system. The paper also includes an audit of the service 8 months after it was started.ResultsWe present a model of service that has proved successful to date. We give details from the audit of the service, its aims, funding, referral numbers, sources, types and criteria.Clinical ImplicationsThe audit suggests that the aims of the service are being achieved but given the fact that the numbers of new referrals significantly outweigh the discharge rate, it is concluded that a greater emphasis is placed on liaison, consultation and joint working with other agencies.

Certain areas of child and adolescent mental health generate a degree of polarised debate, both within and outside the profession. Media attention, the development of self-help groups and the Internet lead to the publishing of papers and opinion, which exist alongside peer-reviewed research and evidence-based medicine. Parents reading such material may find it hard to know what advice is best. One area that falls into this category is chronic fatigue syndrome (CFS).

Many authors have written about the psychological consequences for the survivors when a family member commits suicide. Most clinicians use bereavement as a paradigm for planning therapeutic interventions. We have not been able to find any articles which recognize that the experience may be a form of child abuse. We believe that using the model of child abuse as well as traditionally used models of bereavement and trauma may be helpful when understanding the child’s predicament and planning therapeutic interventions. Two cases, involving four children, illustrate this perspective.

Total loss of colour vision which is acquired is rare and is usually organic. Standard ophthalmological textbooks do not mention psychogenic causes. One case, reported here, highlights the existence of non-organic achromatopsia (loss of colour vision) in children and the importance of maintaining links between child mental-health workers and other disciplines such as ophthalmologists to establish appropriate investigation and management.

The Royal College of Psychiatrists' Higher Specialist Training Handbook (1998) emphasises the need for training schemes to be well organised in order to provide an environment in which training needs can be met. Training programme directors are tasked to provide “regular meetings with the trainees as a group to discuss the scheme and its placements” as well as “occasional meetings with trainers to discuss the scheme and its further development”.

Aims and methodTo discuss the working of a new paediatric liaison service. To review paediatric referrals to a child and adolescent mental health service (CAMHS) 21 months before and 21 months after the establishment of this service.ResultsOne hundred and eighty-three children were discussed in the 21 months after the new service was set up. There was a rise in referral to CAMHS from 72 to 120. Non-attendance rates from paediatric referrals also rose. Likely reasons for these changes are discussed, and include an increase in referrals of children with somatisation.Clinical implicationsInterdisciplinary liaison appears to carry many advantages, but is likely to increase referral rates to the CAMHS. This has both clinical and resource implications.

It has been recommended that child and adolescent mental health services operate on four tiers (NHS Health Advisory Service, 1995). Tier three represents specialist teams, where professionals work together to provide specialist services. Since additional resources have not been forthcoming to support such developments, existing teams frequently restructure themselves in order to operate in this way. One way of rationalising existing resources effectively is to establish interagency links so that multi-disciplinary working is not limited by professional boundaries. This can occur across as well as within teams.

This paper explores the extent of known child sexual and physical abuse in child psychiatric out-patient services in Leeds. We surveyed a one-month period, looking at all out-patient contacts, and found that at least 17.9% of patients had been physically or sexually abused and these patients took up 25.8% of out-patient time. When the 70 abused children were compared to a group matched for age group, clinical team and diagnosis It was found that they were more likely to be followed-up for longer and they received more therapeutic time over a given period than non-abused children. The implications for resources are discussed.