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Abstract Background Childhood adversities worsen physical and mental health across the lifespan. Health and social care practitioners play a key role in identifying and responding to childhood adversity, however, may be reluctant to do so due to a perceived lack of services to refer to, time pressures and a deficit of training and confidence. We aimed to (1) quantify changes in practitioner comfort and confidence to identify and respond to childhood adversity following a multimodal intervention within an integrated child and family health and social care hub and (2) to understand barriers and facilitators of practice change. Methods Hub practitioners were surveyed about their competence and comfort to directly ask about and confidence to respond to adversity at baseline and then at six and twelve months post training. Interviews were undertaken to explore practitioner barriers and enablers of practice change. Interviews were recorded, transcribed verbatim, and analysed using reflexive thematic analysis. The theoretical domains framework was used to identify the key drivers of practice change. Results Fifteen of 18 practitioners completed all three surveys and 70% reported increased competence and comfort to directly ask, and confidence to respond across a range of adversities over the 12-month intervention. Twenty-one practitioners completed interviews. Six themes were identified as either facilitators or barriers to practice change. Facilitator themes included (1) connection matters, (2) knowledge provides assurance, (3) confidence in ability and (4) choosing change. Barrier themes were (1) never enough time and (2) opening Pandora’s box. Following analysis, key drivers of practice change were ‘social influence’, ‘belief in capability’, ‘knowledge’ and ‘behaviour regulation’ while barriers to practice change were ‘environmental context and resources’ and ‘emotion’. Conclusions Practitioners reported improved confidence in identifying and responding to adversity through a multimodal intervention delivered in an integrated Child and Family Hub. Changing practice requires more than just education and training. Opportunities for social connection and coaching to improve self-confidence and perceived competence are needed to overcome the fear of opening Pandora’s box.

Abstract Background Adverse childhood experiences can impact physical and mental health throughout the lifespan. To support families experiencing adversity and improve child health and developmental equity, an integrated, multi-sector response is required. Child and Family Hubs (Hubs) are a feasible and acceptable approach to providing such a response. In the Australian context, a number of federal and New South Wales (NSW) state policies support an integrated, multi-sector response using Hubs to support families experiencing adversity. This study examined NSW policy stakeholder and health service manager perspectives on the barriers and enablers to translating policy into practice in the implementation of Child and Family Hubs. Methods Semi-structured interviews were conducted with 11 NSW government policy stakeholders and 13 community health service managers working in child and family policy and planning or child and family community-based services. Interviews were of 30–60 min duration and explored stakeholder knowledge, perspectives and experiences around childhood adversity, and barriers and enablers to operationalizing policies supporting Hubs. Analysis of barriers and facilitators to implementation of Hub models of care was undertaken using the Consolidated Framework for Implementation Research (CFIR). Results Key barriers that emerged included short-term and inconsistent funding, lack of resourcing for a Hub co-ordinator, limited support for evaluation and insufficient time to plan for Hub implementation. Key enablers included flexibility and adaptability of Hub models to meet local needs, formal change management processes, strong governance structures and engagement among Hub practitioners. Key insights included the importance of targeted strategies to support sustained individual practice change and the need for organization-wide commitment to enable the successful adoption and maintenance of the Hub model of care. Conclusions This study provides valuable insights and contributes evidence around what is needed to strengthen and support the operationalization and scalability of the Hub model of care. Key recommendations for Hub practitioners include the importance of formal change management processes and establishment of strong governance structures, while key recommendations for policymakers include the need for sustainable Hub funding and a standardized, evidence-based framework to support Hub implementation and evaluation.

Objectives: The objective of this study was to develop Service, Research and Policy priorities to prevent the impact of family adversity on child mental health and determine comparative priorities of diverse stakeholders to those with lived experience of adversity. Methods: Value-weighting approach conducted in a staged process: (i) professionals and experts with lived experience from health, education, justice and social care sectors attended a national symposium to identify priorities for family adversity and mental health and (ii) a subsequent resource allocation survey gathered views from participants and external experts on symposium priorities. Results: Consensus was reached on priorities. Service priorities included establishing intersectoral hubs for children and families and early childhood nurse home-visiting programs. Research priorities included scaling up evidence-based interventions and evaluating cross-sector, flexible funding models for services addressing childhood adversity. Policy priorities included developing evidence-based policies with evaluation and implementation plans and flexible funding models to support integrated care. Conclusions: Our results provide detailed and actionable clarity on next steps to address family adversities. Implications for Public Health: The priorities call for a focus on cross-sectoral approaches to preventing or mitigating the effects of family adversity. The current Australian policy environment provides a timely opportunity to action the proposed interventions.

Abstract Background To identify and describe distinct developmental trajectories of health-related quality of life (HRQoL) in a national level Australian population sample, overall and separately for boys and girls. Methods Data were from the Longitudinal Study of Australian Children (LSAC). Participants were children aged 4–5 years recruited in 2004 and followed through to age 16–17 years in 2016, and their caregivers. Group-based trajectory modelling was used to identify groups of children that follow qualitatively distinct developmental trajectories of HRQoL. Results Three distinct trajectories were identified for the total sample: (1) high-stable (52.2% of children); (2) middle-stable (38.0%); and (3) low-declining (9.8%). These trajectories differed for boys, who saw increasing HRQoL in the highest trajectory group; a middle-stable trajectory; and declining and rebounding HRQoL in the lowest trajectory group. In contrast, girls saw no increasing or rebounding trajectories; approximately half of girls had high-stable HRQoL and the remaining half had either steadily or rapidly declining HRQoL from age 4–5 to 16–17 years. Conclusions Our results highlight the importance of considering the distinct trajectories for girls and boys and not relying on population mean levels of HRQoL for decision-making. The presence of developmentally distinct trajectories of HRQoL, and differences in the trajectories faced by boys and girls, should be considered when assessing the effectiveness of treatments and interventions impacting upon HRQoL throughout childhood and adolescence. Failure to account for these pre-existing trajectories may over- or under-estimate treatment effects.

BackgroundAcute gastroenteritis is a highly contagious disease demanding effective public health and clinical care systems for prevention and early intervention to avoid outbreaks and symptom deterioration. The Netherlands and Australia are both top-performing, high-income countries where general practitioners (GPs) act as healthcare gatekeepers. However, there is a lower annual incidence and per-case costs for childhood gastroenteritis in Australia. Understanding the systems and policies in different countries can lead to improvements in processes and care. Therefore, we aimed to compare public health systems and clinical care for children with acute gastroenteritis in both countries.MethodsA cross-country expert study was conducted for the Netherlands and Australia. Using the Health System Performance Assessment framework and discussions within the research group, two questionnaires (public health and clinical care) were developed. Questionnaires were delivered to local experts in the Netherlands and the state of Victoria, Australia. Data synthesis employed a narrative approach with constant comparison.ResultsIn Australia, rotavirus vaccination is implemented in a national program with immunisation requirements and legislation for prevention, which is not the case in the Netherlands. Access to care differs, as Dutch children must visit their regular GP before the hospital, while in Australia, children have multiple options and can go directly to hospital. Funding varies, with the Netherlands providing fully funded healthcare for children, whilst in Australia it depends on which GP (co-payment required or not) and hospital (public or private) they visit. Additionally, the guideline-recommended dosage of the antiemetic ondansetron is lower in the Netherlands.ConclusionsHealthcare approaches for managing childhood gastroenteritis differ between the Netherlands and Australia. The lower annual incidence and per-case costs for childhood gastroenteritis in Australia cannot solely be explained by the differences in healthcare system functions. Nevertheless, Australia's robust public health system, characterized by legislation for vaccinations and quarantine, and the Netherland's well-established clinical care system, featuring fully funded continuity of care and lower ondansetron dosages, offer opportunities for enhancing healthcare in both countries.

Abstract Introduction Sleep problems in children with epilepsy (CWE) are common. However, little is known about parental experiences and feelings about managing sleep in their CWE. To provide the most appropriate services' provision, it is essential that the lived experience of parents of this patient group and the issues and problems that they face in managing their child's sleep is understood. Method In 2018, nine mothers of CWE (aged 5–15 years) were interviewed about their perceptions and experiences around their child's sleep, sleep problems and their management, the impact of sleep difficulties on the child and their family and available support. Results Four themes were identified that represented the nature of the child's sleep problems, including settling and night‐waking issues, parasomnias and child anxiety around sleep. Seven themes represented mothers' experiences of managing their child's sleep and any associated problems, including the longstanding challenging nature of child sleep issues, management strategies adopted, challenges related to managing sleep over time, the link between sleep and seizures, the negative impact of poor sleep on daytime functioning, role of antiseizure medication and maternal concerns about child sleep. One theme represented the perceived lack of information, help and support available. Conclusions Findings suggest there are unmet needs in supporting parents to deal with sleep, sleep problems and their management in CWE. Patient or Public Contribution This individual study was conducted under the umbrella of the CASTLE research programme (see https://castlestudy.org.uk/). Parents who have lived experience of parenting a child with epilepsy were co‐applicants for the programme and were involved in the original conception, aims, design and funding application for the research programme (including the project reported in this paper) and advised on project design. Mothers of CWE who have lived experience of managing sleep and sleep problems in their child were participants who shared their experiences through the interviews, which formed the data of the current study.

BackgroundUnaddressed family adversity has potentially modifiable, negative biopsychosocial impacts across the life course. Little is known about how Australian health and social practitioners identify and respond to family adversity in community and primary health settings.ObjectiveTo describe, in two Australian community health services: (1) the number of adversities experienced by caregivers, (2) practitioner identification of caregivers experiencing adversity, (3) practitioner response to caregivers experiencing adversity, and (4) caregiver uptake of referrals.MethodsSurvey of caregivers of children aged 0–8 years attending community health services in Victoria and New South Wales (NSW). Analysis described frequencies of caregiver self-reported: (1) experiences of adversity, (2) practitioner identification of adversity, (3) practitioner response to adversity, and (4) referral uptake. Analyses were sub-grouped by three adversity domains and site.Results349 caregivers (Victoria: n = 234; NSW: n = 115) completed the survey of whom 88% reported experiencing one or more family adversities. The median number of adversities was 4 (2–6). Only 43% of participants were directly asked about or discussed an adversity with a practitioner in the previous 6 months (Victoria: 30%; NSW: 68%). Among caregivers experiencing adversity, 30% received direct support (Victoria: 23%; NSW: 43%), and 14% received a referral (Victoria: 10%; NSW: 22%) for at least one adversity. Overall, 74% of caregivers accepted referrals when extended.ConclusionThe needs of Australian families experiencing high rates of adversity are not systematically identified nor responded to in community health services. This leaves significant scope for reform and enhancement of service responses to families experiencing adversity.

Background: Financial hardship is a social determinant of health but is rarely assessed by healthcare services. This study (1) investigated the feasibility and acceptability of asking caregivers about financial hardship during a routine clinical encounter, and (2) described associations between financial hardship and caregiver and child mental health. Methods: Design: Cross-sectional survey. Setting: Day Medical Unit of Australia's largest public paediatric hospital, 1 April-31 July 2021. Participants: Families with children aged 2–17 years with chronic medical conditions. Measures: Caregiver-reported: financial hardship (3 study-designed items dichotomised into any (yes) versus none (no)) and mental health (Depression Anxiety Stress Scales (DASS), with subscales classified as poor (moderate/severe/extremely severe) versus not (none/mild)). Caregivers and young people aged 11–17 years reported child mental health (Strengths and Difficulties Questionnaire (SDQ), categorised as normal/borderline/abnormal). Analysis: Feasibility and acceptability were assessed by response proportions. Chi square tests assessed associations between mental health and financial hardship. Results: 160/193 (83%) of caregivers and 50/79 (63%) of 11–17-year-olds consented and completed the surveys. 22% of families reported financial hardship and 24% of caregivers reported moderate-to-severe mental health on at least one DASS subscale. Abnormal mental health (SDQ) was common for children according to caregivers (40%) and young people themselves (43%). Financial hardship was associated with poorer mental health when reported by caregivers for themselves and their children, but not when reported by the young person (noting numbers were small). Discussion: Tertiary healthcare may offer a feasible setting for identifying and responding to common and adverse social conditions such as financial hardship and mental health.

Introduction Sleep and epilepsy have an established bidirectional relationship yet only one randomised controlled clinical trial has assessed the effectiveness of behavioural sleep interventions for children with epilepsy. The intervention was successful, but was delivered via face-to-face educational sessions with parents, which are costly and non-scalable to population level. The Changing Agendas on Sleep, Treatment and Learning in Epilepsy (CASTLE) Sleep-E trial addresses this problem by comparing clinical and cost-effectiveness in children with Rolandic epilepsy between standard care (SC) and SC augmented with a novel, tailored parent-led CASTLE Online Sleep Intervention (COSI) that incorporates evidence-based behavioural components.Methods and analyses CASTLE Sleep-E is a UK-based, multicentre, open-label, active concurrent control, randomised, parallel-group, pragmatic superiority trial. A total of 110 children with Rolandic epilepsy will be recruited in outpatient clinics and allocated 1:1 to SC or SC augmented with COSI (SC+COSI). Primary clinical outcome is parent-reported sleep problem score (Children’s Sleep Habits Questionnaire). Primary health economic outcome is the incremental cost-effectiveness ratio (National Health Service and Personal Social Services perspective, Child Health Utility 9D Instrument). Parents and children (≥7 years) can opt into qualitative interviews and activities to share their experiences and perceptions of trial participation and managing sleep with Rolandic epilepsy.Ethics and dissemination The CASTLE Sleep-E protocol was approved by the Health Research Authority East Midlands (HRA)–Nottingham 1 Research Ethics Committee (reference: 21/EM/0205). Trial results will be disseminated to scientific audiences, families, professional groups, managers, commissioners and policymakers. Pseudo-anonymised individual patient data will be made available after dissemination on reasonable request.Trial registration number ISRCTN13202325.

Background: Collecting data using paediatric health-related quality of life (HRQoL) instruments is complex, and there is a paucity of evidence regarding the comparative performance of paediatric HRQoL instruments. The Australian Paediatric Multi-Instrument Comparison (P-MIC) study was conducted to address this paucity of evidence. This study aims to understand the (1) feasibility of collecting data using paediatric HRQoL instruments in a research setting and (2) acceptability and feasibility for children and their caregivers to complete common paediatric HRQoL instruments using data from the Australian P-MIC study. Methods: Data were from children aged 5–18 years from the Australian P-MIC study. Demographics, cost and time for data collection, dropout rates, and inconsistent responses were used to assess Aim 1. Participant-reported difficulty and completion time were used to assess Aim 2. Subgroup analyses included child age, report type (self/proxy), sample recruitment pathway (hospital/online), and online panel sample type (general population/condition groups). Results: Overall, 5945 P-MIC participants aged 5–18 years completed an initial survey, of these, 2346 also completed the follow-up survey (39.5% response rate). Compared with online panel recruitment, hospital recruitment was more costly and time-consuming and had higher follow-up completion (33.5% versus 80.4%) (Aim 1). Data were of similar good quality (based on inconsistent responses) for both recruitment pathways (Aim 1). Participants completed each instrument in 70% reported each instrument as easy to complete (Aim 2). Conclusions: The Australian P-MIC study was able to collect good-quality data using both online panel and hospital recruitment pathways. All instruments were acceptable and feasible to children and their caregivers.

BackgroundMental health problems, such as behavioural and emotional problems, are prevalent in children. These problems can have long lasting, detrimental effects on the child, their parents and society. Most children with a mental health problem do not receive professional help. Those that do get help can face long wait times. While waiting, parents want to learn how they can help their child. To address this need, we co-designed a new website to help parents find ways of helping their child's mental health problem while waiting to get specialist help.ObjectivesTo assess the acceptability and feasibility of a new co-designed website, FindWays, through a pilot randomised controlled trial. The protocol is registered with ISRCTN (ISRCTN64605513).MethodsThis study will recruit up to 60 parents of children aged two-twelve years old referred to a paediatrician for behavioural and/or emotional problems. Participants will be randomly allocated by computer generated number sequence to either the intervention or control group. Intervention group participants will receive access to the FindWays website to help them manage their child's mental health problem while they wait to see the paediatrician. Acceptability and feasibility will be assessed over the 4-month intervention through mixed methods including: recruitment, adherence, retention, net promoter score (quantitative measures) and semi-structured interviews to gain an in-depth understanding of parents' experience and potential adverse effects (qualitative measure). Secondary outcomes measured by parent survey at 4-months post randomisation include child mental health, parent mental health, impact of the child's mental health problem on their functioning and family, and health service use and associated costs.ResultsRecruitment commenced June 2022 with publication expected in October 2023.ConclusionThis study will provide novel data on the acceptability and feasibility of a new website co-designed with parents to help them find ways of managing their child's behaviour and emotions.

Abstract Background Despite the well-established link between childhood adversity and mental health problems, there is a dearth of evidence to inform decision making about the most acceptable and feasible interventions for preventing mental health problems for children experiencing adversity. Expert consensus is an important input into evidence-informed policy and practice but is often employed at the national level which misses important local contextual factors shaping decision making. This study aimed to: (1) reach consensus on local priority interventions for preventing mental health problems for children living with adversity in Wyndham, Victoria; and (2) understand the enabling factors and barriers to implementing these interventions. Methods This study employed six online modified nominal group technique (NGT) workshops with 19 stakeholders; intersectoral service providers from health, social and education sectors and caregivers of children aged 0–8 years. Results Three interventions reached consensus among the mixed stakeholder groups as being a high or very high priority for implementation in Wyndham: nurse home visiting, parenting programs and community-wide programs. Key rationales were the ability for these interventions to act as a gateway for families to increase their knowledge about topics immediately relevant to them (i.e. parenting), increase their knowledge about available supports and build relationships with service providers. Conclusions Local priorities for preventing mental health problems for children living with adversity emphasized relational approaches to service provision and were shaped by the availability of existing interventions and supports in the locality. The NGT was found to be an effective method for prioritising evidence-based practice interventions in health settings, engaging local stakeholders, and identifying enablers and barriers to implementation.

This review assesses the effectiveness of integrated primary health and social care hubs on mental health outcomes for children experiencing adversity and describes common integration dimensions of effective hubs. PubMed, OVID Medline and PyschINFO databases were systematically searched for relevant articles between 2006–2020 that met the inclusion criteria: (i) interventional studies, (ii) an integrated approach to mental health within a primary health care setting, (iii) validated measures of child mental health outcomes, and (iv) in English language. Of 5961 retrieved references, four studies involving children aged 0–12 years experiencing one or more adversities were included. Most children were male (mean: 60.5%), and Hispanic or African American (82.5%). Three studies with low-moderate risk of bias reported improvements in mental health outcomes for children experiencing adversity receiving integrated care. The only RCT in this review did not show significant improvements. The most common dimensions of effective integrated hubs based on the Rainbow Model of Integrated Care were clinical integration (including case management, patient-centred care, patient education, and continuity of care), professional integration, and organisational integration including co-location. These results suggest hubs incorporating effective integration dimensions could improve mental health outcomes for children experiencing adversity; however, further robust studies are required. Registered with Prospero: CRD42020206015.

Introduction Integrated community healthcare Hubs may offer a ‘one stop shop’ for service users with complex health and social needs, and more efficiently use service resources. Various policy imperatives exist to implement Hub models of care, however, there is a dearth of research specifically evaluating Hubs targeted at families experiencing adversity. To contribute to building this evidence, we propose to co-design, test and evaluate integrated Hub models of care in two Australian community health services in low socioeconomic areas that serve families experiencing adversity: Wyndham Vale in Victoria and Marrickville in New South Wales.Methods and analysis This multisite convergent mixed-methods study will run over three phases to (1) develop the initial Hub programme theory through formative research; (2) test and, then, (3) refine the Hub theory using empirical data. Phase 1 involves co-design of each Hub with caregivers, community members and practitioners. Phase 2 uses caregiver and Hub practitioner surveys at baseline, and 6 and 12 months after Hub implementation, and in-depth interviews at 12 months. Two stakeholder groups will be recruited: caregivers (n=100–200 per site) and Hub practitioners (n=20–30 per site). The intervention is a co-located Hub providing health, social, legal and community services with no comparator. The primary outcomes are caregiver-reported: (i) identification of, (ii) interventions received and/or (iii) referrals received for adversity from Hub practitioners. The study also assesses child, caregiver, practitioner and system outcomes including mental health, parenting, quality of life, care experience and service linkages. Primary and secondary outcomes will be assessed by examining change in proportions/means from baseline to 6 months, from 6 to 12 months and from baseline to 12 months. Service linkages will be analysed using social network analysis. Costs of Hub implementation and a health economics analysis of unmet need will be conducted. Thematic analysis will be employed to analyse qualitative data.Ethics and dissemination Royal Children’s Hospital and Sydney Local Health District ethics committees have approved the study (HREC/62866/RCHM-2020). Participants and stakeholders will receive results through meetings, presentations and publications.Trial registration number ISRCTN55495932.

Abstract Gastro-oesophageal reflux (GOR) is a common physiological state in infants and young children, with gastro-oesophageal reflux disease (GORD) its pathological manifestation. Management of GOR/GORD requires elimination of possible underlying causes, parental reassurance, modification of feeding and symptom mitigation, monitoring, and referral to paediatricians if warning signs are present. Published clinical practice guidelines (CPGs) seek to support clinicians and improve management. This study aimed to measure the proportion of Australian GOR/GORD paediatric care that was in line with CPG recommendations. National and international CPGs for GOR/GORD were systematically identified and candidate indicators extracted; a Delphi process selected 32 indicators relevant to Australian paediatric care in 2012 and 2013. Medical records were identified in General Practices, the offices of general paediatricians, Emergency Departments and inpatient settings. Adherence to indicators was assessed by nine trained paediatric nurses undertaking retrospective medical record review. Medical records were reviewed in 115 healthcare sites; identifying 285 children, three-quarters aged

Introduction: Integrated care research often fails to adequately describe co-design methods. This article outlines the process, principles and tools to co-design an integrated health and social care Hub for families experiencing adversity. Research methods: The Child and Family Hub was co-designed in four stages: (1) partnership building and stakeholder engagement, (2) formative research, (3) persona development and (4) co-design workshops and consultations. Local families, community members and intersectoral practitioners were engaged at each stage. The co-design workshops employed a human-centred design process and were evaluated using the Public and Patient Engagement Evaluation Tool (PEET). Results: 121 family participants and 80 practitioners were engaged in the Hub’s co-design. The PEET highlighted the co-design team’s satisfaction achieved by community members working alongside practitioners to generate mutual learning. Resourcing was a key challenge. Discussion: Human-centred design offered a systematic process and tools for integrating formative evidence with lived and professional experience in the Hub’s co-design. Applying community engagement principles meant that a diverse range of stakeholders were engaged across all stages of the project which built trust in and local ownership of the Hub model. Conclusion: Co-design research with families experiencing adversity should attend to language, engagement methods, team composition and resourcing decisions.

BackgroundMany children with mental health problems do not receive professional help. Despite the frequent use of digital health interventions (DHIs) such as websites or web-based service navigation platforms, their effects on parents’ mental health literacy, help seeking, or uptake of professional services are unclear. ObjectiveThis study aims to provide a systematic review and narrative synthesis to describe whether DHIs improve the aforementioned parental outcomes. MethodsDatabases, including CINAHL, Embase, MEDLINE OVID, PsycINFO, and PubMed (2000-2020), were accessed. Studies were included if they evaluated quantitative changes in mental health literacy, help seeking, or the uptake of services by parents of children with mental health problems. Theoretical frameworks, sample sizes, participant demographics, recruitment, interventions, DHI use, results, and health economic measures were used for data extraction. ResultsOf the 11,379 search results, 5 (0.04%) studies met the inclusion criteria. One randomized controlled trial found the reduced uptake of services after using a DHI coupled with a telephone coach for a child’s behavioral problem. Of 3 studies, 2 (66.7%) found statistically significant improvement in mental health literacy for attention-deficit/hyperactivity disorder but had no control group. One study found nonsignificant improvement in mental health literacy and help-seeking attitudes toward anxiety and depression compared with those in active controls. All studies were rated as having a high or serious risk of bias. Search results were affected because of a single reviewer screening articles, overall low-quality studies, and a lack of consistent nomenclature. ConclusionsThere is no high-quality evidence that DHIs can improve parents’ mental health literacy, help seeking, or uptake of services. More research is needed to evaluate DHIs by using rigorous study designs and consistent measures. Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42020130074; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020130074

Objective Retrospective, parent‐reported data suggest that 50% of Australian children with mental health disorders miss out on care. In a national sample, we aimed to determine the proportion receiving mental health services and associated characteristics, using prospective, objective data. Method Prospective analysis of linked Medicare Benefits Scheme (MBS)‐rebated mental health service use in children aged 8–9, 10–11, and 12–13-years, from the Longitudinal Study of Australian Children K cohort (N = 4,983). Analyses were conducted separately for children scoring above the cut points on the Strength and Difficulties Questionnaire (SDQ) emotional and externalising problems subscales. Characteristics were compared using logistic regressions. Results Nine to 27% of children scoring above SDQ cut points accessed MBS‐rebated mental health services, typically from general practitioners, psychologists and paediatricians. Greater symptom severity, parent perception that child needs help, being a young boy and older were associated with increased service use. Children from more disadvantaged families or families speaking a language other than English were less likely to receive services for internalising problems. Conclusion In the first prospective, objective analysis, most children do not receive mental health services.

Objectives Policy makers in developed countries have long considered the education system an avenue for supporting mental health care for children. Whilst educators have identified many challenges to providing this support (e.g. non-core role, stigma, overcrowded curriculum), understanding clinicians’ views on the role of educators and schools and how clinicians and schools could work together to achieve good mental health outcomes are important questions. However, clinician voices in how schools and health should work together for children’s mental health care are frequently missing from the debate. We aimed to report clinicians’ views about how the education system could support student’s mental health and improve access to mental health care for children and adolescents. Methods 143 clinicians (approximately 35 each of child and adolescent psychiatrists, pediatricians, child psychologists and general practitioners (GPs)) from the states of Victoria and South Australia participated in semi-structured phone interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study aims. Findings Key themes emerged: (1) The role of schools in supporting individual children; (2) School based programs to support children and families; and (3) Challenges of implementing these suggestions. Clinicians across all professional groups suggested the education system could play an important role in improving access to mental health services through harnessing existing staff or co-locating mental health clinicians. They also suggested schools could identify at risk children and implement coping and social skills programs. Conclusions Schools and educators could play a key role in prevention and early intervention of children’s mental health problems. However, before recommending exactly how to do this, key evidence gaps need to be addressed.

Abstract Background Up to 60% of children with Attention-Deficit/Hyperactivity Disorder (ADHD) meet diagnostic criteria for at least one anxiety disorder, including Social, Generalized and/or Separation Disorder. Anxiety in children with ADHD has been shown to be associated with poorer child and family functioning. Small pilot studies suggest that treating anxiety in children with ADHD using cognitive-behavioral therapy (CBT) has promising benefits. In a fully powered randomized controlled trial (RCT), we aim to investigate the efficacy of an existing CBT intervention adapted for children with ADHD and comorbid anxiety compared with usual care. Methods This RCT is recruiting children aged 8–12 years (N = 228) from pediatrician practices in Victoria, Australia. Eligibility criteria include meeting full diagnostic criteria for ADHD and at least one anxiety disorder (Generalized, Separation or Social). Eligible children are randomized to receive a 10 session CBT intervention (Cool Kids) versus usual clinical care from their pediatrician. The intervention focuses on building child and parent skills and strategies to manage anxiety and associated impairments including cognitive restructuring and graded exposure. Minor adaptations have been made to the delivery of the intervention to meet the needs of children with ADHD including increased use of visual materials and breaks between activities. The primary outcome is change in the proportion of children meeting diagnostic criteria for an anxiety disorder at 5 months randomization. This will be assessed via diagnostic interview with the child’s parent (Anxiety Disorders Interview Schedule for Children V) conducted by a researcher blinded to intervention condition. Secondary outcomes include a range of child (e.g., anxiety symptoms, ADHD severity, behavior, quality of life, sleep, cognitive functioning, school attendance) and parent (e.g., mental health, parenting behaviors, work attendance) domains of functioning assessed at 5 and 12 months post-randomization. Outcomes will be analyzed using logistic and mixed effects regression. Discussion The results from this study will provide evidence on whether treating comorbid anxiety in children with ADHD using a CBT approach leads to improvements in anxiety and/or broader functional outcomes. Trial registration This trial was prospectively registered: Current Controlled Trials ISRCTN59518816 (https://doi.org/10.1186/ISRCTN59518816). The trial was first registered 29/9/15 and last updated 15/1/19.

Introduction: Many of the sleep problems experienced by children with epilepsy (CWE) have the same behavioural basis as common sleep problems seen in typically developing (TD) children. Behavioural sleep interventions (BSIs) are widely used to treat these sleep problems in TD children and are hypothesised to be effective for CWE. However, specific considerations need to be addressed and incorporated into a BSI for CWE to ensure the intervention is tailored to this population's needs. This paper details developing and tailoring an online BSI for parents of CWE, to be used in the CASTLE (Changing Agendas on Sleep, Treatment and Learning in Epilepsy) Sleep-E clinical trial.Method: In phase one, two existing theory-driven paediatric BSIs were adapted into a novel online behavioural sleep intervention (CASTLE Online Sleep Intervention or COSI) which specifically incorporated the needs and requirements reported by nine parents of CWE. Scoping their needs included conducting interviews with three CWE so that they could contribute to the overall intervention content. In phase two, six of these parents evaluated COSI, reviewing and feeding back on COSI until parental approval for content and functionality was achieved.Results: In phase one, a range of adaptations was made to the content and presentation of standardised intervention material to acknowledge and emphasise the key seizure-specific issues to ensure COSI best met parents of CWE's needs. Adaptations included embedding parent and child experiences in the intervention, including particular information requested by parents, such as the links between sleep and seizures and managing child and parental anxieties around sleep, as well as developing functionality to personalise the delivery of content. In phase two, parents confirmed that they found the final version of COSI to be functional and appropriate (after one round of review) for use by parents of CWE and that 100% would recommend it to other families who have CWE.Discussion: It is hoped that the use of evidence-based BSIs, adapted to consider salient epilepsy-specific factors, will increase parent-engagement, COSI's relevance for this particular patient group and overall efficacy in improving sleep in CWE. The effectiveness of COSI will be tested in the CASTLE Sleep-E clinical trial (https://castlestudy.org.uk/).

Many of the same sleep problems seen in typically developing (TD) children are frequently experienced by children with epilepsy (CWE). Behavioural sleep interventions (BSIs) are commonly and successfully used to treat these sleep problems in TD children and in some neurodevelopmental disorder populations. Therefore, BSIs should be effective in CWE, however, there are special seizure-related considerations for CWE and their parents which may be salient to consider in any future BSI development for this group. The current study sought to identify, from parents, if there were special considerations for the content and delivery of an online BSI for parents of CWE. Semi-structured interviews were conducted with nine mothers of CWE and thematic analysis was conducted on the interview data. Ten themes were apparent which represented what parents wanted from any online BSI for CWE. Parents wanted (i) other parents’ views and real-life experiences to be included, (ii) recognition of how changes over time may influence the appropriateness of using various sleep-management options, (iii) to be presented with a range of sleep management options from which they could select, (iv) personalised information and suggestions for behaviour-change options, (v) help to address child anxiety around sleep, (vi) for the advice and behaviour-change options to be practical, (vii) general educational information about sleep and the relationship between sleep and epilepsy, (viii) for parental worries and concerns to be acknowledged, (ix) to receive help, support, and reassurance around children’s sleep; and (x) to include the child in the intervention. It was clear that any online BSI would require specific adaptations and additions (to content and delivery format) to best meet the needs of parents of CWE. It is hoped that having identified what parents want from on online BSI for CWE will allow these factors to be acknowledged in future intervention development, with the intention to optimise parental engagement and intervention effectiveness. Practical suggestions for how these aspects could be integrated into any online BSI are suggested.

Embedding digital technologies in healthcare has the potential to streamline and personalize medical care. However, healthcare systems are often fragmented, and therefore achieving a truly integrated digital health program can be challenging. To promote a streamlined, evidence-based approach to implementing digital health solutions in a healthcare system, the Murdoch Children's Research Institute (MCRI) established the Digital Health Translation and Implementation Program (DHTI) bringing together clinicians, researchers and digital health experts. From the program commencement, frontline clinical innovators have collaborated with DHTI team members to develop and implement digital solutions to address pain-points in the healthcare system. Throughout this program, important lessons have been learnt relating to the development, evaluation and implementation of digital solutions in the healthcare system. This paper explores these lessons and makes recommendations for the successful implementation of digital health solutions in healthcare systems under five main categories: (1) design and usability, (2) stakeholder engagement and uptake, (3) project management and resourcing, (4) process and implementation, and (5) evaluation. Recommendations suggested here are designed to support future healthcare-based digital health programs to maximize the impact digital solutions can have on the healthcare system and patients.

Abstract Background Optimal mental health is critical for a child’s learning and academic functioning. As a universal service, early education centres play an important role in promoting children’s mental health. Social-emotional learning programs are efficacious in reducing behavioural difficulties, enhancing competence, and improving learning abilities. Mindfulness practices, known to promote health and wellbeing in adults, have been adapted to education programs for younger populations, including pre-school children. Despite an increasing use of mindfulness-based programs in pre-school settings, there is a limited number of randomised trials and paucity of data on implementation fidelity of these programs. ‘Early Minds’ is a mindfulness-based program developed by Smiling Mind for 3–5-year-old children. This paper describes a protocol of a pilot randomised control trial, evaluating the implementation of the program in early learning centres (ELCs, i.e. pre-schools) in Melbourne, Australia. The primary aim of this pilot study is to examine the feasibility, acceptability, and fidelity of the program. The secondary aims are to assess the acceptability of the design and measures and to investigate preliminary impacts of the program on child social-emotional outcomes. Methods A convenience sample of six ELCs are recruited. Participants include educators, children, and their parents from 3- and/or 4-year-old ELC rooms. Upon completion of baseline surveys, rooms are randomly allocated to intervention and control arms by an independent statistician. ‘Early Minds’ is designed in a flexible delivery manner; meditations and activities are completed at least three times a week. Educators are trained in the program and have access to the activities and meditations on an app. Parents are encouraged to practice with their children at least three times a week. Educators document implementation fidelity throughout the 8 weeks of the program. Parents and educators complete follow-up surveys at 3 and 12 months post-randomisation, capturing feasibility and acceptability, child social-emotional behaviour and sleep, and educator, parent, and family wellbeing outcomes. Discussion This pilot study is the first to assess a mindfulness-based program in ELCs in Australia. Data on feasibility and acceptability, implementation fidelity, and potential impact on children’s behaviour will inform the design of adequately powered evaluation trials. Trial registration number Australian New Zealand Clinical Trials Registry, ACTRN12618000435280. Date registered 26 March 2018.

ObjectiveTo assess General Practitioner (GP) and pediatrician adherence to clinical practice guidelines (CPGs) for diagnosis, treatment and management of attention deficit hyperactivity disorder (ADHD).MethodMedical records for 306 children aged ≤15 years from 46 GP clinics and 20 pediatric practices in Australia were reviewed against 34 indicators derived from CPG recommendations. At indicator level, adherence was estimated as the percentage of indicators with 'Yes' or 'No' responses for adherence, which were scored 'Yes'. This was done separately for GPs, pediatricians and overall; and weighted to adjust for sampling processes.ResultsAdherence with guidelines was high at 83.6% (95% CI: 77.7-88.5) with pediatricians (90.1%; 95% CI: 73.0-98.1) higher than GPs (68.3%; 95% CI: 46.0-85.8; p = 0.02). Appropriate assessment for children presenting with signs or symptoms of ADHD was undertaken with 95.2% adherence (95% CI: 76.6-99.9), however ongoing reviews for children with ADHD prescribed stimulant medication was markedly lower for both pediatricians (51.1%; 95% CI: 9.6-91.4) and GPs (18.7%; 95% CI: 4.1-45.5).ConclusionAdherence to CPGs for ADHD by pediatricians was generally high. Adherence by GPs was lower across most domains; timely recognition of medication side effects is a particular area for improvement.

Background: There is a lack of psychometric evidence about pediatric health-related quality of life (HRQoL) instruments. Evidence on cost effectiveness, involving the measurement of HRQoL, is used in many countries to make decisions about pharmaceuticals, technologies, and health services for children. Additionally, valid instruments are required to facilitate accurate outcome measurement and clinical decision making. A pediatric multi instrument comparison (P-MIC) study is planned to compare the psychometric performance and measurement characteristics of pediatric HRQoL instruments. Methods: The planned P-MIC study will collect data on approximately 6100 Australian children and adolescents aged 2–18 years via The Royal Children’s Hospital Melbourne and online survey panels. Participants will complete an initial survey, involving the concurrent collection of a range of pediatric HRQoL instruments, followed by a shorter survey 2–8 weeks later, involving the collection of a subset of instruments from the initial survey. Children aged ≥7 years will be asked to self-report HRQoL. Psychometric performance will be assessed at the instrument, domain, and item level. Conclusions: This paper describes the methodology of the planned P-MIC study, including benefits, limitations, and likely challenges. Evidence from this study will guide the choice of HRQoL measures used in clinical trials, economic evaluation, and other applications.

Introduction: Over the past two decades, Australia’s child population has grown by 12%, yet fewer children are seen by General Practitioners (GP) (Freed, 2011) and more present to emergency departments (Freed, 2015) and hospital outpatient clinics for relatively simple conditions that could be managed in primary care. We therefore aimed to co-develop and pilot an innovative, integrated GP-paediatrician care model and test its feasibility and acceptability to GPs, families and paediatricians, across 5 Victorian (Australia) general practices. Theory/Methods: GP and paediatrician co-design of an integrated care model comprising: weekly GP-paediatrician co-consulting sessions and monthly hour-long case discussions at each practice led by GPs and facilitated by a paediatrician, and email/telephone support to GPs by paediatricians. Paediatricians recorded data on numbers of children and types of cases seen in co-consults and number and topics and number of attendees in the case discussions. We extracted data on quality of GP care for common conditions and pre/post referral patterns of GPs via GHRANITE electronic medical record data extraction software. GP and paediatrician satisfaction with model of care and family satisfaction with GP care for their child were collected via surveys. Results: After 9 months of implementation, 447 children were seen in co-consults and 27 case discussion sessions were conducted with 206 attendees. GPs report high satisfaction with the model and changes in their knowledge and confidence with paediatric care. GPs referred 9% fewer children to hospital and families reported improved confidence in thier GP's care (complete confidence from 78% to 94%) and increased first preference for followup care with a GP (65.4% to 82.8%). Discussion: A novel, integrated model of care between GPs, paediatricians and families is feasible and acceptable to GPs, general practice staff, paediatricians and families. Challenges include ensuring accurate and complete data on GP referral patterns, payment for the co-consulting sessions, and clear communication to practice staff and parents about the role of the paediatrician as a co-consultant with the GP rather than a stand-alone specialist care provider. Conclusions: Developing and embedding a GP-paediatrician model of integrated care in Australia’s primary health care system is feasible and acceptable. Pilot data suggest that the model improves GP confidence to manage paediatric care, streamlines specialist care for child developmental/behavioural problems and may reduce referrals to hospital outpatient clinics and emergency departments. Lessons learned: Intervention design must involve paediatricians, GPs, practice managers and practice administrative staff from the outset. Mutual expectations and clear roles and responsibilities of GPs and paediatricians in co-consultations must be established. Careful attention to messaging to families about the nature of co-consultations will avoid families seeking a paediatrician without a GP. Limitations: pilot study Future research: controlled trial to test the costs and effectiveness of this model in improving GP quality of care for common paediatric health conditions, reducing referrals to outpatient specialist clinics and emergency departments, improving GP confidence in paediatric care, and family satisfaction with primary care for their child.

OBJECTIVES:Improving mental health outcomes for children and young people has become a priority for policy makers in the developed world. In Australia, up to half of all children and adolescents meeting criteria for mental health disorders receive suboptimal levels of treatment (or no treatment at all) despite the availability of effective treatments. Children with complex mental health conditions are particularly at risk of inadequate treatment as optimal care requires coordination from medical, educational and social services. In Australia, clinicians including pediatricians, psychologists and child and adolescent psychiatrists deliver the bulk of mental health care for children with complex mental health conditions. We aimed to determine perspectives of these Australian clinicians on barriers and enablers within the current system and components of an optimal model of care. METHODS:Inductive content analysis was used to analyse 30 semi-structured interviews with key clinicians managing the care of children with complex mental health conditions across Australia. Interviews were conducted using vignettes with Attention Deficit Hyperactivity Disorder (ADHD) and Autism as exemplars. FINDINGS:Multiple barriers to optimal care exist at a systemic, clinician and family level. However, regional health systems provide an enabling environment from which metropolitan models could learn. Transitioning to adult services was highlighted as the most compromised area of care. Clinicians identified short (e.g. empowering parents to advocate for and deliver their child's care, case conferencing with schools) and long term (e.g. co-locating disciplines to deliver care, workforce training) solutions. CONCLUSIONS:Whilst multiple barriers to optimal care for children with complex mental health conditions exist, clinicians identify several enablers including developing networks with other disciplines and empowering parents to advocate for and co-ordinate care. Systemic changes based on multidisciplinary, co-located and integrated care services should be developed as longer term solutions.

This study examined the sustained and moderating effects of a behavioural sleep intervention for autistic children in a randomised controlled trial. Autistic children (5-13 years) with sleep problems were randomised to the Sleeping Sound intervention or Treatment as Usual (TAU). At 12-month follow-up (n = 150), caregivers of children in the Sleeping Sound group reported greater reduction in child sleep problems compared to TAU (p < 0.001, effect size: - 0.4). The long-term benefits of the intervention were greater for children taking sleep medication, children of parents who were not experiencing psychological distress, and children with greater autism severity. The Sleeping Sound intervention demonstrated sustained improvements in child sleep. Identified moderators may inform treatment by indicating which subgroups may benefit from further support.

BackgroundWhat Were We Thinking (WWWT) is a gender-informed, psychoeducational programme to promote respectful relationships and skilled management of unsettled infant behaviours and thereby reduce postpartum common mental disorders. It comprises a highly structured seminar for couples and babies, usual primary care from a WWWT-trained nurse and take-home print materials. The aim was to assess long-term outcomes after a cluster randomised controlled trial of WWWT.MethodTrial participants who consented completed a computer-assisted telephone interview 18 months postpartum. Depressive symptoms were assessed with the Patient Health Questionnaire (PHQ-9) and anxiety symptoms with the Generalised Anxiety Disorder Scale (GAD-7). Impacts of baseline characteristics and trial arm on changes in scores from baseline to follow-up were calculated using Conditional Latent Growth Curve Models adjusting for prognostic indicators and controlling for clustering effects.ResultsOverall, 314/400 (78.5%) women contributed data at baseline (6 weeks postpartum), trial endline (26 weeks postpartum) and follow-up (12 months after trial endline). In intention-to-treat analyses, there was a significantly greater improvement in adjusted GAD-7 scores [regression coefficient (RC) −0.55; 95% confidence interval (CI) −0.94 to −0.17] and non-significant improvement (RC −0.27; 95% CI −0.63 to 0.08) in PHQ-9 scores from baseline to follow-up in the intervention than the control arm. In a per-protocol analysis, the proportion with GAD-7 scores ⩽4 (asymptomatic) improved 24.1% (55.7% baseline to 79.8% follow-up, p = 0.043) among women who received the full WWWT programme, which included the seminar, compared with 2.4% (77.1–79.5%, p = 0.706) among those who received the partial intervention (usual care from WWWT-trained nurse and print materials).ConclusionsThe WWWT programme has a significant sustained beneficial impact on postnatal generalised anxiety among primiparous women compared with usual care. The in-person seminar is the most influential component of the intervention. Psycho-educational programmes integrated into primary care appear promising as a strategy to reduce postpartum common mental disorders.

Introduction: The aim of this paper is to report on the development of surveys to explore integration of care for children living with complex care needs across the European Union (EU) and European Economic Area (EEA). Theory and methods: Each survey consists of a vignette and questions adapted from the 'Standards for Systems of Care for Children and Youth with Special Health Care Needs and the Eurobarometer Survey'. A Country Agent in each country, a local expert in child health services, will obtain data from indigenous sources. Results: We identified ‘in-principle’ complex problems and adapted surveys to capture care integration. We expect to get rich data to understand perceptions and to inform actions for a number of complex health issues. Conclusion: The study has the potential to make a wide contribution to individual countries of the EU/EEA to understand their own integration of services mapped against responses from other member states. Early results are expected in Spring 2017.