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Abstract Background There is a pressing need to offer more accessible, evidence-based psychological interventions to secondary school students who are increasingly reporting difficulties with anxiety and low mood. The aim of this pragmatic randomised multiple baseline trial is to evaluate the efficacy of a school-based counselling intervention called Knowledge Insight Tools (KIT) for reducing anxiety and low mood in UK secondary school students. KIT is a flexible intervention delivered individually and informed by cognitive behavioural therapy (CBT). Methods We will use a randomised multiple baseline design whereby young people will be randomly allocated to a baseline wait period of 3, 4, 5, 6, 7, or 8 weekly measurements, followed by receiving up to 10 weekly sessions of KIT delivered by trained, school-based practitioners. We aim to recruit 60 young people aged 11–18 who are primarily experiencing problems with low mood and/or anxiety from secondary schools across England and Scotland. We will assess child-reported anxiety, mood, and general psychological distress/coping with the Young Person’s Clinical Outcomes in Routine Evaluation (YP-CORE), recorded at each session during the baseline and intervention phases. We will also assess child-reported anxiety and low mood with the Revised Children’s Anxiety and Depression Scale (RCADS) at the beginning and end of treatment; practitioner-reported treatment fidelity with the KIT Fidelity Checklist; and practitioner-reported feasibility with an end-of-treatment Implementation Survey. We will analyse within-person and between-person change in YP-CORE scores across the baseline and intervention phases using visual analysis and piecewise multilevel growth curve models. We will also analyse pre-post changes in YP-CORE scores using randomisation tests, and reliable and clinically significant change using the RCADS scores. Discussion The KIT trial is a pragmatic, randomised multiple baseline trial aimed at evaluating a school-based, individual CBT counselling intervention for reducing anxiety and low mood in UK secondary school students. Results will directly inform the provision of KIT in school-based counselling services, as well as the growing evidence-base for school-based CBT interventions. Trial registration ClinicalTrials.gov NCT06188962. Retrospectively registered on 02/01/24.

BackgroundThere are more than 1.5 million children and young people in England with special educational needs (SEN), with over 160,000 young people in the United Kingdom attending a special school or alternative provision (AP) setting. Young people with SEN have been found to be at risk for poorer mental health and well-being than non-SEN peers. However, there is a range of both school-related and research challenges associated with identifying difficulties in a timely manner. ObjectiveThis Delphi study aims to determine a list of stakeholder priorities for improving school-based measurement of mental health and well-being among young people with SEN, at an aggregated level, within secondary special school or AP settings. A secondary objective is to inform the implementation of school-based well-being surveys, improve engagement in special schools or AP settings, and improve survey response rates among children and young people with SEN. MethodsA mixed methods Delphi study will be conducted, including a scoping review and preliminary focus groups with school staff members and researchers to establish key issues. This will be followed by a 2-round Delphi survey to determine a list of stakeholder priorities for improving the measurement of mental health and well-being at an aggregate level within special schools and AP settings. A final stakeholder workshop will be held to discuss the findings. A list of recommendations will be drafted as a report for special schools and AP settings. ResultsThe study has received ethical approval from the University College London Research Ethics Committee. The stage 1 scoping review has commenced. Recruitment for focus groups will begin in Autumn 2024. The first round of the Delphi survey will commence in early 2025, and the second round of the Delphi survey in the spring of 2025. The final workshop will commence in mid-2025 with final results expected in late 2025. ConclusionsThere is a need for clear recommendations for special schools and AP settings on priorities for improving the measurement of mental health and well-being problems among young people with SEN. There is also a need for recommendations to researchers implementing school-based well-being surveys, including the #BeeWell program, to enable them to improve their engagement in special schools and AP settings and ensure surveys are accessible. International Registered Report Identifier (IRRID)PRR1-10.2196/58610

Objective Monitoring the incidence of chronic health conditions (CHCs) in childhood in England using administrative data to derive numerators and denominators is challenged by unmeasured migration. We used a birth cohort design and different criteria for contact with health or education services to estimate the cumulative incidence of CHCs to age 16 years. Approach We identified all births in Hospital Episode Statistics (HES) from 2002/3 to 2011/12, with follow-up to 2018/19 (maximum age 8 to 16 years), censoring on death, first non-England residence record or 16th birthday. Children must have linked to later HES records and/or the National Pupil Database (NPD), which provides information on all state-school enrolments. The cumulative incidence of CHCs was estimated to age 16 using diagnostic codes in hospital admission records. We also explored temporal variation. Sensitivity analyses varied denominator criteria. Results Between 423,456 children (79.4%, of all HES-recorded births in 2002/3) and 618,054 (97.5% in 2011/12) linked to later HES or NPD records. The cumulative incidence of ever having a recorded CHC before age 16 among children born in 2002/3 or 2003/4 was 24.6%, ranging from 21% to 32% in sensitivity analyses. There was little temporal variation. At least 28% of children with any CHC had more than one body system affected by age 16. Multimorbidity rates rose with later cohorts. Conclusions Approximately one quarter of children are affected by CHCs, but varies depending on how the denominator is defined. More accurate estimation of the incidence of CHCs requires a dynamic population estimate.

Abstract Background The Brief Educational Workshops in Secondary Schools Trial (BESST) is an England-wide school-based cluster randomised controlled trial assessing the clinical and cost-effectiveness of an open-access psychological workshop programme (DISCOVER) for 16–18-year-olds. This baseline paper describes the self-referral and other recruitment processes used in this study and the baseline characteristics of the enrolled schools and participants. Method We enrolled 900 participants from 57 Secondary schools across England from 4th October 2021 to 10th November 2022. Schools were randomised to receive either the DISCOVER day-long Stress workshop or treatment as usual which included signposting information. Participants will be followed up for 6 months with outcome data collection at baseline, 3-month, and 6-month post randomisation. Results Schools were recruited from a geographically and ethnically diverse sample across England. To reduce stigma, students were invited to self-refer into the study if they wanted help for stress. Their mean age was 17.2 (SD = 0.6), 641 (71%) were female and 411 (45.6%) were from ethnic minority groups. The general wellbeing of our sample measured using the Mood and Feelings Questionnaire (MFQ) found 314 (35%) of students exhibited symptoms of depression at baseline. Eighty percent of students reported low wellbeing on the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) suggesting that although the overall sample mean is below the cut-off for depression, the self-referral approach used in this study supports distressed students in coming forward. Conclusion The BESST study will continue to follow up participants to collect outcome data and results will be analysed once all the data have been collected. Trial registration ISRCTN registry ISRCTN90912799. Registered on 28 May 2020.

Background Depression and anxiety are increasingly prevalent in adolescents. The Brief Educational Workshops in Secondary Schools Trial investigated the effectiveness of a brief self-referral stress workshop programme for sixth-form students aged 16–18 years old.Objective This study conducted a secondary analysis on the outcomes of participants with elevated depressive symptoms at baseline.Methods This is an England-wide, multicentre, cluster randomised controlled trial to evaluate the clinical effectiveness and cost-effectiveness of a brief cognitive–behavioural therapy workshop (DISCOVER) compared with treatment-as-usual (TAU) (1:1). The primary outcome was depression symptoms (Mood and Feelings Questionnaire (MFQ)) at 6-month follow-up, using the intention-to-treat (ITT) population and analysed with a multilevel linear regression estimating a between-group adjusted mean difference (aMD). Cost-effectiveness, taking a National Health Service (NHS) and personal social services perspective, was explored using quality-adjusted life years (QALYs).Findings Between 4 October 2021 and 10 November 2022, 900 adolescents at 57 schools were enrolled. 314 students were identified as having elevated symptoms of depression at baseline (>27 on MFQ). In this prespecified subgroup, the DISCOVER arm included 142 participants and TAU included 172. ITT analysis included 298 participants. Primary analysis at 6 months found aMD to be −3.88 (95% CI −6.48, –1.29; Cohen’s d=−0.52; p=0.003), with a similar reduction at 3 months (aMD=−4.00; 95% CI −6.58, –1.42; Cohen’s d=0.53; p=0.002), indicating a moderate, clinically meaningful effect in the DISCOVER arm. We found an incremental cost-effectiveness ratio of £5255 per QALY, with a probability of DISCOVER being cost-effective at between 89% and 95% compared with TAU.Conclusions and clinical implications DISCOVER is clinically effective and cost-effective in those with elevated depressive symptoms. This intervention could be used as an early school-based intervention by the NHS.Trial registration number ISRCTN90912799.

Abstract Background Individuals from marginalised groups experience higher levels of mental health difficulties and lower levels of wellbeing which may be due to the exposure to stress and adversity. This study explores trajectories of mental health over time for young women and girls and young people with other marginalised identities. Methods We conducted a secondary analysis on N = 14,215 children and young people (7,501 or 52.8% female, 6,571 or 46.2% male, and 81 or 0.6% non-binary or questioning) who completed a survey at age 11 to 12 years and at least one other annual survey aged 12 to 13 years and/or aged 13 to 14 years. We used group-based trajectory models to examine mental health difficulties. Results Except for behavioural difficulties, young women’s and girls’ trajectories showed that they consistently had higher levels of mental health difficulties compared to young men and boys. A similar pattern was shown for non-binary and questioning children and young people. Children and young people with economic disadvantage and/or special education needs, and/or for whom there were welfare concerns, were generally more likely to experience higher levels of mental health difficulties. Conclusions This information could inform public policy, guidance and interventions.

Abstract Background Adolescence is a period of heightened vulnerability to developing mental health problems, and rates of mental health disorder in this age group have increased in the last decade. Preventing mental health problems developing before they become entrenched, particularly in adolescents who are at high risk, is an important research and clinical target. Here, we report the protocol for the trial of the ‘Building Resilience through Socioemotional Training’ (ReSET) intervention. ReSET is a new, preventative intervention that incorporates individual-based emotional training techniques and group-based social and communication skills training. We take a transdiagnostic approach, focusing on emotion processing and social mechanisms implicated in the onset and maintenance of various forms of psychopathology. Methods A cluster randomised allocation design is adopted with randomisation at the school year level. Five-hundred and forty adolescents (aged 12–14) will be randomised to either receive the intervention or not (passive control). The intervention is comprised of weekly sessions over an 8-week period, supplemented by two individual sessions. The primary outcomes, psychopathology symptoms and mental wellbeing, will be assessed pre- and post-intervention, and at a 1-year follow-up. Secondary outcomes are task-based assessments of emotion processing, social network data based on peer nominations, and subjective ratings of social relationships. These measures will be taken at baseline, post-intervention and 1-year follow-up. A subgroup of participants and stakeholders will be invited to take part in focus groups to assess the acceptability of the intervention. Discussion This project adopts a theory-based approach to the development of a new intervention designed to target the close connections between young people’s emotions and their interpersonal relationships. By embedding the intervention within a school setting and using a cluster-randomised design, we aim to develop and test a feasible, scalable intervention to prevent the onset of psychopathology in adolescence. Trial registration ISRCTN88585916. Trial registration date: 20/04/2023.

Despite recent investments in school-based mental health and wellbeing promotion in England, the sustainability of mental health interventions remains a substantial challenge. This article brings together potential solutions to sustaining interventions in schools, drawing on insights from an online roundtable discussion held in July 2022. Facilitated by researchers and informed by recent research on barriers and facilitators to sustaining school-based mental health interventions, 16 participants came together to discuss challenges and solutions. Participants included school staff, policy makers, educational psychologists, researchers and mental health intervention developers. The discussion explored the need for accountability at all levels (e.g., from school leaders to policy makers and Ofsted) and the potential value of engaging schools more consistently with academic evidence. Participants also discussed the importance of creating a healthy and sustainable ecosystem for interventions (underscoring the significance of staff wellbeing, adequate resourcing, and longer-term funding commitments), and moving beyond separate, isolated interventions. The findings offer a range of recommendations for school decision makers, mental health researchers, intervention developers, and those working in the wider system around schools.

Abstract Background Social prescribing is a mechanism of connecting patients with non-medical forms of support within the community and has been shown to improve mental health and wellbeing in adult populations. In the last few years, it has been used in child and youth settings with promising results. Currently, pathways are being developed for social prescribing in Child and Adolescent Mental Health Services (CAMHS) to support children and young people on treatment waiting lists. The Wellbeing While Waiting study will evaluate whether social prescribing benefits the mental health and wellbeing of children and young people. Methods This study utilises an observational, hybrid type II implementation-effectiveness design. Up to ten CAMHS who are developing social prescribing pathways as part of a programme run across England with support from the Social Prescribing Youth Network will participate. Outcomes for children and young people receiving social prescribing whilst on CAMHS waiting lists will be compared to a control group recruited prior to the pathway roll-out. Questionnaire data will be collected at baseline, 3 months and 6 months. Primary outcomes for children and young people are mental health symptoms (including anxiety, depression, stress, emotional and behavioural difficulties). Secondary outcomes include: loneliness, resilience, happiness, whether life is worthwhile, life satisfaction, and service use. An implementation strand using questionnaires and interviews will explore the acceptability, feasibility, and suitability of the pathway, potential mechanisms of action and their moderating effects on the outcomes of interest, as well as the perceived impact of social prescribing. Questionnaire data will be analysed mainly using difference-in-differences or controlled interrupted time series analysis. Interview data will be analysed using reflexive thematic analysis. Discussion The Wellbeing While Waiting study will provide the first rigorous evidence of the impact of social prescribing for children and young people on waiting lists for mental health treatment. Findings will help inform the prioritisation, commissioning, and running of social prescribing in other CAMHS. To maximise impact, findings will be available on the study website ( https://sbbresearch.org ) and disseminated via national and international networks. Trial Registration N/A.

Abstract There are increasing rates of internalising difficulties, particularly anxiety and depression, being reported in children and young people in England. School-based universal prevention programmes are thought to be one way of helping tackle such difficulties. This paper describes an update to a four-arm cluster randomised controlled trial ( http://www.isrctn.com/ISRCTN16386254 ), investigating the effectiveness of three different interventions when compared to usual provision, in English primary and secondary pupils. Due to the COVID-19 pandemic, the trial was put on hold and subsequently prolonged. Data collection will now run until 2024. The key changes to the trial outlined here include clarification of the inclusion and exclusion criteria, an amended timeline reflecting changes to the recruitment period of the trial due to the COVID-19 pandemic and clarification of the data that will be included in the statistical analysis, since the second wave of the trial was disrupted due to COVID-19. Trial registration ISRCTN Registry ISRCTN16386254. Registered on 30 August 2018.

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

Abstract Anxiety and depression are increasingly prevalent in adolescents, often causing daily distress and negative long-term outcomes. Despite the significant and growing burden, less than 25% of those with probable diagnosis of anxiety and depression are receiving help in England. Significant barriers to help-seeking exist in this population, with a scarcity of easily accessible, effective, and cost-effective interventions tailored specially for this age group. One intervention that has been shown to be feasible to deliver and with the promise of reducing stress in this age group is a school-based stress workshop programme for 16–18-year-olds (herein called DISCOVER). The next step is to rigorously assess the effectiveness, and cost-effectiveness, of the DISCOVER intervention in a fully powered cluster randomised controlled trial (cRCT). If found to be clinically and cost-effective, DISCOVER could be scaled up as a service model UK-wide and have a meaningful impact on the mental health of adolescents across the country. Trial registration: ISRCTN registry ISRCTN90912799. Registered with ISRCTN 28 May 2020.

IntroductionAbsence from school is more frequent for children with chronic health conditions (CHCs) than their peers and may be one reason why average academic attainment scores are lower among children with CHCs.MethodsWe determined whether school absence explains the association between CHCs and academic attainment through a systematic review of systematic reviews of comparative studies involving children with or without CHCs and academic attainment. We extracted results from any studies that tested whether school absence mediated the association between CHCs and academic attainment.ResultsWe identified 27 systematic reviews which included 441 unique studies of 7, 549, 267 children from 47 jurisdictions. Reviews either covered CHCs generally or were condition-specific (e.g., chronic pain, depression, or asthma). Whereas reviews found an association between a range of CHCs (CHCs generally, cystic fibrosis, hemophilia A, end-stage renal disease (pre-transplant), end-stage kidney disease (pre-transplant), spina bifida, congenital heart disease, orofacial clefts, mental disorders, depression, and chronic pain) and academic attainment, and though it was widely hypothesized that absence was a mediator in these associations, only 7 of 441 studies tested this, and all findings show no evidence of absence mediation.ConclusionCHCs are associated with lower academic attainment, but we found limited evidence of whether school absence mediates this association. Policies that focus solely on reducing school absence, without adequate additional support, are unlikely to benefit children with CHCs.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285031, identifier: CRD42021285031.

Abstract Background To examine the predictors of treatment outcome or improvement in mental health difficulties for young people accessing child and adolescent mental health services. Methods We conducted a secondary analysis of routinely collected data from services in England using the Mental Health Services Data Set. We conducted multilevel regressions on N = 5907 episodes from 14 services (M age = 13.76 years, SD age = 2.45, range = 8–25 years; 3540 or 59.93% female) with complete information on mental health difficulties at baseline. We conduct similar analyses on N = 1805 episodes from 10 services (M age = 13.59 years, SD age = 2.33, range = 8–24 years; 1120 or 62.05% female) also with complete information on mental health difficulties at follow up. Results Girls had higher levels of mental health difficulties at baseline than boys (β = 0.28, 95% CI = 0.24–0.32). Young people with higher levels of mental health difficulties at baseline also had higher levels of deterioration in mental health difficulties at follow up (β = 0.72, 95% CI = 0.67–0.76), and girls had higher levels of deterioration in mental health difficulties at follow up than boys (β = 0.09, 95% CI = 0.03–0.16). Young people with social anxiety, panic disorder, low mood, or self-harm had higher levels of mental health difficulties at baseline and of deterioration in mental health difficulties at follow up compared to young people without these presenting problems. Conclusions Services seeing higher proportions of young people with higher levels of mental health difficulties at baseline, social anxiety, panic disorder, low mood, or self-harm may be expected to show lower levels of improvement in mental health difficulties at follow up.

Abstract Background Preventing parental intimate partner violence (IPV) or mitigating its negative effects early in the lifecourse is likely to improve population mental health. However, prevention of IPV is highly challenging and we know very little about how the mental health of children exposed to IPV can be improved. This study assessed the extent to which positive experiences were associated with depressive symptoms among children with and without experience of IPV. Method This study used data from the Avon Longitudinal Study of Parents and Children, a population‐based birth cohort. After excluding those without information on depressive symptoms at age 18, the final sample comprised 4490 participants. Parental intimate partner violence (physical or emotional cruelty reported by mother or partner) when the cohort child was aged 2–9 years. Depressive symptoms were measured with the Short Mood and Feelings Questionnaire (SMFQ) at age 18 years. Results Each additional report of parental intimate partner violence (over six reports) was associated with 0.047 (95% CI 0.027–0.066), or 4.7%, higher SMFQ score. Conversely, each additional positive experience (over 11 domains) was linked with −0.042 (95% CI −0.060 to −0.025) or 4.1%, lower SMFQ score. Among those with parental intimate partner violence (19.6% of participants), relationship with peers (effect size = 3.5%), school enjoyment (effect size = 1.2%), neighbourhood safety and cohesion (effect size = 1.8%) were associated with lower levels of depressive symptoms. Conclusions Most positive experiences were linked with lower levels of depressive symptoms regardless of parental intimate partner violence exposure. However, among those with parental IPV, this association was found only for relationships with peers, school enjoyment, neighbourhood safety and cohesion on depressive symptoms. If our findings are assumed to be causal, nurturing these factors may mitigate the harmful effects of parental intimate partner violence on depressive symptoms in adolescence.

Abstract Background Children and adolescents’ mental health problems have been largely assessed with conventional symptom scales, for example, Strengths and Difficulties Questionnaire (SDQ) given that it is one of the mostly widely used measures in specialist Child and Adolescent Mental Health Services (CAMHS). However, this emphasis on symptom scales might have missed some important features of the mental health challenges that children and young people experience including day to day functioning and life satisfaction aspect (i.e. qualify of life). Method The study examined longitudinal association between a young person’s self-perceptions of quality of life and mental health difficulties and referral to specialist CAMHS service using a population cohort study (Targeted Mental Health in Schools service data) nested within a large-scale linkage between school (National Pupil Data base) and child mental health service administrative data (South London and Maudsley NHS Foundation Trust children and adolescent mental health services health records). Cox proportional hazard regression to estimate crude and adjusted hazard ratios (HRs) for the association between participant psychopathology, and incidence of CAMHS referral. Results Pupils experiencing more behavioural difficulties, had an increased incidence of CAMHS referral (adjusted hazard ratio 1.1, 95% confidence interval 1.0–1.2). However, pupils who reported higher health related quality of life had a lower incidence of CAMHS referral over the follow-up period (adjusted hazard hario 0.94, 95% confidence interval 0.9–0.98). Conclusion Children and young people’s perception of their quality of life should be considered at the stages of a clinical needs assessment.

Abstract Background Mental health and subjective well‐being are of great interest in both health policy and research. There has been considerable debate regarding whether mental health difficulties and subjective wellbeing are two distinct domains or different ends of a single mental health spectrum. This study investigates if predictors of mental health difficulties and subjective wellbeing are the same or different in a large‐scale community‐based sample in the United Kingdom. Methods 13,500 adolescents in year 7 (aged 11–12) and again in year 8 (aged 12–13) completed surveys on emotional strengths and skills, support networks, mental health difficulties and wellbeing. Socio‐demographic factors were gathered from the National Pupil Database. Mental health difficulties and wellbeing scores were standardized to allow comparisons. Results The correlation between mental health difficulties and subjective wellbeing was −0.48, indicating a moderate overlap between the two domains. Some of the predictors (e.g., gender, ethnicity, problem solving, emotion regulation) in year 7 predicted both mental health difficulties and subjective wellbeing in year 8. However, some of the predictors in year 7 only predicted mental health difficulties (e.g., special education needs, empathy) and some only subjective wellbeing (e.g., prosocial behaviour, peer support) in year 8. Conclusion This study provides further evidence for differences in what predicts adolescents’ mental health difficulties and subjective wellbeing. It highlights the importance of not only focusing on preventing or treating symptoms of mental illness but also focusing on improving children’s wellbeing.

Abstract Background In recent years there has been growing interest in child and adolescent mental health and wellbeing, alongside increasing emphasis on schools as a crucial site for research and intervention. This has coincided with an increased use of self-report mental health and wellbeing measures in research with this population, including in school-based research projects. We set out to explore the way that children and young people perceive and experience completing mental health and wellbeing measures, with a specific focus on completion in a school context, in order to inform future measure and research design. Methods We conducted semi-structured interviews and focus groups with 133 participants aged 8–16 years following their completion of mental health and wellbeing measures as part of school-based research programmes, using thematic analysis to identify patterns of experience. Findings We identified six themes: Reflecting on emotions during completion; the importance of anonymity; understanding what is going to happen; ease of responding to items; level of demand; and interacting with the measure format. Conclusions Our findings offer greater insight into children and young people’s perceptions and experiences in reporting on their mental health and wellbeing. Such understanding can be used to support more ethical and robust data collection procedures in child and adolescent mental health research, both for data quality and ethical purposes. We offer several practical recommendations for researchers, including facilitating this in a school context.

Despite widespread concern about the impact of COVID-19 on adolescent mental health, there remains limited empirical evidence that can causally attribute changes to the pandemic. The current study aimed to overcome existing methodological limitations by exploiting a serendipitously occurring natural experiment within two ongoing, multi-phase cluster randomized controlled trials. Depressive symptoms (primary outcome), externalizing difficulties and life satisfaction (secondary outcomes) were assessed at baseline (phase 1 [pre-COVID-19 group]: September – October 2018, phase 2 [COVID-19 group]: September – October 2019) and 1-year follow-up (pre-COVID-19 group: January – March 2020, COVID-19 group: February – April 2021). Participants in phase 1 (N = 6419) acted as controls. In phase 2, participants (N = 5031) were exposed to the COVID-19 pandemic between the baseline and follow-up assessments providing a natural experimental design. The primary analysis used a random intercept linear multivariable regression model with phase (exposure to the COVID-19 pandemic) included as the key predictor while controlling for baseline scores and individual and school-level covariates. Depressive symptoms were higher and life satisfaction scores lower in the group exposed to the COVID-19 pandemic. Had the COVID-19 pandemic not occurred, we estimate that there would be 6% fewer adolescents with high depressive symptoms. No effect of exposure to the pandemic on externalizing difficulties was found. Exploratory analyses to examine subgroup differences in impacts suggest that the negative impact of the COVID-19 pandemic on adolescent mental health may have been greater for females than males. Given the widespread concern over rising adolescent mental health difficulties prior to the pandemic, this paper quantifies the additional impacts of the pandemic. A properly resourced, multi-level, multi-sector public health approach for improving adolescent mental health is necessary. Following in-principle acceptance, the approved Stage 1 version of this manuscript was preregistered on the OSF at https://doi.org/10.17605/OSF.IO/B25DH. This preregistration was performed prior to data analysis.

BackgroundDigital interventions, including mobile apps, represent a promising means of providing effective mental health support to children and young people. Despite the increased availability of mental health apps, there is a significant gap for this age group, especially for children (aged 10-12 years). Research investigating the effectiveness and development process of child mental health apps is limited, and the field faces persistent issues in relation to low user uptake and engagement, which is assumed to be a result of limited user involvement in the design process. ObjectiveThis study aims to present the development and design process of a new mental health app for children that targets their emotion regulation abilities. We describe the creation of a new interdisciplinary development framework to guide the design process and explain how each activity informed different app features. MethodsThe first 2 stages of the framework used a variety of methods, including weekly classroom observations over a 6-month period (20 in total); public engagement events with the target group (N=21); synthesis of the existing evidence as part of a meta-analysis; a series of co-design and participatory workshops with young users (N=33), clinicians (N=7), researchers (N=12), app developers (N=1), and designers (N=2); and finally, testing of the first high-tech prototype (N=15). ResultsFor the interdisciplinary framework, we drew on methods derived from the Medical Research Council framework for complex interventions, the patient–clinician framework, and the Druin cooperative inquiry. The classroom observations, public engagement events, and synthesis of the existing evidence informed the first key pillars of the app and wireframes. Subsequently, a series of workshops shaped and reshaped the content and app features, including games, psychoeducational films, and practice modules. On the basis of the prototype testing sessions, we made further adjustments to improve the app. ConclusionsAlthough mobile apps could be highly suitable to support children’s mental health on a wider scale, there is little guidance on how these interventions could be designed and developed. The involvement of young users across different design activities is very valuable. We hope that our interdisciplinary framework and description of the used methods will be helpful to others who are hoping to develop mental health apps for children and young people.

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

Abstract Background There are increasing rates of internalising difficulties, particularly anxiety and depression, being reported in children and young people in England. School-based, universal prevention programmes are thought to be one way of helping tackle such difficulties. This protocol describes a four-arm cluster randomised controlled trial, investigating the effectiveness of three different interventions when compared to usual provision, in English primary and secondary pupils. The primary outcome for Mindfulness and Relaxation interventions is a measure of internalising difficulties, while Strategies for Safety and Wellbeing will be examined in relation to intended help-seeking. In addition to the effectiveness analysis, a process and implementation evaluation and a cost-effectiveness evaluation will be undertaken. Methods and analysis Overall, 160 primary schools and 64 secondary schools will be recruited across England. This corresponds to 17,600 participants. Measures will be collected online at baseline, 3–6 months later, and 9–12 months after the commencement of the intervention. An economic evaluation will assess the cost-effectiveness of the interventions. Moreover, a process and implementation evaluation (including a qualitative research component) will explore several aspects of implementation (fidelity, quality, dosage, reach, participant responsiveness, adaptations), social validity (acceptability, appropriateness and feasibility), and their moderating effects on the outcomes of interest, and perceived impact. Discussion This trial aims to address important questions about whether schools’ practices around the promotion of mental wellbeing and the prevention of mental health problems can: (1) be formalised into feasible and effective models of school-based support and (2) whether these practices and their effects can be sustained over time. Given the focus of these interventions on mirroring popular practice in schools and on prioritising approaches that present low-burden, high-acceptability to schools, if proved effective, and cost-effective, the findings will indicate models that are not only empirically tested but also offer high potential for widespread use and, therefore, potentially widespread benefits beyond the life of the trial. Trial registration ISRCTN16386254. Registered on 30 August 2018.

Abstract Background Positive mental health may support healthy development in childhood, although few studies have investigated this at a population level. We aimed to construct a measure of mental health competence (MHC), a skills-based assessment of positive mental health, using existing survey items in a representative sample of UK children, and to investigate its overlap with mental health difficulties (MHD), socio-demographic patterning, and relationships with physical health and cognitive development. Methods We analysed the UK Millennium Cohort Study (MCS) when children were aged 11 years. Maternal (n = 12,082) and teacher (n = 6739) reports of prosocial behaviours (PS) and learning skills (LS) were entered into latent class models to create MHC measures. Using descriptive statistics, we examined relationships between MHC and MHD, and the socio-demographic patterning of MHC. Associations between MHC and physical health and cognitive development were examined with relative risk ratios [RRR] (from multinomial models): BMI status (healthy weight, overweight, obesity); unintentional injuries since age 7 (none, 1, 2+); asthma symptoms (none, 1, 2+); and tertiles of test scores for verbal ability, spatial working memory and risk-taking. Models were adjusted for potential confounding. Results Four MHC classes were identified [percentages for maternal and teacher reports, respectively]: high MHC (high PS, high LS) [37%; 39%], high-moderate MHC (high PS, moderate LS) [36%; 26%]; moderate MHC (moderate PS, moderate LS) [19%; 19%]; low MHC (moderate PS, low LS) [8%; 16%]. Higher MHC was less common in socially disadvantaged children. While MHC and MHD were associated, there was sufficient separation to indicate that MHC captures more than the absence of MHD. Compared to children with high MHC, those in other MHC classes tended to have poorer physical health and cognitive development, particularly those with low MHC or high-moderate MHC. For example, children with maternal-report Low MHC were more likely to have experienced 2+ unintentional injuries (RRR: 1.5 [1.1–2.1]) and to have lower verbal ability scores (RRR: 2.5 [1.9–3.2]). Patterns of results were similar for maternal- and teacher-report MHC. Conclusion MHC is not simply the inverse of MHD, and high MHC is associated with better physical health and cognitive development. Findings suggest that interventions to improve MHC may support healthy development, although they require replication.

BackgroundMost mental health disorders are first experienced in childhood. The rising rates of mental health difficulties in children highlight the need for innovative approaches to supporting children and preventing these difficulties. School-based digital interventions that address shared risk factors and symptoms, such as emotion dysregulation, present exciting opportunities to enhance mental health support for children on a larger scale. ObjectiveThis study investigates the use of a new app-based intervention designed to support children’s emotion regulation in schools. The aim is to optimize the usability, acceptability, and utility of the app and explore its scope for implementation with the target user in the school context. MethodsAs part of an interdisciplinary development framework, the app is being evaluated in a 3-month trial across 4 primary schools. In total, 144 children (aged 10-12 years) took part and accessed the intervention app in the classroom or at home. Outcomes regarding usability, acceptability, and implementation opportunities were assessed through digital user data, self-report questionnaires (132/144, 91.6%), and semistructured interviews with children (19/144, 13.2%) and teachers (6/8, 75%). ResultsThe app usage data showed that 30% (128/426) of the users were returning users. Self-report data indicated that 40.1% (53/132) of the children had not used the app, whereas 57.5% (76/132) had used it once or more. Of the children who had used the app, 67% (51/76) reported that the app was helpful. Interviews with children and teachers suggested positive experiences with the app and that it helped them to calm down and relax. Children reported that they perceived the app as acceptable, usable, and helpful. In terms of the intervention’s usability, most features functioned well; however, certain technical issues were reported, which may have led to reduced engagement levels. Teachers not only reported overall positive experiences but also discussed access difficulties and reported a lack of content as one of the main barriers to implementing the app. Having a web-based app significantly enhanced accessibility across devices and settings and provided teachers with more opportunities to use it. We identified the need for new, activating app features in addition to the existing, primarily relaxing ones. The findings indicated that it is possible to use and evaluate an app intervention in the school context and that the app could help enhance children’s emotion regulation. We discuss areas for improvement regarding the app, study design, and future implementation strategies. ConclusionsWe share important insights with regard to the development, implementation, and evaluation of a new app for supporting children’s emotion regulation in schools. Our results demonstrate that mental health apps represent a promising means to facilitate effective mental health service provision in and outside of the school context. Important lessons learned are shared to support other researchers and clinicians on similar journeys.

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

Objective Situation Awareness For Everyone (SAFE) is a quality improvement programme aiming to improve situation awareness in paediatric clinical teams. The aim of our study was to examine hospital staff perceptions of the facilitators and barriers/challenges to the sustaining and subsequent spread of the huddle, the key intervention of the SAFE programme.Setting Interviews were held on two wards in two children hospitals and on two children wards in two district general hospitals.Method Semistructured interviews were conducted with 23 staff members from four National Health Service paediatric wards. A deductive thematic analysis was conducted, drawing on an existing framework, which groups the factors influencing programme sustainability into four categories: innovation, leadership, process and context.Participants 23 staff in two children’s hospitals and two children’s wards across four UK hospitals, comprising of nurses and doctors, administration or housekeeping staff, ward managers and matrons, and allied professionals.Primary outcomes Understanding factors contributing to the sustaining and spread of a quality improvement intervention.Results Perceptions of the benefits, purpose and fit of the huddle, team commitment, sharing learning, adaptation of the method and senior leadership were identified as facilitators. High staff turnover, large multiple specialty medical staff teams, lack of senior leadership and dislike of change were identified as barriers/challenges.Conclusions Sustaining and spreading quality improvement interventions in a complex clinical setting requires understanding of the interplay between the actual innovation and existing leadership, process and contextual factors. These must be considered at the planning stage of an innovation to maximise the potential for sustainability and spread to other settings.

BackgroundAccess to timely care is a quality standard underpinning many international healthcare models, and long waiting times for child and adolescent mental health services are often reported as a barrier to help-seeking.AimsThe aim of this study was to examine whether young people with more severe problems have shorter waiting times for mental health services.MethodMultilevel multinomial regression analysis controlling for service-area deprivation, age, gender, ethnicity, referral source and contextual factors was conducted on N = 21 419 episodes of care (mean age 12.37 years (s.d. = 3.71), 11 712 (55%) female) using data from child and adolescent mental health services.ResultsThere was high variation in waiting times, which ranged from 0 days to 1629 days (mean 50.65 days (s.d. = 78.03), median 32 days). Compared with young people with less severe problems young people with severe problems, self-harm, psychosis or eating disorders were less likely to experience longer waiting times. Moreover, referrals from sources other than primary care were generally less likely to have longer waiting times than referrals from primary care sources, especially referral from accident and emergency services.ConclusionsThe findings suggest that young people with more severe problems had shorter waiting times. Intermediary information and resources for support before access to services is needed to prevent escalation of problems and to support individuals and families while waiting for care. Interventions to reduce waiting times should be considered without compromising on the quality and experience of care that young people and families deserve when seeking help.

Introduction The prevalence of emotional difficulties in young people is increasing. This upward trend is largely accounted for by escalating symptoms of anxiety and depression. As part of a public health response, there is increasing emphasis on universal prevention programmes delivered in school settings. This protocol describes a three-arm, parallel group cluster randomised controlled trial, investigating the effectiveness and cost-effectiveness of two interventions, alongside a process and implementation evaluation, to improve mental health and well-being of Year 9 pupils in English secondary schools.Method A three-arm, parallel group cluster randomised controlled trial comparing two different interventions, the Youth Aware of Mental Health (YAM) or the Mental Health and High School Curriculum Guide (The Guide), to Usual Provision. Overall, 144 secondary schools in England will be recruited, involving 8600 Year 9 pupils. The primary outcome for YAM is depressive symptoms, and for The Guide it is intended help-seeking. These will be measured at baseline, 3–6 months and 9–12 months after the intervention commenced. Secondary outcomes measured concurrently include changes to: positive well-being, behavioural difficulties, support from school staff, stigma-related knowledge, attitudes and behaviours, and mental health first aid. An economic evaluation will assess the cost-effectiveness of the interventions, and a process and implementation evaluation (including a qualitative research component) will explore several aspects of implementation (fidelity, quality, dosage, reach, participant responsiveness, adaptations), social validity (acceptability, feasibility, utility), and their moderating effects on the outcomes of interest, and perceived impact.Ethics and dissemination This trial has been approved by the University College London Research Ethics Committee. Findings will be published in a report to the Department for Education, in peer-reviewed journals and at conferences.Trial registration number ISRCTN17631228.Protocol V1 3 January 2019. Substantial changes to the protocol will be communicated to the trials manager to relevant parties (eg, ISRCTN).

Evidence for the longitudinal associations between internalising symptom development and academic attainment is sparse and results from existing studies are largely inconclusive. The approaches that have been used in existing studies examining this relationship have in common the limitation of grouping together all individuals in the sample which makes the assumption that the relationship between time, symptoms and attainment across all individuals is the same. The current study aimed to use heterogeneous trajectories of symptom development to examine the longitudinal associations between internalising symptom development and change in academic attainment over a three years period in early adolescence, a key period for internalising symptom development. Internalising symptoms were assessed for 3 consecutive years in a cohort from age 11-14 years (n = 2647, mean age at T1 = 11.7 years). National standardised test scores prior to the first wave and subsequent to the last wave were used as measures of academic attainment. Heterogeneous symptom development trajectories were identified using latent class growth analysis and socio-demographic correlates, such as gender, SES and ethnicity, of the different trajectory groupings were investigated. Derived trajectory groupings were examined as predictors of subsequent academic attainment, controlling for prior attainment. Results demonstrate that symptom trajectories differentially predicted change in academic attainment with increasing trajectories associated with significantly worse academic outcomes when compared to pupils with low levels of symptoms in all waves. Hence, a trajectory based approach provides a more nuanced breakdown of complexities in symptom development and their differential relationships with academic outcomes and in doing so helps clarify the longitudinal relationship between these two key domains of functioning in early adolescence.