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Abstract Background There is growing evidence that Technology Assisted Sexual Abuse (TASA) represents a serious problem for large numbers of children. To date, there are very few evidence-based interventions available to young people (YP) after they have been exposed to this form of abuse, and access to support services remains a challenge. Digital tools such as smartphones have the potential to increase access to mental health support and may provide an opportunity for YP to both manage their distress and reduce the possibility of further victimization. The current study explores the acceptability of a digital health intervention (DHI; the i-Minds app) which is a theory-driven, co-produced, mentalization-based DHI designed for YP aged 12–18 who have experienced TASA. Methods Semi-structured interviews were conducted with 15 YP recruited through Child and Adolescent Mental Health Services, a Sexual Assault Referral Centre and an e-therapy provider who had access to the i-Minds app as part of a feasibility clinical trial. Interviews focused on the acceptability and usability of i-Minds and were coded to themes based on the Acceptability of Healthcare Interventions framework. Results All participants found the i-Minds app acceptable. Many aspects of the app were seen as enjoyable and useful in helping YP understand their abuse, manage feelings, and change behavior. The app was seen as usable and easy to navigate, but for some participants the level of text was problematic and aspects of the content was, at times, emotionally distressing at times. Conclusions The i-Minds app is useful in the management of TASA and helping change some risk-related vulnerabilities. The app was designed, developed and evaluated with YP who had experienced TASA and this may account for the high levels of acceptability seen. Trial registration The trial was registered on the ISRCTN registry on the 12/04/2022 as i-Minds: a digital intervention for young people exposed to online sexual abuse (ISRCTN43130832).

IntroductionOnline child sexual abuse (OCSA) affects considerable numbers of children globally and is associated with a variety of mental health problems. Existing practitioner studies suggest that young people are infrequently asked about online abuse and practitioners have a fragmented understanding of the problems experienced or how they might approach them. There are very few evidence-based interventions that guide clinical assessment or practice. Digital Health Interventions (DHIs) have the potential to be an effective option where children and young people's services are challenged, including accessibility and anonymity. The aim of this study was to explore mental health practitioners' views of how DHIs may play a role in supporting young people who have experienced OCSA, and the role they can play in healthcare delivery.MethodIn-depth qualitative interviews and one focus group were conducted with 25 child mental health professionals across two sites (Manchester and Edinburgh). Data was analyzed using reflexive thematic analysis.ResultsThree overarching themes and 9 sub-themes were identified: (1) feeling a little bit lost; (2) seeing potential problems; and (3) knowing what works. Practitioners expressed interest in a DHI to support this client group and saw it as a way of managing waiting lists and complementing existing therapies. They felt that many young people would see this as a preferred medium to in-person therapy, would be empowering, and offers new ways of learning how to stay safe online. However, there were concerns about how much time would be needed by staff to deliver a DHI, anxieties about safety issues in relation to content and data protection, some of which may be unique to this population of young people, and concerns about the absence of a therapeutic relationship with vulnerable children.DiscussionOur findings indicated that practitioners were uncertain about working with children subjected to OCSA but were receptive to the possibility of using a DHI to support their practice and to reduce waiting lists. Concerns were expressed about the time needed for staff training and support as well as concerns over patient safety and the lack of evidence about the effectiveness of an unsupported DHI.

Background During the initial phases of the COVID-19 pandemic, children and young people (CYP) faced significant restrictions. The virus and mitigation approaches significantly impacted how health services could function and be safely delivered. Aims To investigate the impact of COVID-19 lockdowns on CYP psychiatric admission trends during lockdown 1 (started 23 Mar 2020) and lockdown 2 (started 5 Nov 2020) of the COVID-19 pandemic in England. Method Routinely collected, retrospective English administrative data regarding psychiatric hospital admissions, length of stay and patient demographic factors were analysed using an interrupted time series analysis (ITSA) to estimate the impact of COVID-19 lockdowns 1 and 2 on service use trends. We analysed data of 6250 CYP (up to 18 years of age) using ordinary least squares (OLS) regression analysis with Newey–West standard errors to handle autocorrelation and heteroscedasticity. Results Psychiatric hospital admissions for CYP significantly fell during lockdown 1, and then fell even further during lockdown 2. A greater proportion of admissions during lockdown were out of area or to independent sector units. During lockdown, the average age of CYP admitted was higher, and a greater proportion were female. There was also a significant increase in the proportion of looked-after children and CYP from the most socioeconomically deprived areas admitted during lockdown 2. Conclusions During both lockdowns, fewer CYP had psychiatric admissions. The subsequent rise in admissions for more socioeconomically deprived CYP and looked-after children suggests that these CYP may have been disproportionately affected by the pandemic, or overlooked during earlier phases.

BackgroundChildren in custodial settings are a vulnerable group. Prior to the COVID-19 pandemic there were concerns about the safety of children in these settings. COVID-19 has had an impact on everyone but given the vulnerability of children in custody, there were concerns about the impact of COVID-19 restrictions. All custody settings for children are independently inspected and this research aimed to analyse data from inspection reports. Twenty-six inspection reports undertaken between March 2020 and October 2021 were analysed to understand the impact of COVID-19 on delivery of usual care/regime.ResultsData showed that across all site's children spent considerable amounts of time isolated and in some cases, this was deemed to amount to solitary confinement. There was evidence of some positive experiences, in the smaller sites, around COVID-19 slowing the pace of life allowing staff and children could foster relationships. However, in the larger sites, isolation was extreme and COVID-19 policies such as 'bubbles' appear to have created unintended consequences as sites have moved into recovery, leading to increased violence and stress. COVID-19 directly impacted staffing levels. This and the COVID-19 policies to reduce mixing also had an impact on how children's behaviour, welfare and safeguarding was managed. In some larger sites, being COVID-19 secure was prioritised over the needs of the children.ConclusionsThis research highlights the importance of multi-site longitudinal research to understand how children, staff and institution's function. The experiences of children in custody during COVID-19 differed by site type. The research suggests that the larger sites are struggling to keep children safe and there should be a shift towards smaller, more therapeutic environments. More research is needed to understand the longer-term unintended consequences of COVID-19 policy in custody, for these vulnerable children.

Background Terrorist incidents lead to a range of mental health outcomes for people affected, sometimes extending years after the event. Secondary stressors can exacerbate them, and social support can provide mitigation and aid recovery. There is a need to better understand distress and mitigating factors among survivors of the Manchester Arena attack in 2017. Aims We explored three questions. First, what experiences of distress did participants report? Second, how might secondary stressors have influenced participants’ psychosocial recoveries? Third, what part has social support played in the relationships between distress and participants’ recovery trajectories? Method We conducted a cross-sectional online survey of a convenience sample of survivors of the Manchester Arena bombing (N = 84) in January 2021 (3 years 8 months post-incident), and a longitudinal study of the same participants’ scores on mental health measures over 3 years from September 2017. Results Survivors’ mental well-being scores in early 2021 were significantly lower than general population norms. Longitudinal follow-up provided evidence of enduring distress. Secondary stressors, specifically disruptions to close relationships, were associated with greater post-event distress and slower recovery. We found an indirect relationship between identifying with, and receiving support from, others present at the event and mental well-being >3 years later. Conclusions The Arena attack has had an enduring impact on mental health, even in survivors who had a mild response to the event. The quality of close relationships is pivotal to long-term outcome. Constructive support from family and friends, and people with shared experiences, are key to social cure processes that facilitate coping and recovery.

IntroductionThis qualitative study explored healthcare professionals' current understanding of, and clinical practices related to, Online Child Sexual Abuse (OCSA).MethodsData were collected across two UK sites (Manchester and Edinburgh). Interviews and one focus group were held with 25 practitioners working in services offering clinical support to young people who have experienced OCSA. Thematic analysis of the data identified three overarching themes and 10 subthemes related to the research questions: (1) the breadth of the problem; (2) working with OCSA; and (3) the emotionally charged nature of OCSA.ResultsWhile practitioners recognized OCSA as problematic, they differed in how they conceptualized it. There was a heightened awareness of the role that sexual images played in OCSA and concerns about first-person-produced imagery by Children and Young People (CYP). Practitioners described a generational gap related to their technology use and that of the young people they worked with. Practitioners also described a paucity of referral pathways and concerns that there was no training available to them. Organizational barriers meant that questions about technology use were not routinely included in assessments and often there was reliance on young people making disclosures.DiscussionNovel findings from this study were the psychological impacts that such cases had on practitioners, which may indicate a need for organizational support for staff as well as further training needs. Existing frameworks that help conceptualize and assess the role of technology as part of the ecology of the child may have great utility for practitioners.

BackgroundNo evidence-based support has been offered to young people (YP) who have experienced technology-assisted sexual abuse (TASA). Interventions aimed at improving mentalization (the ability to understand the mental states of oneself and others) are increasingly being applied to treat YP with various clinical issues. Digital technology use among YP is now common. A digital intervention aimed at improving mentalization in YP who have experienced TASA may reduce the risk of revictimization and future harm and make YP more resilient and able to manage distress that might result from TASA experiences. ObjectiveIn this paper, we describe a protocol for determining the feasibility of the i-Minds trial and the acceptability, safety, and usability of the digital intervention (the i-Minds app) and explore how to best integrate i-Minds into existing routine care pathways. MethodsThis is a mixed methods nonrandomized study aimed to determine the feasibility, acceptability, safety, and usability of the intervention. Participants aged between 12 and 18 years who report distress associated with TASA exposure will be recruited from the United Kingdom from the National Health Service (NHS) Trust Child and Adolescent Mental Health Services, sexual assault referral centers, and a web-based e-therapy provider. All participants will receive the i-Minds app for 6 weeks. Coproduced with YP and a range of stakeholders, the i-Minds app focuses on 4 main topics: mentalization, TASA and its impact, emotional and mental health, and trauma. A daily prompt will encourage YP to use the app, which is designed to be used in a stand-alone manner alongside routine care. We will follow participants up after the intervention and conduct interviews with stakeholders to explore the acceptability of the app and trial procedures and identify areas for improvement. Informed by the normalization process theory, we will examine barriers and enablers relevant to the future integration of the intervention into existing care pathways, including traditional clinic-based NHS and NHS e-therapy providers. ResultsThis study was approved by the Research Ethics Board of Scotland. We expect data to be collected from up to 60 YP. We expect to conduct approximately 20 qualitative interviews with participants and 20 health care professionals who referred YP to the study. The results of this study have been submitted for publication. ConclusionsThis study will provide preliminary evidence on the feasibility of recruiting YP to a trial of this nature and on the acceptability, safety, and usability of the i-Minds app, including how to best integrate it into existing routine care. The findings will inform the decision to proceed with a powered efficacy trial. Trial RegistrationInternational Standard Randomised Controlled Trial Number Registry (ISRCTN) ISRCTN43130832; https://www.isrctn.com/ISRCTN43130832 International Registered Report Identifier (IRRID)DERR1-10.2196/40539

Objectives QbTest has been shown to improve time to decision/diagnosis for young people with attention deficit hyperactivity disorder (ADHD). The aim was to assess the feasibility of QbTest for young people in prison.Design Single-centre feasibility randomised controlled trial (RCT), with 1:1 allocation. Concealed random allocation using an online pseudorandom list with random permuted blocks of varying sizes.Setting One Young Offenders Institution in England.Participants 355 young people aged 15–18 years displaying possible symptoms of ADHD were assessed for eligibility, 69 were eligible to take part and 60 were randomised.Intervention QbTest—a computer task measuring attention, activity and impulsivity.Main outcome measures Eligibility, recruitment and retention rates and acceptability of randomisation and trial participation.Results Of the 355 young people assessed for eligibility, 69 were eligible and 60 were randomised (n=30 QbTest plus usual care; n=30 usual care alone). The study achieved the specified recruitment target. Trial participation and randomisation were deemed acceptable by the majority of participants. 78% of young people were followed up at 3 months, but only 32% at 6 months, although this was also affected by COVID-19 restrictions. Secondary outcomes were mixed. Participants including clinical staff were mostly supportive of the study and QbTest; however, some young people found QbTest hard and there were issues with implementation of the ADHD care pathway. There were no serious adverse events secondary to the study or intervention and no one was withdrawn from the study due to an adverse event.Conclusions With adaptations, a fully powered RCT may be achievable to evaluate the effectiveness of QbTest in the assessment of ADHD in the Children and Young People Secure Estate, with time to decision (days) as the primary outcome measure. However, further programme developmental work is required to address some of the challenges highlighted prior to a larger trial.Trial registration number ISRCTN17402196.

Abstract Background A 2017 terrorist attack in Manchester, UK, affected large numbers of adults and young people. During the response phase (first seven weeks), a multi-sector collaborative co-ordinated a decentralised response. In the subsequent recovery phase they implemented a centralised assertive outreach programme, ‘The Resilience Hub’, to screen and refer those affected. We present a process evaluation conducted after 1 year. Methods Case study, involving a logic modelling approach, aggregate routine data, and semi-structured interviews topic guides based on the Inter-Agency Collaboration Framework and May’s Normalisation Process Theory. Leaders from health, education and voluntary sectors (n = 21) and frontline Resilience Hub workers (n = 6) were sampled for maximum variation or theoretically, then consented and interviewed. Framework analysis of transcripts was undertaken by two researchers. Results Devolved government, a collaborative culture, and existing clinical networks meant that, in the response phase, a collaboration was quickly established between health and education. All but one leader evaluated the response positively, although they were not involved in pre-disaster statutory planning. However, despite overwhelming positive feedback there were clear difficulties. (1) Some voluntary sector colleagues felt that it took some time for them to be involved. (2) Other VCSE organisations were accused of inappropriate, harmful use of early intervention. (3) The health sector were accused of overlooking those below the threshold for clinical treatment. (4) There was a perception that there were barriers to information sharing across organisations, which was particularly evident in relation to attempts to outreach to first responders and other professionals who may have been affected by the incident. (5) Hub workers encountered barriers to referring people who live outside of Greater Manchester. After 1 year of the recovery phase, 877 children and young people and 2375 adults had completed screening via the Resilience Hub, 79% of whom lived outside Greater Manchester. Conclusions The psychosocial response to terrorist attacks and other contingencies should be planned and practiced before the event, including reviews of communications, protocols, data sharing procedures and workforce capacity. Further research is needed to understand how the health and voluntary sectors can best collaborate in the wake of future incidents.

Background Distress after major incidents is widespread among survivors. The great majority do not meet the criteria for mental health disorders and rely on psychosocial care provided by their informal networks and official response services. There is a need to better understand their experiences of distress and psychosocial care needs. Aims The aims of our study were to enhance understanding of the experience of distress among people present at the Manchester Arena bombing in 2017, identify their experiences of psychosocial care after the incident and learn how to better deliver and target effective psychosocial care following major incidents. Method We conducted a thematic analysis of semi-structured interviews with 18 physically non-injured survivors of the Manchester Arena attack, who registered with the NHS Manchester Resilience Hub. Results Distress was ubiquitous, with long-lasting health and social consequences. Initial reluctance to seek help from services was also common. Early and open access to authoritative sources of information and emotional support, and organised events for survivors, were viewed as helpful interventions. Inappropriate forms of psychosocial and mental healthcare were common and potent stressors that affected coping and recovery. Conclusions This paper extends our understanding of how people react to major events. Provision for the large group of people who are distressed and require psychosocial care may be inadequate after many incidents. There is a substantial agenda for developing awareness of people's needs for psychosocial interventions, and training practitioners to deliver them. The findings have substantial implications for policy and service design.

Background: Previous research has mainly focused on the impacts of epidemics on those people who are directly affected by the epidemic infection, or of healthcare workers caring for them. Less is known about the impact on mental health of their relatives, and potential interventions to support them.Methods: Systematic review and narrative synthesis.Outcomes: 28 studies were identified, sixteen quantitative and twelve qualitative. One involved health workers' relatives, and the rest covered relatives of directly affected individuals. We found considerable burden of mental ill-health in both groups. Among relatives of healthcare workers, 29.4% reported symptoms consistent with probable anxiety disorder and 33.7% with probable depression. Prevalence rates for probable anxiety disorder ranged from 24-42% and probable depression 17–51% for the relatives of affected people. One study found a 2% prevalence of PTSD and another found odds of PTSS were significantly higher among relatives of affected individuals compared with the general population. Only two intervention studies were identified and both were descriptive in nature.Interpretation: Available evidence suggests relatives of people affected by infective outbreaks report mental ill-health. Having a relative who died particularly increased risk. Good outcomes for relatives of affected individuals were promoted by practical and social support, public health guidance that recognises the caring role of relatives, and being supported to see the positives as well as negatives in their situation. Good outcomes for relatives of health workers were promoted by perceived effectiveness of protective equipment. High quality evidence on potential interventions to support relatives is lacking.Funding: No external funding sought.

Abstract Background Around 25% of prisoners meet diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD). Because ADHD is associated with increased recidivism and other functional and behavioural problems, appropriate diagnosis and treatment can be a critical intervention to improve outcomes. While ADHD is a treatable condition, best managed by a combination of medication and psychological treatments, among individuals in the criminal justice system ADHD remains both mis- and under-diagnosed and consequently inadequately treated. We aimed to identify barriers within the prison system that prevent appropriate intervention, and provide a practical approach to identify and treat incarcerated offenders with ADHD. Methods The United Kingdom ADHD Partnership hosted a consensus meeting to discuss practical interventions for youth (

Introduction The prevalence of attention deficit hyperactivity disorder (ADHD) within the Children and Young People Secure Estate (CYPSE) is much higher than seen in the general population. To make a diagnosis of ADHD, clinicians draw on information from multiple sources, including parents and teachers. However, obtaining these is particularly difficult for young people in the secure estate. There is increasing evidence in the community that QbTest is able to assist in the accurate and earlier diagnosis of ADHD. The objective of this study is to assess the feasibility and acceptability of QbTest in the assessment of ADHD within the CYPSE.Methods and analysis A single-centre parallel group feasibility randomised controlled trial will be conducted. Sixty young people within the CYPSE identified as displaying possible symptoms of ADHD will be randomised to the intervention arm (n=30; QbTest plus usual care) or control arm (n=30; usual care). Primary analyses will be descriptive and a process evaluation will be conducted to assess the contexts involved in implementing the intervention. Interviews will be conducted to explore acceptability and thematic analysis will be used to analyse the data.Ethics and dissemination This study was approved by National Health Service Wales research ethics committee 3 (18/WA/0347) on 15 February 2019. The findings will be published in peer-reviewed journals, presented at relevant conferences and disseminated to the public via summaries cocreated with our patient and public involvement group.Trial registration number ISRCTN17402196

BackgroundTerrorist attacks have increased globally since the late 1990s with clear evidence of psychological distress across both adults and children and young people (CYP). After the Manchester Arena terrorist attack, the Resilience Hub was established to identify people in need of psychological and psychosocial support.AimsTo examine the severity of symptoms and impact of the programme.MethodThe hub offers outreach, screening, clinical telephone triage and facilitation to access evidenced treatments. People were screened for trauma, depression, generalised anxiety and functioning who registered at 3, 6 and 9 months post-incident. Baseline scores were compared between screening groups (first screen at 3, 6 or 9 months) in each cohort (adult, CYP), and within groups to compare scores at 9 months.ResultsThere were significant differences in adults' baseline scores across screening groups on trauma, depression, anxiety and functioning. There were significant differences in the baseline scores of CYP across screening groups on trauma, depression, generalised anxiety and separation anxiety. Paired samples t-tests demonstrated significant differences between baseline and follow-up scores on all measures for adults in the 3-month screening group, and only depression and functioning measures for adults in the 6-month screening group. Data about CYP in the 3-month screening group, demonstrated significant differences between baseline and follow-up scores on trauma, generalised anxiety and separation anxiety.ConclusionsThese findings suggest people who register earlier are less symptomatic and demonstrate greater improvement across a range of psychological measures. Further longitudinal research is necessary to understand changes over time.Declaration of interestNone.

Given the established association between foetal alcohol spectrum disorders (FASD) and risk of criminality and criminalisation, this systematic review examines the prevalence of FASD within youth justice systems. Four relevant sources were identified. Each source suggests a disproportionate prevalence in comparison to the general youth population. However, this masks significant variation between studies, and a much-heightened prevalence of FASD among Aboriginal youth in custody. The continued lack of research establishing prevalence, limits the potential for strong conclusions and suggests an imperative for improved processes of identification. This highlights systematic deficits in the ability to assess or even screen for FASD, with particular challenges for the youth justice system. Until such challenges can be resolved, it is likely that young people with FASD will remain hidden within a system in which they are at great risk of inadequate support, discrimination and criminalisation.