Background Parenting programmes are widely implemented to help alleviate conduct problems in children. This qualitative study was undertaken as part of the Personalised Programmes for Children Randomised Controlled Trial (PPC RCT) which evaluated a personalised parenting programme for those who had either declined or not responded to previous standard group-based parenting interventions. The narratives of parents or carers taking part in the RCT were explored to understand their experiences of personalisation. Methods Twenty-five parents took part in semi-structured interviews either in person or online. Verbatim transcripts were analysed using a thematic codebook approach. Results Three main themes were identified from the parents’ narratives: (1) the importance of choice, (2) the importance of the relationship with the practitioner, and (3) the importance of going beyond the usual. Conclusions Our findings demonstrate that offering parents choices within an intervention (such as location or time) is essential in creating an appropriate personalised approach that was valued by the study participants. Parents also highly valued the inclusion of their children. To engage parents who have previously not engaged or responded to prior group interventions, a more personalised approach utilising the element of choice and parent-led approaches should be considered.

Understanding predictors of offending is essential for developing effective crime prevention. Educational attainment is a readily available metric for pupils in many countries, with performance on standardised tests often systematically collected throughout school. If changing attainment is associated with offending risk, it could present a signal to check in with pupils and offer appropriate support. We analysed an existing linkage between the National Pupil Database and the Police National Computer in England. In a cohort of 4.3 million pupils born between the academic years 1990/91 and 1996/97, we modelled trajectories of standardised attainment on statutory tests at ages 7, 11 and 16 years. We then investigated the association between these attainment trajectories and subsequent first offence convictions or cautions during young adulthood. Among pupils showing relative declines in attainment over their school career, 1 in 3 were convicted or cautioned for a first offence before the end of school, and 1 in 10 were convicted or cautioned for a first offence during young adulthood. Additionally, among pupils who performed at below average levels towards the beginning of school, their odds of offending during young adulthood were 53

Background:Young people's mental health worsened during and since the coronavirus disease discovered in 2019 pandemic. School environments play a key role in young people's mental health. Learning Together for Mental Health is a whole-school intervention aiming to promote mental health in secondary schools, adapted from the previous Learning Together intervention which was found effective in reducing bullying and promoting mental health. Objective:To adapt Learning Together to increase focus on mental health so producing the Learning Together for Mental Health intervention and evaluate the appropriateness of conducting a Phase III trial of the Learning Together for Mental Health intervention regarding pre-defined progression criteria relating to the intervention and trial methods, and assessing intervention feasibility, reach and acceptability, feasibility of trial measures and procedures, potential mechanisms and possible harms. Design and methods:We conducted a feasibility study with baseline and follow-up surveys, process evaluation and economic-evaluation feasibility-testing. Setting and participants:One school participated in intervention adaptation. Our feasibility study included four state, mixed-sex secondary schools in southern England (one of which dropped out after baselines and was replaced with another). We recruited 640 year-7 (age 11-12) students at baseline survey and 566 year-10 (age 14-15) students at 12-month follow-up. Baseline and follow-up participants were different groups, as the focus was assessing feasibility for the age groups to be surveyed at baseline and follow-up in a Phase III randomised controlled trial. Twenty staff, 27 year-8 (age 12-13) students and 22 year-10 students participated in qualitative research as did two trainers and one external facilitator. Interventions:As part of our feasibility study, all schools received the Learning Together for Mental Health intervention for one academic school year. Main outcome measures:Pre-defined criteria for progression to a Phase III trial. Results:The intervention was successfully adapted from the previous intervention using public involvement. The trial met all criteria for progression to Phase III. The all-staff and in-depth restorative practice training were implemented with fidelity in all schools and all schools had at least two staff trained in-depth in restorative practice. Curriculum training was delivered with fidelity in three of four schools. The response rate to the baseline (needs) survey across the three participating schools was 79%. Progression required at least two schools to have delivered the curriculum with at least 50% fidelity, which was achieved; one of the two schools which delivered the curriculum reported over 80% fidelity and the other school reported over 75% fidelity. All students and staff across all four schools who completed the action group survey and 93% of senior leadership team members who completed the senior leadership team survey reported that Learning Together for mental health was a good way to promote student Mental Health. Potential mechanisms of action involve promoting student sense of school belonging and practical reasoning and skills. No harms were reported. Trial measures and procedures were feasible and acceptable to implement. Intervention and trial refinement are suggested. Limitations:Our study involved a small, purposive sample of schools and students which are not representative of those in England. Conclusions:With some minor amendments, Learning Together for Mental Health should be subject to a future Phase III trial of effectiveness. Future work:The intervention should be refined by making the curriculum optional and improving materials. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.

BACKGROUND:Behaviour problems are common in childhood and are associated with higher rates of mental health problems, educational and relationship difficulties throughout life. This study assessed whether a Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) has sustained benefit 6 years after delivery. It had previously been shown to reduce behavioural problems in children aged 2 and 4 years old. METHODS:The Healthy Start, Happy Start study was a 2-arm, multisite randomised clinical trial conducted in 6 NHS trusts in England. Participants (N = 300) were parents/caregivers of children (aged 12-36 months) at risk of behaviour problems. Participants were randomised to receive either VIPP-SD (n = 151) or usual care (n = 149). Those allocated to VIPP-SD were offered 6 home-based video-feedback sessions. Six-year follow-up data were collected from May 2022 to July 2023. The primary outcome was the total score on Parental Account of Children's Symptoms (PACS). The analysis used prespecified longitudinal Bayesian models to handle missing data, and findings are reported as posterior probabilities of superiority alongside treatment effect estimates with 95% credible interval. RESULTS:Analysis included 294 of the 300 participants, with 6-year primary outcome data available for 244/300 (81%) (106 girls [43%]; mean age, 8.2 years). The probability of superiority for VIPP-SD on PACS was 86%. The mean difference in the total PACS score was -1.23 (95% Cred.I [-3.34, 0.90]); d = -0.11 (95% Cred.I [-0.032, 0.09]), with fewer behavioural problems in children in the VIPP-SD group (mean [SD] score of 25.30 [9.63] vs. 26.36 [11.05]). CONCLUSIONS:This trial found a probability of 86% that VIPP-SD was superior for reducing behaviour problems in children up to 6 years later. Taken together with the earlier positive trial findings, this suggests a small enduring positive impact of a brief early intervention with potential for scaling.

Objective: Although parenting programs are the most widely used approach to reduce disruptive behavior in children, there is a notable lack of understanding of the exact changes in parenting that underlie their effects. Challenges include the frequent use of composite measures of parenting behavior and insufficient power to detect mediation effects and individual differences in these in individual trials. Method: Individual participant data from 14 European randomized controlled trials of social learning-based parenting programs were pooled to examine which specific parenting behaviors best explain program effects. Participants included 3,252 families with children ages 1 to 13 years. Parental use of praise, tangible rewards, physical discipline, harsh verbal discipline, and not following through on discipline were included as putative mediators. Additionally, the study explored whether subgroups of families showing different mediational pathways exist. Results: Changes in parenting partially mediated program effects, with all included parenting behaviors except parental use of praise serving as unique mediators. Less harsh verbal discipline and increased following through on discipline were the strongest mediators. The study identified 3 subgroups with distinct responses to parenting programs. Most families benefited, partly through increased following through on discipline; families with the least or most difficulties were more likely to benefit less or not at all. Conclusion: These findings offer insight into the specific parenting behavior changes key to reducing disruptive child behavior, while highlighting the need for innovative research methodologies to gain a deeper understanding of individual differences in parenting program benefits and mechanisms. Plain language summary: Parenting programs are the most widely used strategy to reduce children's disruptive behavior. In this analysis of individual data of 3,252 families that participated in 14 European randomized controlled trials, the authors examined which specific changes in parenting behaviors best explain the effects of parenting programs on children's behavior, and whether these changes might differ across different types of families. The authors found that changes in parenting behavior partially explained program effects on disruptive behavior. Reduced harsh verbal discipline and increased following through on discipline seemed the most important parenting behaviors. While most families benefited from parenting programs, those facing the most or the least difficulties benefited less. Study preregistration information: Study Preregistration: Individual Participant Data Meta-analysis: Individual Differences in Mediators of Parenting Program Effects on Disruptive Behavior; https://doi.org/10.1016/j.jaac.2023.11.005.

Background:Despite high rates of adolescent mental health problems, there are few effective school-based interventions to address this. Whole-school interventions offer a feasible and sustainable means of promoting mental health, but to date, few have been evaluated. Previously we trialled the Learning Together intervention comprising local needs assessment, student and staff participation in decision-making, restorative practice, and a social and emotional skills curriculum. This was effective not only in preventing bullying (primary outcome) but also in promoting mental well-being and psychological functioning (secondary outcomes). We adapted Learning Together to develop Learning Together for Mental Health, focused on promoting mental health. Objective:This paper reports on quantitative data on intervention implementation fidelity, reach and acceptability to assess progression to a Phase III trial. Design:We drew on student baseline and follow-up surveys and an integral process evaluation from a non-randomised feasibility study involving four secondary schools. Setting:Southern England. Participants:Students in year 8 (age 12/13) at baseline and year 10 (age 14/15) at follow-up and school staff and students and intervention trainers and facilitators completing process evaluation tools. Interventions:Whole-school intervention featuring student needs assessment, action groups involving staff and students which selected actions from an evidence-based menu, restorative practice to improve relationships and address student behaviour and a social and emotional skills curriculum. Results:Restorative practice training was implemented with fidelity in all schools. Curriculum training was implemented with fidelity in three of four schools. The response rate to the needs survey across the three schools that participated was 79%. Action groups were implemented with fidelity. Action groups at all four schools completed at least one locally decided action and chose at least one action from the menu of evidence-based options. Restorative practice was implemented across all schools. Of lessons that were observed and lessons for which teachers returned logbooks, curriculum delivery was implemented with fidelity. However, two schools delivered 50% or less of the recommended lessons, and not all teachers completed logbooks. All students and staff completing surveys reported finding the Learning Together for Mental Health intervention a good way to promote student mental health. Over a third of students reported definite awareness of actions being undertaken by their schools to improve student mental health. All pre-defined progression criteria to proceed to a Phase III trial were met. The intervention was delivered with good fidelity and had strong acceptability. Limitations:The schools involved may not be representative of those which we would recruit to a Phase III trial. Conclusions:The study met all pre-determined progression criteria, and the intervention is ready for a Phase III trial with minor adaptations. Future work:A Phase III trial of effectiveness is justified. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.

Background Autism is a neurodevelopmental condition whose core symptoms include impairments in social communication, restricted and repetitive behaviours and sensory atypicalities, which can have varying severity. Most autistic people experience additional, impairing mental health and behavioural problems, but these are often under-recognised by healthcare professionals, autistic people and their caretakers. Objective(s) We aim to improve identification of mental health problems by developing a tool for clinical use, which can also be used to monitor treatment response. Design Work package 1: we developed and validated a new instrument to provide improved detection of mental health and behavioural problems in autistic people from childhood through to adult life. Work package 2: we explored how autistic young adults understand and manage their mental health. Work package 3: we undertook a cohort study to identify risk and protective factors for mental health and behavioural problems in autistic adolescents. Work package 4: we undertook a pilot feasibility randomised controlled trial of Predictive Parenting compared to group-based psychoeducation and active control intervention. It was not the aim of the pilot feasibility randomised controlled trial to undertake hypothesis testing. Setting Participants in work package 1 were ascertained through clinical sites within London and Liverpool and through specialist autism schools in London. In work package 2, participants were selected from a cohort originally ascertained from 11 regions across south-east England. Participants were drawn from London Boroughs of Bromley and Lewisham (work packages 3 and 4) and London Borough of Lambeth (work package 4). Participants Work package 1: 255 parents of autistic children/adolescent; work package 2: 19 autistic young adults; work package 3: QUEST cohort of 277 children; work package: 62 children. Intervention Predictive Parenting – a novel parent-mediated intervention. Main outcome measure Work package 4: a blinded observational measure of child behaviours that challenge. Results We developed the Assessment of Concerning Behaviour to be completed by parents/caretakers, autistic children/young people/adults and teachers, and showed it has two reliable and valid subscales reflecting emotional and behavioural problems. We identified that poor or incomplete understanding of autism affected young adults’ and parents’ understanding, discernment and management of mental health difficulties. We showed strong continuity of emotional and behavioural problems as well as attention deficit hyperactivity disorder from early childhood to late adolescence, with prediction being largely within domain (emotional, behavioural or attention deficit hyperactivity disorder). Early childhood attention deficit hyperactivity disorder symptoms had a significant negative impact on adolescent everyday functioning. At an individual level, parents’ accounts suggested multiple factors may affect mental health trajectories and outcomes in the late teenage years. Our pilot feasibility trial of our new intervention, Predictive Parenting, directed at parents of young autistic children was highly acceptable and feasible to deliver. Limitations To date, only the parent version of the Assessment of Concerning Behaviour has had its psychometric properties ascertained. We combined clinical and non-clinical samples and the scale could have different psychometric properties for these two groups. The qualitative work in work package 2 was limited to young adults without an intellectual disability and there was under-representation of females and non-white ethnicity, as well as those with severe mental health problems. The QUEST cohort in work package 3 was derived from those receiving an early autism diagnosis, who are more likely to have severe autistic presentations and intellectual disability, so the results may not generalise to the full autistic population. The pilot feasibility study had a small sample size and hence modest power to detect group differences; the lack of an objective rating of intervention fidelity; the lack of a treatment as usual group to track the natural trajectory of child and parent behaviours over time; and the fact that although the researchers who coded the observational measure were blinded to intervention allocation, they were not blinded to time point. Conclusions The research undertaken in the current programme shows that mental health and behavioural problems are more common in autistic people and are strongly persistent over time, even when they commence in the early childhood period. Interventions for mental health and behavioural problems are a priority for autistic people and their families. However, we showed that autistic people and their families often find it difficult to discern the difference between autistic features and mental health and behavioural problems. Future work A definitive randomised controlled trial including an economic evaluation is needed to determine the effectiveness and cost-effectiveness of Predictive Parenting. Future longitudinal research could focus on modifiable risk and resilience factors related to mental health problems in autistic people and could determine whether routine use of mental health screening questionnaires increases the identification and treatment of mental health problems in autistic children and young people. Trial registration This trial is registered as Current Controlled Trials ISRCTN91411078. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-1211-20016) and is published in full in Programme Grants for Applied Research; Vol. 13, No. 5. See the NIHR Funding and Awards website for further award information. Plain language summary Background Two-thirds of autistic people have mental health disorders. These disorders are distressing to autistic people and their families/caretakers, may limit access to education and reduce employment opportunities and community participation. Autistic people and their families prioritise research that will improve their mental health. Methods We wanted to better understand how autistic people and their families recognise and seek help for mental health problems. To identify early risk factors for ongoing health problems, we followed a group of young autistic children to adolescence. To reduce distressing mental health and behavioural problems, we undertook a small pilot feasibility randomised controlled trial of a novel parent-mediated group intervention for young autistic children to see whether parents were interested and could take part in the intervention. Results We discovered that autistic young adults found it difficult to distinguish between autism and mental health. They were less likely to seek help for their mental health problems. Our new measure of mental health and concerning behaviours, co-produced with autistic people and parents, shows good reliability and validity. From childhood to adolescence, mental health and behaviour problems are likely to persist rather than go away on their own. Parents’ accounts indicate that many factors may affect an autistic child or teenager’s mental health – both in positive and negative ways. Our novel intervention showed high rates of completion and satisfaction. Conclusions Mental health and behaviour problems in autistic people are common and persist over time. Better identification and effective, targeted interventions are required to improve outcomes. These should start in early childhood. It is important to ensure autistic people and their families know about mental health problems. Mental health questionnaires that are easy for autistic people to complete could improve recognition by autistic people, parents/caretakers and professionals alike. Scientific summary Background Autism involves pervasive impairments of reciprocal social interaction and communication as well as repetitive behaviours and interests and sensory atypicalities, including hyper- and hypo-sensitivity to different stimuli. Autism is common, occurring in ~1–1.5% of the population, lifelong and hugely expensive. Currently, there are very limited treatments for its core symptoms. There are also widely divergent views on whether core autistic traits should be a target for intervention or rather that societies and environments should be more flexible to accommodate neurodivergence (or both). However, previous research and consultation with autistic people and their families/caretakers highlighted the importance of commonly associated mental health problems (MHP). Referred to as mental health and behavioural problems (MHBP), these can lead to exclusion from everyday family life, educational and community activities, poor quality of life and increased stress for family members as well as high costs in service use and lost opportunities. Previous research has shown elevated rates of MHBP at all ages among autistic people, affecting up to two-thirds of individuals, but at the inception of this programme, it was not known whether these problems persisted over time in the same individuals, nor what are the risk factors for persistence. Aims and objectives This programme focused on decreasing MHBP as a strategy for improving outcomes for autistic people and their families. These outcomes include improved mental health, quality of life and community participation for autistic people; reduced family stress; and decreased economic costs by ultimately lowering the need for high-cost (often residential) care and integration into the community. To achieve this, we focused on improved recognition, early intervention and identification of the factors that predict MHBP and influence transitions to adolescence/early adult life. Autism is a lifelong condition, and this programme reflected this through work packages focusing on key time points from early childhood to young adult life. To achieve our aims, we addressed the following objectives: We developed and validated a measure of MHBP in autism, to assist professionals in detecting these problems, identifying their causes and monitoring treatment/intervention. (Work package 1 – instrument development.) We interviewed young adults and parents of autistic young people and young adults, in order to understand and describe their perception of the emergence of MHP their experiences of seeking help; and the impact of these on their lives. (Work package 2 – biographies.) We undertook a longitudinal study of a cohort of autistic adolescents in order to identify the personal, family and wider environmental risk/protective factors related to persistence/desistence of MHBP from early childhood to late adolescence. A nested qualitative study investigated parents’ accounts of their child’s mental health trajectories. (Work package 3 – predictors.) We developed and completed a pilot feasibility randomised controlled trial (RCT) of a novel intervention for parents of recently diagnosed children aimed at reducing MHBP, enhancing child and family functioning and decreasing parental stress. We compared it to a control intervention. (Work package 4 – treatment.) Work package 1: instrument development Methods We undertook focus groups with autistic adolescents and adults and their parents/caretakers as well as mental health professionals. With autistic people and their parents, we wanted to identify the most effective and understandable ways of conveying item content and appropriate scoring. To assess the instrument, participants were identified through mental health and paediatric clinics, schools for autistic children and schools with special units for autistic children. We then asked autistic people, their parents and teachers to complete the questionnaire. A subset completed the questionnaire on two occasions to obtain test–retest reliability. Exploratory factor analysis (EFA) identified the structure which was replicated in an independent sample using confirmatory factor analysis (CFA). Reliability and validity were assessed for the final solution, for each factor separately. Convergent and discriminant validity were measured against existing measures. Key findings Item content, presentation and response format are very important to autistic people. The Assessment of Concerning Behaviour (ACB) was completed by 255 parents, 149 autistic children and young people and 30 teachers; test–retest data were available from 121 parents and 61 children/young people. Target participants (across all respondents) had an age range of 7–29 years; self-reports were completed by youth aged 8–14 years. Male preponderance varied from 75% to 83.6%. Mean IQ varied from 63.8 to 77.8 with a range from the profound intellectual disability (ID) range to superior IQ. EFA supported a two-factor model as providing the best fit [χ2/degrees of freedom (df) = 1.7, root-mean-square error of approximation (RMSEA) = 0.053, Comparative Fit Index (CFI) = 0.91] compared to a one- or three-factor model. This was validated by CFA on a second sample (χ2/df = 1.7, RMSEA = 0.057, CFI = 0.88) which was compared to a one-factor model. Within-factor reliability and stability were judged satisfactory with Cronbach’s weighted kappas ranging from 0.51 to 0.72 and per cent agreement from 83% to 95.5%. Concurrent, convergent and discriminant validity was supported by the pattern of correlations with other measures. Limitations There were relatively low completion rates by children, adolescents, and young adults, as well as teachers, in comparison with parents, meaning that a full psychometric profile could only be generated for the parent version. However, up till adult life, among autistic populations, it is usual to rely on parent report as the primary informant. Interpretation Co-design of a questionnaire with autistic people and their families led to a different structure and response format than is typical for questionnaires about MHBP. The ACB was subjected to stringent psychometric evaluation, including replication of the structure in a second sample, and was found to be robust. Work package 2: biographies Methods Using an existing research cohort, we purposively sampled autistic young adults with previous experience of a range of MHBP. Nineteen autistic young adults aged 23–24 years were recruited. Parallel interviews were undertaken with parents. In-depth interviews explored how they understood and managed MHP. Data were analysed thematically, and this framework was shared at an early stage with the patient and public involvement (PPI) panels. Key findings Young adults adopted self-management strategies rather than seeking advice or intervention from more conventional sources, including clinical services. Factors contributing to this included beliefs about the causes of MHP and increased vulnerability with the context of a diagnosis of autism, knowledge of self-management and, based on prior experiences, a view that professional support or intervention was unavailable or inadequate. Where help was sought, this was only at the point of psychological distress becoming very apparent to parents (typically due to concomitant physical symptoms such as significant weight loss) who typically either initiated or supported help-seeking. Limitations The study focused on young adults without learning difficulties (IQ < 70). There was an under-representation of females and people from ethnic minority backgrounds in the cohort from which we recruited. This means that we have only a partial understanding of these issues for autistic adults. Interpretation Young autistic adults and their families may hold erroneous beliefs about autism and mental health, and, as a result, struggle to discern when they might need mental health support. Negative or unhelpful experiences of mental health support during childhood and the teenage years may engender a suspicion or reluctance to seek help from mental health services. There were few systematic opportunities for autistic young people or their parents to learn about autism, including its implications for mental health. In addition, health and social care professionals need to be aware of the high rate of MHBP in autistic people and that autistic people may not recognise their own MHBP or feel confident in seeking professional help for them. Work package 3: predictors Methods We followed up the QUEST cohort, a sample of 277 autistic children first assessed at age 4–9 (Wave 1) and followed up at ages 11–16 (Wave 2) and 13–18 years (Wave 3). A particular focus was on the role of family factors, including maternal stress and mental health and family child-rearing practices, alongside wider environmental experiences, such as type of schooling and bullying, on MHBP. MHBP were assessed with parent- and teacher-reported questionnaire measures at Wave 2 and parent- and self-reported questionnaires and parental psychiatric interview for the intensive subset at Wave 3. These were conceptualised in three domains: emotional problems, behavioural problems and attention deficit hyperactivity disorder (ADHD) symptoms. Parents reported on their own MHP at each Wave. Regression analysis and structural equation modelling were used to examine longitudinal relationships. A nested qualitative study of parents (n = 33) of autistic teenagers (15–19 years), purposively recruited from the cohort, sought to collect parents’ accounts of their child’s mental health from diagnosis to the present, their beliefs and observations about the factors which affected it, and the impacts of MHBP on them as parents. Key findings We demonstrated moderate to strong persistence of mental health symptoms and diagnoses in autistic children over more than 10 years. Once initial comorbidity of symptom domains was accounted for, stability was largely within domain. Adolescent adaptive functioning was predicted not only by early childhood autistic symptoms and IQ and ADHD symptoms. Higher parental MHP at Wave 1 was found to be associated with lower child IQ (β = 0.2), but not autistic symptoms. The nested qualitative study revealed that multiple factors may protect against, or increase the risk of, MHBP during a child’s life. These include bio-psychological (e.g. IQ, communication skills, puberty, social and cognitive development) and social ecological factors (e.g. parenting skills, family and school environment) factors. Parents described feeling skilled and competent in supporting their autistic child until the early teenage years, when they encountered new, more challenging difficulties. Limitations The QUEST cohort is ascertained from a population of children diagnosed in two London boroughs before age 4 years. Thus, while this is a carefully characterised population, it reflects children diagnosed early in life and does not include those with more subtle presentations who may only be recognised as having autism later. The nested qualitative study focused only on parents’ accounts. Interpretation Mental health and behavioural problems showed moderate to strong stability from early childhood to adolescence, supporting the importance of early detection and appropriate intervention. While parents self-report high levels of MHP, these do not appear to be strong predictors of subsequent child MHBP. Nevertheless, the association between parent MHP and child IQ suggests that clinicians should attend to the well-being of parents, especially those whose children have ID. Efforts to minimise the risk of MHBP among autistic children and teenagers need to be multifaceted with interventions and support available for children, parents and schools. Work package 4: treatment Methods This was a pilot feasibility RCT comparing a 12-week group behavioural parenting intervention [Predictive Parenting (PP)] to an attention control [psychoeducation (PE)]. Parents of 62 4- to 8-year-old autistic children were randomised to PP (n = 31) or PE (n = 31). The primary outcome was a blinded observational measure of child behaviours that challenge. Secondary outcomes included observed child compliance and parenting behaviours; parent- and teacher- reported child emotional and behavioural problems; self-reported parenting practices, parental stress, self-efficacy and well-being. Key findings Recruitment, retention, completion of measures, treatment fidelity and parental satisfaction were high for both interventions. There were no significant differences on other measures. Limitations Predictive Parenting was compared to an active intervention of PE delivered by experienced clinicians. Although recommended by many professionals, PE is not routinely available as treatment as usual and thus this comparison does not reflect the potential augmentation of current practice that could be conferred by PP. This is a pilot feasibility trial that requires a definitive evaluation including estimation of cost-effectiveness. Interpretation Predictive Parenting is an acceptable and feasible intervention to deliver. The MHBP it is tackling are important targets for intervention. Conclusions We have shown that MHBP in autistic people at different time points show high levels of persistence in the same individuals, highlighting the importance of early recognition and targeted, autism-specific interventions. Furthermore, our finding that young autistic adults may have difficulty recognising MHP as distinct from autistic symptoms increases the need for autism-specific instruments to detect MHBP, such as the ACB. Co-design of instruments with autistic people and their parents may be important in using language and formats that assist autistic people and those informing on their symptoms to provide accurate accounts leading to timely help. Interventions should be offered from early childhood and more work is required to identify the most effective and cost-effective treatments. Study registration This study is registered as Current Controlled Trials ISRCTN91411078. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-1211-20016) and is published in full in Programme Grants for Applied Research; Vol. 13, No. 5. See the NIHR Funding and Awards website for further award information.

Parenting programs have proven effective in reducing disruptive child behavior. However, not all families benefit equally, and, to date, we have little insight into who benefits more or less and why. One possible solution is to explore how different potential moderators cluster together in individual families and whether such family profiles predict who benefits more or less from these programs. This study explores (a) how family, child, and parenting risk factors for disruptive behavior cluster together in families enrolled in the popular and evidence-based Incredible Years Parenting Program using latent profile analyses; (b) how family profiles relate to covariate family characteristics; and (c) whether profiles predict program engagement (i.e., number of sessions attended by caregivers) and effectiveness of (i.e., pre-post changes in disruptive behavior). Individual participant data from six studies across four countries (Norway, the Netherlands, England, Portugal) were used, including a total sample of 772 families with children aged 2.5-9 years (M = 5.14; SD = 1.10; 58.0% boys). Families could be profiled into a low- and high-risk profile, which differed on most child and family (but not parenting) risk factors as well as on covariate family characteristics, such as severity of disruptive behavior. Profile membership predicted engagement in, but not effectiveness of, the program. These findings provide useful insights into the heterogeneity in families participating in parenting programs, although there is a need for further research on how such differences may relate to differences in program effectiveness. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

One of the most highly replicated neural correlates of Conduct Problems (CP) is amygdala hypoactivity to another person’s fear. We recently reported that this correlate was only observed in boys with persistent CP (i.e. antisocial behaviour that persisted following a gold-standard psychological intervention), suggesting that amygdala hypoactivity to fear could be an important neural signature for treatment-resistant CP, and a putative target for future treatments. Potential treatment candidates include the oxytocin system, as this has been reported to modulate amygdala activity and social behaviour across species. Further, in adults with antisocial personality disorder, intranasal oxytocin improved facial emotion recognition for fearful and happy faces. However, to-date, no-one has studied whether intranasal oxytocin can normalise neural processing differences in children with CP. Twenty boys (mean age 9.85±1.26 years) with persistent CP underwent functional magnetic resonance imaging in a within-subject randomised control design to investigate whether, compared to placebo, a single-dose of intranasal oxytocin could ‘shift’ abnormal neural processing to fear. Oxytocin failed to reduce amygdala hypoactivity to fearful faces, but increased activation in the posterior cingulate cortex / precuneus to happy faces. These findings tentatively suggest that intranasal oxytocin may promote a more neurotypical profile in treatment-resistant CP children, therefore, supporting the merit of investigating oxytocin in further larger clinical studies in this population.

Background:Population mental health in young people worsened during and since the COVID-19 pandemic. School environments can play a key role in improving young people's mental health. Learning Together for Mental Health is a whole-school intervention aiming to promote mental health and well-being among young people in secondary schools. Before progressing to a Phase III effectiveness evaluation of the intervention, it is critical to assess the feasibility of trial measures at baseline and follow-up. Objective:To evaluate the feasibility of trial measures and procedures within a feasibility study of a whole-school intervention aiming to promote mental health and well-being among young people in secondary schools, including whether we met our progression criterion of survey response rates of 60% or more in two or more schools at baseline and follow-up. Design and methods:We conducted a feasibility study which included assessment of the indicative primary and secondary outcomes measures and procedures to be used in a future Phase III trial. Setting and participants:Setting for our feasibility study included five state, mixed-sex secondary schools in southern England (one of which dropped out after baselines and one of which replaced this). We recruited year-7 students to participate in the baseline survey and year-10 students to participate in the follow-up survey at 12-month follow-up. Baseline and follow-up participants were different groups, as the focus was assessing feasibility of measures for the age groups that would be surveyed at baseline and follow-up in a Phase III randomised controlled trial. Our study was not powered or designed to estimate intervention effects. Interventions:As part of our feasibility study, all schools received the Learning Together for Mental Health intervention for one academic school year. Main outcome measures:The indicative primary outcome measure trialled was the total difficulties score of the Strengths and Difficulties Questionnaire. Indicative secondary outcomes measures trialled were the: Warwick-Edinburgh Mental Well-being Scale; Short Moods and Feelings Questionnaire; Generalised Anxiety Disorder-7 scale; Eating Disorders Examination - Questionnaire Short, self-harm (single item from the Health Behaviour in School-aged Children study); bullying victimisation (Gatehouse Bullying Scale); cyberbullying (two items adapted from the Dose Adjustment for Normal Eating II questionnaire); substance use (National Health Service measure); and Beyond Blue School Climate Questionnaire. Results:Trial measures and procedures were feasible to implement and were acceptable to year-7 and year-10 students, teachers and parents. At baseline, response rates ranged from 58% to 91% between schools. Only two students were opted out by parents, and no students opted out in advance. Students refusing consent on the day of survey was rare (7%). Twelve per cent of students were absent. The follow-up survey had an overall response rate of 66%, ranging from 44% to 91%. Only two students were opted out by parents, and three students opted out in advance. Overall, 12% opted out on the day. Twenty per cent of students were absent. Variation in response rate reflected specific problems at certain schools. Surveys took 40-45 minutes at baseline and 30 minutes at follow-up. The trial progression criterion concerning response rates was achieved, with three of four schools at baseline and two of four schools at follow-up having responses rates above 60%. Limitations:Our study involved a small, purposive sample of schools and students which are not representative of those in England. Conclusions:With some minor amendments, trial measures and procedures should be applied in a future Phase III effectiveness evaluation of the Learning Together for Mental Health intervention. Future work:Survey response rates could be improved if baseline and follow-up surveys are not scheduled in the last weeks of term, on Fridays or near mock General Certificate of Secondary Education exams. Completion of some measures (such as Eating Disorders Examination - Questionnaire Short) among year-7 students may be improved if question wording is tailored to be age-appropriate. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.

Background:The high prevalence of mental health disorders among adolescents point to the need for interventions that prevent or minimise harms from these. Schools are the ideal setting for such interventions, given almost all children can be reached. We adapted a whole-school health intervention to target mental health. As part of this research, we aimed to provide schools with a report on mental health needs among their students and a menu of evidence-based actions that schools could take to address these needs. Given the multiple existing systematic reviews in this area, the actions to be included in the menu were informed by a rapid systematic review of reviews. Aims:To identify effective school-level or simple interventions to address student needs across various domains of mental health in secondary schools or an equivalent phase, which have been identified in existing systematic reviews. Methods:We undertook a rapid systematic review of reviews. In January 2022, we searched three databases [PubMed, PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Library] for systematic reviews of mental health interventions in the domains of: antisocial behaviour, anxiety, body image, depressive symptoms, digital health, eating problems, emotional issues, general well-being, lesbian, gay, bisexual, trans, questioning and other (LGBTQ+) inclusion, mental health first aid, physical activity for mental health, positive mental health, self-harm, student voice and substance use. Eligible for inclusion were systematic reviews of randomised trials or quasi-experimental studies evaluating school-based interventions among secondary school- or equivalent-aged children. We retrieved 95 reviews, of which 41 were eligible for the present review. We defined effective intervention strategies as those identified as being effective in an eligible study in any review. Results:We identified a number of effective school-level or simple school interventions for addressing mental health in the above domains. Nine intervention focus areas were identified: (1) positive mental health and promotion of healthy development (five intervention strategies identified); (2) mental health literacy and awareness (six strategies); (3) LGBTQ+ mental health (two strategies); (4) mental health first aid (one strategy); (5) peer mentoring (two strategies); (6) support for transition from primary to secondary school (one strategy); (7) body image and body confidence (one strategy); (8) creative arts activities (one strategy); (9) physical activity (seven strategies) and (10) increasing access to nature (one strategy). Altogether, 27 strategies were identified. Conclusions and limitations:This rapid review identified 27 evidence-based school-level strategies that were used to inform the development of a menu of evidence-based whole-school actions, which were simple and inexpensive to implement in schools. This menu was piloted in a feasibility study, the results of which are reported elsewhere. Our findings were limited by a lack of quality assessment and single screening of abstracts. Future work:If Learning Together for Mental Health is demonstrated as feasible to implement and acceptable to teachers and students, a phase III cluster randomised trial will be conducted to evaluate the effectiveness of the intervention. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.

BACKGROUND:Early parenting interventions are the gold-standard treatment for reducing antisocial behavior (ASB) in children with conduct problems (CPs), but the neurocognitive mechanisms that underpin treatment response are unknown. METHODS:We assessed functional magnetic resonance imaging (fMRI) and performance data from a reward learning task in boys with CPs (ages 5-10 years) before and after a gold-standard group parenting intervention. Matched control boys were assessed concurrently at 2 equally spaced time points. The CP group was subdivided into boys whose ASB improved or persisted over the course of treatment. Longitudinal group (control, improving CP, persistent CP) × time (pre-, postintervention) analyses were then conducted on task-based fMRI and reinforcement learning data. RESULTS:Following the intervention, a comparison of the improving CP group with the persistent CP and control groups showed 1) increased neural activity in the direction of typically developing children within the ventromedial prefrontal cortex, insula, posterior cingulate cortex, and hippocampus in the improving CP, but not the persistent CP, group and 2) distinct changes in learning rate, action bias, and reward/punishment sensitivity. Furthermore, changes in insula activity and punishment/reward sensitivity correlated with changes in parenting behavior. CONCLUSIONS:Improved ASB after early intervention was associated with changes in reward-processing regions and specific reinforcement learning parameters. These changes were not observed in boys with persistent CPs and correlated with changes in parenting behavior. These findings highlight the importance of early interventions for CPs and reveal potential mechanisms that underpin successful treatment.

Background Conduct disorders (CD) are among the most frequent psychiatric disorders in children and adolescents, with an estimated worldwide prevalence in the community of 2–4%. Evidence-based psychological outpatient treatment leads to significant improvement in about two-thirds of cases. However, there seems to be considerable variation in rates of CD diagnoses and implementation of evidence-based interventions between nations. The aim of this study was to compare administrative prevalence and treatment patterns for CD in children and adolescents seen in health care systems across four Western countries (Denmark, Germany, Norway, and the USA). Methods Cross-sectional observational study using healthcare data to identify children and adolescents (aged 0–19 years) with an ICD-10 code for CD within the calendar year 2018. Within each country’s study population, the prevalence of CD, psychiatric comorbidity, psychopharmacological treatment, and psychiatric hospitalisation was calculated. Results The prevalence of diagnosed CD differed 31-fold between countries: 0.1% (Denmark), 0.3% (Norway), 1.1% (USA) and 3.1% (Germany), with a male/female ratio of 2.0–2.5:1. The rate of psychiatric comorbidity ranged from 69.7 to 86.1%, with attention-deficit/hyperactivity disorder being most common. Between 4.0% (Germany) and 12.2% (USA) of youths with a CD diagnosis were prescribed antipsychotic medication, and 1.2% (Norway) to 12.5% (Germany) underwent psychiatric hospitalisation. Conclusion Recognition and characteristics of youths diagnosed with CD varied greatly by country. In some countries, the administrative prevalence of diagnosed CD was markedly lower than the average estimated worldwide prevalence. This variation might reflect country-specific differences in CD prevalence, referral thresholds for mental health care, diagnostic tradition, and international variation in service organisation, CD recognition, and availability of treatment offers for youths with CD. The rather high rates of antipsychotic prescription and hospitalisation in some countries are remarkable, due to the lack of evidence for these therapeutic approaches. These findings stress the need of prioritising evidence-based treatment options in CD. Future research should focus on possible reasons for inter-country variation in recognition and management of CD, and also address possible differences in patient-level outcomes.

Background Despite high rates of adolescent mental health problems, there are few effective school-based interventions to address this. Whole-school interventions offer a feasible and sustainable means of promoting mental health, but few have to date been evaluated. Previously we trialled the Learning Together intervention comprising local needs assessment, student and staff participation in decision-making, restorative practice, and a social and emotional skills curriculum. This was effective not only in preventing bullying (primary outcome), but also in promoting mental well-being and psychological functioning (secondary outcomes). Objective We aimed to adapt Learning Together to develop Learning Together for Mental Health, focused on promoting mental health. This paper reports on how we refined and elaborated intervention materials to produce the Learning Together for Mental Health intervention including through patient and public involvement and engagement. Design We reviewed evidence to inform choice of the curriculum component and the contents of our needs assessment survey. We conducted patient and public involvement and engagement with school staff and students, and children and young people from the National Children’s Bureau to adapt the intervention. We also conducted a systematic review of reviews to inform a menu of evidence-based actions, but this is reported separately. Setting Southern England. Participants Patient and public involvement and engagement was conducted with four staff and five students from one secondary school, and a group of two school senior leadership team members from different schools, and about eight children and young people who were members of the Young National Children’s Bureau. Interventions None. Results We refined and elaborated our initial plans for Learning Together for Mental Health to generate an intervention supported by full materials, training and external facilitation. We focused needs assessment on mental health, added a menu of evidence-based whole-school mental health actions, and switched to a different social and emotional skills curriculum. We retained restorative practice and staff/student involvement in decisions. No further refinements were made to the intervention theory of change or overall approach. Patient and public involvement and engagement was useful, but not all suggestions were acted on either because some participants suggested dropping pre-determined elements (e.g. needs survey) or because suggestions (e.g. to include aromatherapy) lacked evidence of effectiveness. Limitations Not all of our engagements with patient and public involvement and engagement stakeholders were sustained over time. Our patient and public involvement and engagement work was affected by its having occurred within the recovery period from COVID-19 when schools were more stressed than normal. We had planned for the school involved in patient and public involvement and engagement to be above average in student free-school-meals eligibility, but the school initially recruited dropped out at the last minute. Its replacement had a lower-than-average rate of free-school-meal entitlement. Conclusions This paper reports on the process of adaptation and reflects on the various ways in which engagement and evidence review were useful in this process. We found that it is possible to refine interventions and elaborate them to provide full materials and support via processes drawing on evidence review and patient and public involvement and engagement. The latter proved valuable in informing refinement of Learning Together for Mental Health in terms of ensuring its feasibility, acceptability, and inclusiveness. However, in our opinion, not all suggestions from patient and public involvement and engagement can or should be acted on, especially when they do not align with the evidence base. Future work A feasibility study to optimise the intervention and assess whether progression to a full trial is justified. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.

Behavioral parenting programs, such as Incredible Years (IY), reduce conduct problems in children. However, conduct problems encompass many different behaviors, and little is known about the effects of parenting programs on specific aspects of children's conduct problems, such as children's relationships with others. The aim of this study was to examine, for the first time, the effects of the IY parenting program on children's levels of conflict with their parents, siblings, and peers. We used individual participant-level data pooled across 12 randomized trials in Europe, comprising a total of 1,409 families: child aged 1-11 years (M = 5.53 years, SD = 1.56) and 61% male, 60% low-income families, and 30% from an ethnic minority. Multilevel models were used to explore the effects of IY on children's conflict with parents, siblings, and peers. The IY program reduced children's conflict with their parents (beta = -.21), but there were no main effects of the program on conflict with siblings or peers. Moderation analyses showed that IY reduced conflict in sibling relationships for the 22% of families with the most severe sibling conflict at baseline. This suggests that high-quality behavioral parenting programs, such as IY, can effectively reduce children's conflict within the home (i.e., with parents and siblings), especially when initial levels of sibling conflict are high, but do not have broader benefits on children's interpersonal conflict outside of the home (i.e., with peers).