CAPMH Corner (Updated Dec 2024)

Child and Adolescent Psychiatry and Mental Health (CAPMH) is the official IACAPAP Journal. The "CAPMH Corner" of the December 2024 issue of IACAPAP Bulletin summarizes the following three studies recently published in CAPMH – Multilevel barriers to guideline implementation: a nationwide multi-professional cross-sectional study within child and adolescent psychiatry (Santesson et al., 2024), Training approaches for the dissemination of clinical guidelines for NSSI: a quasi-experimental trial (Koenig et al., 2024), and “I’m trying to take the lead from my child”: experiences Parenting Young Nonbinary Children (Sweder et al., 2024).

Santesson et al., (2024) discuss the potential of clinical practice guidelines to improve the quality of care, and the multilevel barriers to their uptake, particularly clinician-related factors like awareness, training, and involvement. Addressing the sparse literature on CAMHS clinicians' attitudes toward guideline implementation, their study forms part of Project Deplyftet, a nationwide program launched in 2014 to improve care for depressed youth. 

The authors provide an overview of primary clinical practice guidelines for childhood depression in the Swedish context to establish a background for their study. The Swedish National Board of Health and Welfare (NBHW) issued a 2010 guideline to help decision-makers prioritize evidence-based treatments for depression and anxiety. In 2014, the Swedish Association for Child and Adolescent Psychiatry developed a clinical practice guideline based on NBHW's framework, featuring a stepped-care approach with checklists and recommendations for clinicians. Unique to this guideline is its recommendation of brief psychosocial intervention as a first step for mild and moderate depression, similar to the approach used in the IMPACT study (Goodyer et al., 2017). 

The team analyzes data from 440 clinicians (52% response rate) working in 10 of 31 eligible CAMHS clinics, serving approximately 550,000 youth (26% of Swedish children) between 2016 and 2018, representing publicly funded clinics with similar catchment areas. The typical participant was female (84%), had a bachelor’s degree (61%) and had five or less years in child and adolescent psychiatry (47%). They evaluate the participants using the Barriers and Facilitators Assessment Instrument (BFAI), a validated tool for guideline implementation, to assess barriers across four scales: Innovation, Provider, Context, and Patient. They analyze barriers at both scale and item levels. They use Generalized Linear Modelling (GLM) to investigate differences between scale means, Chi Square, and one-way ANOVA to test for between-group differences and correlation analyses to test the relationship between continuous and ordinal variables. 

The authors report that psychiatrists generally perceived fewer barriers than other professions, with no significant correlations found between barriers and gender, age, or years of experience. Counsellors and psychologists were more likely than psychiatrists to report not thoroughly reading or remembering the guideline, though the effect sizes were small (V = 0.17–0.29). Psychiatrists viewed the guideline as more flexible and were more involved in implementation planning compared to nurses and counsellors, but these differences also had small effect sizes (V = 0.19–0.25). 

They highlight the strengths of their study –  the use of a standardised and validated measure, a large sample of front-line CAMHS clinicians representing various professions (nurses, psychologists, psychiatrists, counsellors and others), recruitment from a geographically diverse area with the sample’s characteristics being similar to available national data describing the CAMHS workforce, and a good response rate of over 50%. They acknowledge its limitations such as the use of a self-report measure, lack of descriptive data for non-respondents to investigate any potential selection bias, and missing data pattern was not completely at random, which can introduce uncertainty and may reduce generalizability. 

They conclude that while guidelines are critical for delivering and adhering to evidence-based treatments in CAMHS, their adoption can be hindered by multilevel barriers. They highlight that their findings indicate an overall positive attitude toward adopting the depression guideline in Swedish CAMHS. However, suggest that enhancing adoption requires addressing key issues, such as adapting guideline components to meet specific patient needs, providing staff education and training, and tailoring implementation strategies to different professional groups. 
 

Koenig et al., (2024) discuss the significant clinical relevance of non-suicidal self-injury (NSSI) due to its high prevalence and long-term implications. They underscore the critical need for clinician training to implement evidence-based guidelines in clinical practice effectively. They aimed to examine the impact of three dissemination strategies—printed educational material (PEM), e-learning (EL), and blended learning (BL) – on enhancing physicians' and psychotherapists' knowledge and capacities related to implementing NSSI guideline recommendations. This study was part of the cooperative project STAR (Self-injury: Treatment, Assessment, Recovery), funded by the German Federal Ministry of Education and Research. 

The authors recruit a total of 671 physicians and psychotherapists between August 2018 and August 2020 through an online survey. Their quasi-experimental study involves three measurement points (T1: pre-training, T2: post-training, and T3: 3-month follow-up), with data collected pseudonymously via online questionnaires, each requiring approximately 30 minutes to complete. The PEM (printed educational material) was a 60-page A5 brochure summarizing NSSI guidelines across four key topics, including a brief on Therapeutic Assessment (TA), a cognitive-analytic therapy-based intervention, and was accredited with 2 CME points. TA involved constructing a vicious cycle diagram, identifying exits, and drafting an understanding letter, which has been shown to improve the quality of self-harm assessments. The e-learning (EL) module provided texts, videos, case exercises, and worksheet templates for therapy, featuring a more interactive TA practice; it required approximately 7.5 hours to complete and was accredited with 18 CME points. The blended learning (BL) condition was similar to EL but included a 3.5-hour face-to-face TA workshop with role-play exercises and group discussions, increasing the total processing time to 9 hours, and was also accredited with 18 CME points. 

The team uses a 15-question multiple-choice test and 5-point Likert scales for assessments. At T3, they evaluated participants on their application of the short intervention ‘Therapeutic Assessment,’ included in all trainings, while user satisfaction and training evaluations were conducted at T2. They use descriptive statistics and linear mixed-effects models with fixed factors (training type, time, and their interaction) to analyze differences across the three training conditions over time for primary outcomes, including NSSI knowledge, competencies, treatment effectiveness attitudes, and attitudes toward NSSI and those who self-injure. 
They report that majority of the sample was female, the average age was M(SD) = 43.80 (9.25) years. Most of the participants worked as psychotherapists. The printed educational material (PEM) condition showed the least improvement in scores for ‘negative attitudes toward NSSI and those who self-injure.’ Participants in the PEM, EL, and BL groups did not significantly differ in the frequency of applying Therapeutic Assessment (TA), with high ratings of its helpfulness across all training types. The blended-learning condition reported the highest application rate of intervention techniques in clinical practice. Overall, user satisfaction was high for all three training strategies, with PEM receiving the lowest and BL the highest evaluations for training quality. 

The authors highlight the study's strengths, including the direct comparison of dissemination strategies, innovative training formats (EL and BL), a large sample size, and a multiple-assessment design with a 3-month follow-up. They also acknowledge limitations, including limited generalizability due to the self-selected sample with prior NSSI knowledge, biased randomization based on participant preferences, a high dropout rate in the BL group affecting result validity, and the use of unvalidated questionnaires relying on self-reports. They conclude that future research should compare different training strategies, particularly in light of COVID-19’s impact on education. They suggest exploring synchronous online workshops with role-plays to replace in-person workshops and recommend including objective outcome data to assess changes in professionals' practices and patient outcomes. 
 

Sweder et al., (2024) emphasize the role of parents in raising children who can self-advocate while discussing the need for parental support for the well-being of LGBTQIA + youth. This aimed to explore how parents of nonbinary children ages 5–8 learn to support their child’s identity, examining initial reactions, emotional processes, supportive behaviors, societal responses, and associated challenges and rewards. 

A qualitative study was conducted using Reflexive Thematic Analysis (RTA) within a paradigmatic framework of ontological relativism and epistemological constructivism. They conduct semi-structured interviews (10 predetermined questions) of nine parents of nonbinary children aged 5–8 from the Northeastern United States lasting 60–80 min. The questions explore various aspects of parenting nonbinary children, including the child’s gender identity, parental feelings, experiences sharing the child’s identity, and challenges and rewards of raising a gender-diverse child. The research team, comprising individuals who identify as trans, genderqueer, and nonbinary, employ collaborative coding and thematic development. 

The team constructs four themes that emerged from the accounts of participating parents. The first theme, Parents hear and support their child’s nonbinary identity, details how children share their nonbinary identity with their parents and documents parents’ initial reactions and meaning-making processes. The second theme, Parents learn about ways cisnormative society harms their child, captures how parents learn about the struggles their child faces living in a cisnormative society as a nonbinary person. The third theme, Parents take significant and proactive steps to affirm their child, documents participants taking action to support their child in environments that do not validate their gender identity. The fourth and final theme, Gender is just one aspect of who my child is, discusses insights and conclusions drawn by parents about their child, as well as gender identity. 

The authors mention that their study provides insights into the experiences of parents supporting young nonbinary children, emphasizing the importance of affirming expressed identity, the parent-child relationship, and proactive support in navigating cisnormative societal structures. They conclude that their findings can inform supportive interventions and policies for nonbinary children and their families. 
 

REFERENCES:  

• Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., Holland, F., Kelvin, R., Midgley, N., Roberts, C., Senior, R., Target, M., Widmer, B., Wilkinson, P., & Fonagy, P. (2017). Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial. Health technology assessment (Winchester, England), 21(12), 1–94. https://doi.org/10.3310/hta21120.  
   
• Koenig, E., Hoffmann, U., Fegert, J.M. et al. Training approaches for the dissemination of clinical guidelines for NSSI: a quasi-experimental trial. Child Adolesc Psychiatry Ment Health 18, 99 (2024). https://doi.org/10.1186/s13034-024-00789-x.  
   
• Santesson, A.H.E., Holmberg, R., Bäckström, M. et al. Multilevel barriers to guideline implementation: a nationwide multi-professional cross-sectional study within child and adolescent psychiatry. Child Adolesc Psychiatry Ment Health 18, 115 (2024). https://doi.org/10.1186/s13034-024-00803-2.  
   
• Sweder, N., Garcia, L. & Salinas-Quiroz, F. “I’m trying to take the lead from my child”: experiences Parenting Young Nonbinary Children. Child Adolesc Psychiatry Ment Health18, 117 (2024). https://doi.org/10.1186/s13034-024-00807-y.  
   

IACAPAP Bulletin, Issue 76