Title: Relationships in Good Hands Trial: clinical and cost-effectiveness of Dyadic Developmental Psychotherapy for abused and neglected young children with maltreatment-associated problems and their parents
Funder: Chief Scientist Office, Scotland

Abstract: Our questions are: Can we recommend better ways for social care and health services to work work together to help adoptive and foster families? Can a therapy called DDP improve the mental health of 5-12 year old fostered or adopted children? Is DDP worth the commitment families need to give to it - and the extra cost to the services that deliver it? _x000D_ _x000D_ Why is this important? Nearly all adopted or fostered children in the UK have been abused and neglected. More than half have mental health problems including ADHD (i.e. hyperactivity, impulsive behaviour and poor concentration), antisocial behaviour and problems with relationships. Abused and neglected children are more likely than others to have problems in school, become homeless, get involved in crime and even die young (e.g. from suicide), yet we have no fully tested treatments for their complex mental health problems. This is a huge problem because early treatment could greatly improve their life chances - and reduce strain on health and social care budgets. Dyadic Developmental Psychotherapy (DDP) is a parent-child therapy that takes around 20 sessions and focusses on “Playfulness, Acceptance, Curiosity and Empathy”. We don’t yet have really good evidence for or against it: many UK therapists like DDP, but it is a big commitment for families: once a week for about six months children will need time off school, their parents will need time off work - and this can be hard to explain to school friends, colleagues and bosses. We don’t just need to know if DDP improves children’s mental health – we also need to know if the commitment needed is worth it for families and whether the costs to services outweigh the benefits. _x000D_ _x000D_ How do we plan to do this? In PHASE 1 (9 months) we will find out whether DDP can work smoothly in the three different settings where it is usually delivered: the NHS, Social Care and Private Practice. Many abused children need other medical and psychiatric support so, before including an area in the next phase of the study, we will assess whether children can get any additional assessments or referrals they might need. We will use in-depth interviews with therapists and service managers linked to DDP and usual services to make this judgement. In PHASE 2 (17 months), we plan to find out if it is practically possible to run a high quality trial of DDP. This phase will involve 60 families to find out if they are happy to take part (whether offered DDP or usual services) and make sure everything works well. If all goes to plan, these 60 families will contribute to the final results, along with the 120 families involved in the next phase. In PHASE 3 (27 months) we will test whether DDP is better than usual services and, if it is, whether the improvements in child mental health outweigh the costs. _x000D_ Adoptive parents, foster carers and young people who have been in care as well as Health and Social Care Commissioners have advised us and will continue to do so throughout the study. _x000D_ _x000D_ What impact will the research have? NICE Guidelines say abused and neglected children need help from health AND social care but, in practice, families often bounce around services without getting what they need. This study will make recommendations about how services should work together to help abused and neglected children and their families. If we find that DDP is worth the time and money, it could improve the mental health of abused and neglected children across the world.

Lay abstract: Research Questions: Within three contrasting service contexts (NHS, Social Care, Private Practice), what is the clinical and cost-effectiveness of an intensive therapy (DDP) for improving mental health in abused and neglected children?_x000D_ _x000D_ Background: 92,000 UK children are in care or adopted, nearly all have been abused and neglected and > 50% have psychiatric problems – often complex difficulties with genetic and environmental underpinnings. These maltreatment-associated psychiatric problems (MAPP) can include ADHD, Conduct Disorder, PTSD and Attachment Disorders. Maltreated children are at high lifetime risk of educational difficulties, homelessness, crime and premature mortality, yet a systematic review has found no evidence-based treatments for MAPP. Successful early intervention could greatly impact lifetime prospects – as well as UK health and social care budgets. DDP is a parent-child therapy taking around 20 sessions, focusing on “Playfulness, Acceptance, Curiosity and Empathy”. It is UK practitioners’ preferred treatment for MAPP, but requires weekly commitment for around 6 months from children and families. NICE has recommended a randomised controlled trial of DDP. _x000D_ _x000D_ Methods and timelines for delivery: _x000D_ PHASE 1 (9 months, cost £388,710) will optimise DDP and care pathways in the service contexts in which DDP is delivered: NHS, Social Care and Private Practice. We will conduct 24-36 qualitative interviews/focus groups with therapists and managers linked to DDP and services as usual (SAU) in each site, feeding into early stage economic modelling. If a site can deliver adequate assessment and pathways of referral to any additional services that children need, that site will be included in Phase 2. _x000D_ _x000D_ PHASE 2 (17 months, cost £653,549) will be a feasibility randomised controlled trial within the three contexts. Outcomes include acceptability of clinical and economic data collection methods, trial processes and recruitment/retention rates for DDP and SAU. _x000D_ _x000D_ PHASE 3 (27 months, cost £1,152,488) will be a definitive randomised controlled trial examining clinical and cost-effectiveness of DDP for improving child mental health, compared to SAU. The principle outcome will be child mental health at 12 months post randomisation. _x000D_ _x000D_ Adoptive parents, foster carers, care experienced young people, Health and Social Care Commissioners have advised us on study design and, with our Trial Steering Committee, will do so throughout._x000D_ _x000D_ Anticipated impact and dissemination: NICE Guidelines recommend that abused and neglected children need services from health AND social care but, in practice, families often ricochet around an incoherent service landscape, using resources to little effect. Workable multi-agency service models would be a major advance in improving care for children with MAPP, regardless of trial outcome. If DDP is cost-effective, the study could have a major impact on abused and neglected children, their families and on society by allowing the first evidence-based treatment for children with MAPP to be implemented in the UK and beyond. By updating NICE Guidelines and directly lobbying service leaders, the families, young people and Commissioners involved will help us ensure dissemination goes beyond traditional conferences and high profile papers to translate quickly into an effective multi-agency service to benefit our most vulnerable children and families.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH