Title: Personalised assessment and intervention packages for children with conduct problems in child mental health services
Funder: Department of Health and Social Care

Abstract: Aim The overarching aim is to develop an improved treatment for conduct problems in young children that can be readily implemented in the NHS. Objectives 1) Identify key features of children and parents with conduct problems who respond differentuially to parent training. 2) Identify groups with good and poor outcomes from standard parent training for qualitative study, and identify predictors of outcome to improve the efficiency of the proposed randomized controlled trial. 3) Conduct a large qualitative study with parents to identify processes associated with high and low participation in parent training groups, and with good and poor treatment outcomes. 4) Work with parents to develop a new personalized treatment approach for conduct problems. 5) Test the feasibility of the approach. 6) Conduct an internal pilot, and, conditional on success, a full scale RCT, to compare the personalized approach with standard, evidence based group parenting training. Background and Rationale Conduct problems in young children commonly endure and are associated with poor outcomes in adult life. Early treatment is essential. Group parent training programmes have proven effectiveness but also substantial drop out and failure rates. It is crucial to develop a new generation of treatments and there is a strong case for using ideographic approaches to understanding the processes, and for establishing approaches to treatment that take account of diverse needs. Hence we propose a programme to make use of quantitative indices of heterogeneity, alongside qualitative methods, as a basis for personalized treatment. Research Plan Work stream 1 (WS1) &ndash; systematic review of treatments for sub-groups of children and parents who differentially respond to parent training.. Work stream 2 (WS2) &ndash; prospective study of parent training for parents of 160 children referred with conduct problems followed up at 3 and 6 months. Baseline and follow up assessments will include the Parent Account of Child Symptoms (PACS) a standard interview measure of conduct problems and poor outcome will be defined as 0.4s.d change or lower. This will establish 3 groups for qualitative study, i) 20 parents of children with a good outcome ii) 20 parents who either did not attend any training sessions or who dropped out, iii) 20 parents who attended but whose children did not improve. Economic hardship, parental depression, high callous unemotional traits, marital discord or single parent status, and parental hostility will be examined in logistic regression as predictors of outcome as a basis for creating a screening tool for the RCT. Work stream 3 (WS3) &ndash; qualitative study with parents in the 3 groups identified in WS2. Interviews will invite parents accounts of their experience of parent training and explore the reasons for the various outcomes and parents perception of the possible role of factors identified quantitatively in WS2. Work stream 4 (WS4) - will work with parents identified from WS2 and WS3, to develop a personalized approach to treatment. The outcome will be a treatment manual for the personalized approach, a training programme, and a set of criteria for judging fidelity. Work stream 5 (WS5) &ndash; feasibility study of the personalized approach with nine CYP-IAPT staff each working with 5 children. Work streams 6 and 7 (WS6, WS7) &ndash; internal pilot and, if successful, full scale RCT to compare the personalized approach with standard parent training. From an initial sample of the parents of 150 children the screening procedure devised in WS2 will be used to generate a sample of 90 for randomization and follow up at 3, 6, and 9 months using the same baseline predictors and follow up measures as in WS2. If the pilot supports the feasibility we will proceed to the full scale RCT to generate a total sample of 450 yielding, after screening, 270 for randomization. The primary outcome measure will be the conduct problems score of the PACS. The screen increases the statistical power of the sample by omitting parents of children likely to do well with standard treatment, and we predict the sample will provide 80% power to detect an effect size of 0.35, at p = .05. Economic evaluation - the costs of the two treatments will be compared using a standard net benefit approach. Projected outputs and dissemination Publication in high quality peer reviewed journals will be the priority to ensure rigorous scrutiny of the findings. If the personalized approach is superior we will seek to make it widely available in the NHS through CYP-IAPT, and will present findings to a wide range of health professionals. Benefits to patients and the NHS The long term outlook for children with conduct problems will be improved, with less suffering, better functioning, and greater mental health. The personalized approach will greatly increase the ability of the NHS to reach children not helped by current approaches, with the potential that this is at no added cost leading to substantial economic gains.

Lay abstract: About half of those pre-school children who regularly hit other children or disobey rules have long-term problems in many areas of their lives. The NHS has invested in early treatment through parent training delivered in groups. These training sessions are helpful for some parents and carers, but not all, and many children still have behaviour problems after their parents have attended the training. In this programme we will work with parents to develop something new that is tailored to the parents and children s needs (personalised), and then find out whether this works better than current parent training. This work will be carried out by leading researchers and practitioners in child behaviour problems and parenting. First, we will assess some key features of 160 parents (e.g. whether they suffer from depression) and children (e.g. how responsive they are to other children s distress), and follow their journey through parent training groups. We will carry out in-depth interviews both with parents who completed the training and those who did not, including those whose children did or did not respond. The interviews will find out about parents experience of the training and their views on their own and their child s characteristics. With parents who felt things went well we will ask why they thought that was so. Where it did not go so well we will explore what might have been more helpful. The information will help us predict the likely success or failure of the group approach. The research team will also use that information to work with parents and their children to produce a new personalised treatment, write a manual, and train therapists working in the NHS in the approach. The personalised package will be different for each parent and, drawing on evidence from research and the parent s own wishes, may include individual parenting work, help with parental distress, work with the parent and child together, individual work with the child and also practical help with things like transport and finances. We will then try out the personalised approach with 30 children with behaviour problems and their parents to refine the approach and to make sure it can be compared with current parent training in a bigger study. If that is successful we will go on to find out in a large trial whether the personalised treatment is better than parent training groups at improving children s behaviour and wellbeing. The new approach will be among the first of a new generation of personalised treatments that bring together evidence about what treatments work with service users wishes and choices. It has the potential to improve parents wellbeing and many children s lives, including vulnerable children s chances of making a productive, satisfying contribution to society.

Research activity codes: 5.6 PSYCHOLOGICAL AND BEHAVIOURAL;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH