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Childhood family adversity is associated with increased risk of developing mental health problems over the life course. We investigated how perceived emotional support in adolescence may mitigate the impact of childhood family adversity on adolescent mental health. We used longitudinal data from the UK Millennium Cohort Study on 9,269 children followed to age 17 years. Individuals were assigned to exposure trajectories characterised using group-based trajectory models that included measures of poverty and family dynamics up to age 14 years. Using counterfactual causal mediation analysis and four-way decomposition modelling approach, we evaluated how perceived emotional support at age 14 (measured using the three-item Short Social Provisions Scale) influences the association of childhood family adversity trajectories on mental health at ages 14 and 17, assessing the relative contributions of mediation and interaction simultaneously. Compared with children experiencing low family adversity and poverty, those exposed to childhood family adversity were almost three times more likely to experience poor mental health (RR 2·99, 95% CI 2 ·41 to 3·57) at age 14 and age 17 (RR 2·58, 95% CI 2·09 to 3·06). Perceived emotional support mitigates up to 18% (95% CI: 9% to 26%) of this effect at age 14, and 13% (95% CI: 5% to 22%) at age 17, mainly due to interactive mechanisms. Childhood family adversity has a strong effect on mental health, which is partially mitigated by emotional support in adolescence. Policies that support positive family functioning may be particularly beneficial for children who have experienced adversity.

Young people in state care, often due to abuse or neglect, have a four-fold increased risk of drug and alcohol use compared to their peers. The SOLID study aimed to investigate the feasibility of a definitive randomised controlled trial, comparing two behaviour change interventions to reduce risky substance use (illicit drugs and alcohol), and improve mental health, in young people in care. We recruited young people in care aged 12-20 years, self-reporting substance use within the previous 12 months and residing in 1 of 6 participating local authority sites in the North East of England. Participants were randomised to either i. Motivational Enhancement Therapy (MET), ii. Social Behaviour and Network Therapy (SBNT) or iii. Control (usual care). All interventions were delivered by trained drug and alcohol workers. Follow-up data were collected 12 months post recruitment. Feasibility for trial progression was compared to pre-specified stop: go criteria (recruitment of 60% of eligible participants, 80% of participants attending 60% of offered sessions and retention of 70% of participants at 12 month follow up). Of 1450 eligible participants, 860 (59%) were screened for drug and alcohol use by social workers, 211 (24.5%) met inclusion criteria for the trial and 112 young people (7.7%) consented and were randomised. Sixty of these 112 participants (54%) completed 12-month follow-up questionnaires. Only 15 out of the 76 (20%) participants allocated to an intervention arm attended any of the offered MET or SBNT sessions. By reference to pre-specified stop: go criteria it is not feasible to conduct a definitive trial for SOLID in its current format. Despite co-designing procedures with staff and young people in care, the screening, referral and treatment pathway did not work here. Future work may require dedicated clinically embedded research resource to evaluate effectiveness of new interventions in services.

Background Children and young people (CYP) in contact with child welfare services are at high risk of developing mental health problems. There is a paucity of evidenced-based preventative interventions provided to this population. Objective This project worked in partnership with CYP, their parents/caregivers and the professionals who support them to co-produce a preventative mental health intervention for CYP in contact with child welfare services. Participants and setting We recruited a purposive sample of CYP in contact with child welfare services ( n  = 23), parents/caregivers ( n  = 18) and practitioners working within child welfare services and mental health services ( n  = 25) from the North East of England and convened co-production workshops ( n  = 4). Methods This project followed the established principles for intervention development, applying the six steps to quality intervention development (6SQUID) approach. The mixed method research consisted of four work packages with continuous engagement of stakeholders throughout the project. These were: a systematic review of reviews; focus groups with practitioners; interviews with parents/caregivers and CYP; co-production workshops. Results We identified that the primary risk factor affecting CYP in contact with child welfare services is the experience of childhood adversity. The quality of relationships that the CYP experiences with both their parent/caregivers and the professionals involved in their care are considered to be the main factors amenable to change. Conclusions We found that a trauma-informed, activity-based intervention with an embedded family-focused component provided to CYP who have experienced adversity is most likely to prevent mental health problems in those in contact with child welfare services.

Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions. Current Controlled Trials ISRCTN 93681536.

Care-experienced young people (CEYP) have higher rates of PTSD than their peers; however, their post-traumatic stress disorder (PTSD) symptoms are often missed. The Child Revised Impact of Events Scale (8 items; CRIES-8) is a well-validated and widely available screening tool, which could identify children at risk of PTSD. This project aimed to understand barriers and facilitators for the use of the CRIES-8 with CEYP accessing mental health services, as a means of increasing their access to evidence-based support. We recruited 243 mental health professionals from 28 mental health teams across England and provided training in the CRIES-8 and cognitive therapy for PTSD. Focus groups and interviews were conducted approximately every three months for 12-18 months, as well as a brief one-off questionnaire about implementation completed 6-9 months post-training. Qualitative data were analysed via thematic analysis. While 80% of the sample did use the CRIES-8, only 50% used it with CEYP, and overall use was sporadic and inconsistent. The main barriers included capacity, CEYP access to mental health services, and professionals' beliefs around diagnoses and routine outcome measures, particularly for CEYP. Flexibility and proactivity amongst the team were important facilitators. In practice, there were a variety of methods to implement the CRIES-8, each with a different impact on service resources and the young person completing it. Further service-based research to develop and test methods to address the identified barriers is essential to ensure that CEYP receive access to best-evidenced, needs-matched treatments.

Background Looked after children and care leavers have an increased risk of drug and alcohol use compared to their non-LAC peers. Despite high prevalence rates within this population, looked after children are reported to show low levels of engagement in services resulting in unmet needs emerging from substance use. This paper reports on the initial formative phase of a pilot feasibility randomised controlled trial; SOLID ( S upp o rting L ooked After Children and Care Leavers I n D ecreasing Drugs, and Alcohol) that aimed to adapt two evidence-based psychosocial interventions, Motivational Enhancement Therapy and Social Behaviour and Network Therapy, which will aim to reduce substance misuse by looked after children. Methods We conducted qualitative semi-structured interviews and focus groups with 19 looked after children aged 12 to 20 years old, 16 carers and 14 professionals across four local authorities in the North East of England. The data gathered were analysed and then presented within co-production workshops inclusive of 13 young people and 14 professionals (drug and alcohol practitioners and social workers). Findings were used to adapt and refine the interventions prior to the trial. Results Overall findings suggested that whilst original components of both interventions were feasible to deliver and acceptable, specific process areas were highlighted including: increased emphasis upon therapeutic relationships, the benefits of using creative non-traditional methods of engagement and identification of treatment goals wider than those narrowly focused on substance misuse. Conclusion This paper provides an example of methods used to collect multiple perspectives to refine and co-develop interventions to reduce drug and alcohol use in the specific population of looked after children. Trial registration ISRCTN80786829 (first registered 06.06.2016- prospectively registered).

Children in care of the state are amongst the most disadvantaged in society. They have often experienced adverse childhood experiences leading to their care entry including abuse and neglect. Longitudinal data suggests problems children in care of the state experience within adolescence persist into adulthood, showing “a continuing legacy of adversity.” Emerging literature shows that edge of care interventions can bring about benefits. These interventions support families to meet their child’s needs and prevent, or reduce, the likelihood of children going into care. However, it is not clear how or why these interventions work. It is important to develop this understanding to inform the development of effective, theory-informed practice to benefit this population. We reviewed and synthesised published literature to expose mechanisms by which interventions may promote and support family preservation for children at the edge of care. Our synthesis uses a realist approach to examine mechanisms by which interventions, in various contexts, can promote and support family preservation for children at the edge of care. Previous work by the team shaped the initial search strategy and in line with RAMESES realist review guidelines, no restrictions were placed on the types of study to be included in the synthesis. From 7,530 potentially relevant references identified, 61 papers were included in final extraction. Extracted data was themed, prior to developing narrative and formulating programme theories. Effective edge of care service operation seemed to be based on four core programme theories pertaining to the need for family skills training, home-based delivery, dedicated worker, and rapid response to need.

Background Healthcare-based Independent Domestic Violence Advisors (hIDVA) are evidence-based programmes that provide emotional and practical support to service users experiencing domestic abuse. hIDVA programmes are found to improve health outcomes for service users and are increasingly delivered across a range of healthcare settings. However, it is unclear how hIDVA programmes are implemented across maternity services and the key facilitators and barriers to their implementation. The aim of this study was to identify; how many English National Health Service (NHS) Trusts with maternity services have a hIDVA programme; which departments within the Trust they operate in; what format, content, and variation in hIDVA programmes exist; and key facilitators and barriers of implementation in maternity services. Methods A national survey of safeguarding midwives (Midwives whose role specifically tasks them to protect pregnant women from harm including physical, emotional, sexual and financial harm and neglect) within all maternity services across England; descriptive statistics were used to summarise responses. A World Café event (a participatory method, which aims to create a café atmosphere to facilitate informal conversation) with 38 national key stakeholders to examine barriers and facilitators to hIDVA programme implementation. Results 86/124 Trusts (69%) with a maternity service responded to the survey; 59(69%) of respondents reported that they had a hIDVA programme, and 47(55%) of the hIDVA programmes operated within maternity services. Key facilitators to implementation of hIDVA programmes included training of NHS staff about the hIDVA role and regular communication between Trust staff and hIDVA staff; hIDVA staff working directly from the Trust; co-creation of hIDVA programmes with experts by experience; governance and middle- and senior-management support. Key barriers included hIDVA staff having a lack of access to a private space for their work, insecure funding for hIDVA programmes and issues with recruitment and retention of hIDVA staff. Conclusions Despite hIDVA programmes role in improving the health outcomes of service users experiencing domestic abuse, increased funding and staff training is needed to successfully implement hIDVA staff in maternity services. Integrated Care Board commissioning of acute and mental health trust services would benefit from ensuring hIDVA programmes and clinician DVA training are prioritised.

To explore adolescents' experiences of consenting to, and participating in, alcohol intervention trials when attending for emergency care. In-depth semi-structured interviews with 27 adolescents (16 males; aged 14-17 years (Mage = 15.7)) who had taken part in one of two linked brief alcohol intervention trials based in 10 accident and emergency departments in England. Interviews were transcribed verbatim and subject to thematic analysis. Research and intervention methods were generally found to be acceptable though confidentiality was important and parental presence could hinder truthful disclosures regarding alcohol use. Participants discussed the importance of being involved in research that was relevant to them and recognised alcohol consumption as a normative part of adolescence, highlighting the importance of having access to appropriate health information. Beyond this, they recognised the benefits and risks of trial participation for themselves and others with the majority showing a degree of altruism in considering longer term implications for others as well as themselves. Alcohol screening and intervention in emergency care is both acceptable and relevant to adolescents but acceptability is reliant on confidentiality being assured and may be inhibited by parental presence. ISRCTN Number: 45300218.

Background Clustering and co-occurring of family adversities, including mental health problems, substance use, domestic violence and abuse, as well as poverty can increase health and behavioural risks for children, which persist throughout the life course. Yet, interventions that acknowledge and account for the complex interactive nature of such risks are limited. This study aimed to develop intervention principles based on reflections from mothers, fathers, and young people who experience multiple and interacting adversities. These principles will show how family members perceive an intervention may bring about positive change and highlight key insights into design and delivery. Methods A series of six co-design workshops with mothers, fathers, and young people who experienced multiple and interacting adversities ( n  = 41) were iteratively conducted across two regions in England (London and North-East) by four researchers. Workshop content and co-design activities were informed by advisory groups. Data from facilitator notes and activities were analysed thematically, resulting in a set of intervention principles. Results The intervention principles highlighted that: (1) to reduce isolation and loneliness parents and young people wanted to be connected to services, resources, and peer support networks within their local community, particularly by a knowledgeable and friendly community worker; (2) to address feelings of being misunderstood, parents and young people wanted the development of specialised trauma informed training for practitioners and to have the space to build trusting, gradual, and non-stigmatising relationships with practitioners; and (3) to address the needs and strengths of individual family members, mothers, fathers, and young people wanted separate, tailored, and confidential support. Conclusions The current study has important implications for practice in supporting families that experience multiple and interacting adversities. The intervention principles from this study share common characteristics with other intervention models currently on offer in the United Kingdom, including social prescribing, but go beyond these to holistically consider the whole families’ needs, environments, and circumstances. There should be particular focus on the child’s as well as the mothers’ and fathers’ needs, independently of the family unit. Further refinement and piloting of the developing intervention are needed. Plain English summary Families can experience multiple difficulties. These difficulties include parental mental health problems, alcohol and drug use, domestic violence, and poverty. These difficulties can impact the wellbeing of both parents and children. Currently, support that is provided to families rarely accounts for these complex and multiple difficulties. This study aimed to gather insights from mothers, fathers, and young people about how to best support families who experience multiple difficulties at the same time. We ran six workshops with community groups of mothers, fathers, and young people from London and North East England. We learned that: (1) Parents and young people wanted to be connected to services, resources and peer support networks within their local community. (2) Parents and young people wanted to build trusting, gradual, and non-stigmatising relationships with practitioners. (3) Parents and young people wanted support that was personalised to their own needs and that focused on their strengths. This research contributes key ideas for supporting families, which will be used alongside other studies to develop new ways of supporting families. The next steps will be to complete and test the developing support model, by delivering it to families and measuring how well it works.