Kapil Sayal

Background: Attention deficit hyperactivity disorder (ADHD) is more commonly missed in females than males, partly because the diagnostic criteria may not fully capture the female presentation. This study aimed to qualitatively identify difficulties experienced by females with ADHD, especially those beyond the current diagnostic criteria, from the perspective of parents/carers and professionals. Method: Seven focus groups were conducted in the UK in 2023: three with parents/carers, two with healthcare professionals, and two with educational professionals, involving a total of 35 individuals. Participants were asked to describe their experiences of supporting girls with ADHD. Data were analysed using the framework method. Results: Four themes were identified: (1) attention regulation difficulties and their social impact, (2) hyperactivity and impulsivity manifest more verbally and subtly, (3) prominent difficulties with emotional impulsivity and regulation and (4) difficulties are more obvious at home than at school. Conclusion: Female ADHD might be missed as difficulties are less externally disruptive and more emotional than the current ADHD diagnostic criteria. Additionally, females may engage in masking behaviours. Improving current ADHD diagnostic assessments and criteria to reflect this presentation would benefit diagnostic inequalities and access to care for females with ADHD.

Background: Minoritised ethnic families in England experience disproportionate barriers to accessing neurodevelopmental disorder (NDD) assessment and support despite universal healthcare provision. Existing evidence has focused on caregivers’ perspectives or non-UK settings but little is known about how healthcare professionals (HCPs) perceive and interpret these inequities. Addressing this gap is essential for improving access, service design and workforce development. Objective: To explore HCPs’ perceptions of the barriers and facilitators influencing minoritised ethnic families’ access to NDD services in England. Methods: A multiple methods design was used, comprising an online national survey (n=264) and two online focus groups with primary, secondary and allied health professionals (n=9). Survey data were summarised descriptively and free text responses analysed using summative content analysis. Focus group transcripts underwent reflexive thematic analysis. Findings were summarised following parallel analysis of each data set. Patient and public involvement and engagement members from minoritised ethnic backgrounds contributed throughout. Findings: HCPs identified four interconnected barriers they perceived to influence access for minoritised ethnic families: (1) language, communication and meaning-making challenges, including differences in how concepts and expressions are understood, inconsistent interpretation and limited mental health literacy; (2) difficulties navigating complex, fragmented NDD pathways, exacerbated by digital literacy demands and unclear referral routes; (3) limited caregiver knowledge and understanding of NDDs, affecting symptom recognition and the ability to advocate effectively and (4) cultural norms, beliefs and stigma, including preferences for non-Western models of care, fear of diagnostic labels and the influence of extended family. Professionals also highlighted the impact of unconscious bias and limited cultural representation within services on referral decision-making and caregiver engagement. HCPs described several effective strategies for mitigating these barriers, such as culturally attuned communication, community-based engagement and flexible assessment approaches. Conclusions: Inequitable access to NDD services arises from the interaction of cultural, relational and structural factors across the healthcare pathway. HCPs’ insights reveal multiple entry points for improving equity, particularly through communication support, culturally responsive practice and simplified referral processes. Clinical implications: Embedding culturally informed communication, improving caregiver education, strengthening workforce diversity and coproducing service changes with communities may reduce avoidable delays and promote equitable access to neurodevelopmental assessment and support.

Background: Young peoples’ mental health is worsening, increasing demands on Child and Adolescent Mental Health Services (CAMHS) crisis teams. However, evidence is lacking regarding the effectiveness of such services. To pave the way for service developments and robust evaluation, it is crucial to establish a consensus on the core competencies for CAMHS crisis clinicians and the most desirable outcomes from their input. Objective: To elicit and establish consensus among experts, including those with relevant lived experience, regarding the most important staff competencies and outcomes in this service context. Methods: A three-round Delphi study was conducted with young people (aged 18–25 years with relevant lived experience of CAMHS crisis team input), parents/carers and mental health clinicians/academics. The study aimed to establish consensus (≥70% agreement) on which core staff competencies and outcomes were perceived as ‘essential’/‘very important’ in relation to CAMHS crisis services. Findings: Of 69 initial participants, 43 (62%, mainly young people) completed all three rounds. A broad consensus was reached, with over 90% of proposed items meeting the consensus threshold. The strongest agreement was found for competencies in the therapeutic alliance domain, particularly cultural competency (93%) and validation (91%). For the case formulation domain, a holistic mental state examination (91%) was highly prioritised. Key outcomes with high consensus included improved communication with support networks (91%), better understanding of the young person (88%), feeling validated (88%) and reduced involuntary inpatient admissions (88%). The findings were integrated into a Theory of Change-based logic model illustrating how these skills and knowledge could lead to the desired outcomes. Conclusions: Our results demonstrate a clear stakeholder consensus prioritising relational, validating and personalised approaches to assessment and intervention over an emphasis on administrative or diagnostic processes in CAMHS crisis care. The findings also highlight a desire to move from a perception of a paternalistic risk management style to collaborative, community-based support. Clinical implications: These findings underscore the need for crisis team clinicians to be trained and supported to deliver care that is relationship-based, trauma-informed and culturally responsive. These should potentially translate into better outcomes for young people, their families and the crisis team workforce itself.

Background: Many children and young people (CYP) with significant mental health difficulties face barriers to accessing care from mental health services, impacting their clinical outcomes and recovery. Sociodemographic and socioeconomic factors may contribute to inequalities in access and outcomes. Aims: To investigate the roles of sociodemographic, socioeconomic and clinical factors in influencing access to services, receipt of clinical care or diagnoses and clinical outcomes. Method: Using data from a large, nationally representative, randomised controlled trial in England (STADIA), 1225 children aged 5–17 years and with emotional difficulties referred to child and adolescent mental health services (CAMHS) were followed up over 18 months post-referral to investigate predictors of referral acceptance, receipt of care and their clinical outcomes. Results: Older CYP (for each 1-year increase in age, odds ratio 1.07, 95% CI: 1.02, 1.11) and those living in the least deprived neighbourhoods (deprivation index, least versus most deprived quintile: odds ratio 1.60, 95% CI: 1.05, 2.43) were more likely to have their referral accepted by CAMHS. Clinical severity (i.e. scoring above cut-off for symptoms and/or impact) was not associated with receipt of a clinical diagnosis or treatment/intervention. At 12-month post-referral, 61% met mental health ‘caseness’ criteria ( v . 67% at baseline). CYP living in less deprived neighbourhoods had better clinical outcomes at 12-month follow-up (least versus most deprived quintile: odds ratio 0.49, 95% CI: 0.30, 0.81, for meeting caseness criteria, i.e. the presence of clinically significant symptoms and impairment). Females were more likely than males to have clinically significant levels of depression at 12-month follow-up (odds ratio 1.77, 95% CI: 1.28, 2.45). Conclusions: There appear to be sociodemographic and socioeconomic inequalities in access to care and outcomes for clinically referred CYP with emotional mental health difficulties, with limited improvements in clinical outcomes 1 year following referral to CAMHS. CYP living in more deprived areas and younger children appear less likely to receive help, hampering earlier intervention efforts even in help-seeking populations.

Background: Females are less likely than males to be diagnosed with attention–deficit hyperactivity disorder (ADHD). When diagnosed, females are older than males. Aims: In this study, we examined the childhood antecedents of later ADHD diagnosis and its impact on adolescent/emerging adult outcomes, with a focus on females. Method: In this cohort study, we used data from a Welsh nation-wide electronic cohort of 13 593 individuals ( n = 2680 (19.7%) females) diagnosed with ADHD and 578 793 individuals ( n = 286 734 (49.5%) females) without ADHD. We compared females with later diagnoses (ages 12–25) to those with earlier, timely diagnoses (ages 5–11) and no diagnosis, in terms of childhood (ages 5–11) antecedents and adolescent/adult (ages 12–25) outcomes. We also tested for sex differences. Results: Although females with earlier ADHD diagnosis showed more health and educational difficulties in childhood than those with later diagnosed ADHD (odds ratios ranged from 0.18 to 0.92), there was clear evidence of these difficulties in females with later diagnosed ADHD, compared with females without ADHD (odds ratios: 1.07–9.02). In adolescence/early adulthood, females with later diagnosed ADHD used more healthcare services and had worse mental health, educational and socioeconomic outcomes than females diagnosed earlier (odds ratios: 1.39–4.96) and those without ADHD (odds ratios: 1.54–23.98). Many of these outcomes were exacerbated in females compared with males. Conclusions: The results demonstrate that later ADHD diagnosis is associated with significant negative outcomes by adolescence and disproportionately disadvantages females. Despite later diagnosis, there was clear evidence of childhood mental health and educational difficulties when compared with females without ADHD. Therefore, timely childhood ADHD diagnosis may help to mitigate later risks, especially for females.

Summary: When thoroughly assessed, the prevalence of attention-deficit hyperactivity disorder (ADHD) in children/adolescents is estimated at 5%. There is no evidence that ADHD is over-diagnosed in the UK. Indeed, available data point to under-diagnosis, even though rigorous updated post-COVID-19 pandemic data are not available. Some cases may be misdiagnosed due to low-quality assessment, poor adherence to national guidance or inappropriate differential diagnosis. Beyond the controversy around over- or under-diagnosis and over-medicalisation of ordinary behaviours or emotions, the main issue is that UK clinical services cannot adequately support individuals with ADHD who need help. There is a risk that the narrative claiming ‘ADHD is over-diagnosed’ could be used to deny people with properly-diagnosed ADHD the care they deserve.

Background: There are substantial age‐related changes in emotional and behavioural problems over childhood. In order to establish the impact of the Covid‐19 pandemic on child emotional and behavioural problems, longitudinal designs which take into account age‐related trends are needed. This study examined trajectories of children's emotional and behavioural difficulties both before and during the pandemic in a prospective birth cohort. Methods: Data were from 708 children from the third generation of a birth cohort study; the Avon Longitudinal Study of Parents and Children in England. The study population comprised of 708 children (median age at COVID data collection was 2.75 years [interquartile range 0.8, 4.4]) whose parents provided pre‐pandemic surveys and a survey between 26 May and 5 July 2020. Multi‐level mixed effects models with random intercepts and slopes examined whether children's trajectories of emotional and behavioural difficulties during the pandemic differ from those expected pre‐pandemic. Results: Children's emotional and behavioural difficulties trajectories pre‐pandemic increased during infancy peaking around the age of 2 and then declined throughout the rest of childhood. Pre‐pandemic, decline in difficulties scores after age 2 was 0.6 points per month; but reduced by 35% during the pandemic. This slower decline in scores translated to older children having difficulty scores higher than would be expected, during the pandemic. By age 8.5, there is a 9.5‐point difference in pre‐ and during‐pandemic scores (95% CI: 4.5–14.5). This represents an average 48% increase from scores expected at this age (pre‐pandemic mean score = 20; 95% CI: [15–25]). Results remained similar although somewhat attenuated after adjusting for parental anxiety. Conclusion: The COVID‐19 pandemic may be associated with greater persistence of emotional and behavioural difficulties after the age of 2 years.

Background: Emotional disorders are common in children and young people and can significantly impair their quality of life. Evidence-based treatments require a timely and appropriate diagnosis. The utility of standardised diagnostic assessment tools may aid the detection of emotional disorders, but there is limited evidence of their clinical value. Objectives: To assess the clinical effectiveness and cost effectiveness of a standardised diagnostic assessment for children and young people with emotional difficulties referred to Child and Adolescent Mental Health Services. A nested qualitative process evaluation aimed to identify the barriers and facilitators to using a standardised diagnostic assessment tool in Child and Adolescent Mental Health Services. Design: A United Kingdom, multicentre, two-arm, parallel-group randomised controlled trial with a nested qualitative process evaluation. Setting: Eight National Health Service Trusts providing multidisciplinary specialist Child and Adolescent Mental Health Services. Participants: Children and young people aged 5–17 years with emotional difficulties referred to Child and Adolescent Mental Health Services, excluding emergency/urgent referrals that required an expedited assessment. In the qualitative process evaluation, 15 young people aged 16–17 years, 38 parents/carers and 56 healthcare professionals participated in semistructured interviews. Interventions: Participants were randomly assigned (1 : 1) following referral receipt to intervention (the development and well-being assessment) and usual care, or usual care only. Main outcome measures: Primary outcome was a clinician-made diagnosis decision about the presence of an emotional disorder within 12 months of randomisation, collected from Child and Adolescent Mental Health Services clinical records. Secondary outcomes collected from clinical records included referral acceptance, time to offer and start treatment/interventions and discharge. Data were also self-reported from participants through online questionnaires at baseline, 6 and 12 months post randomisation, and the cost effectiveness of the intervention was investigated. Results: One thousand two hundred and twenty-five (1225) children and young people were randomly assigned (1 : 1) to study groups between 27 August 2019 and 17 October 2021; 615 were assigned to the intervention and 610 were assigned to the control group. Adherence to the intervention (full/partial completion of the development and well-being assessment) was 80% (494/615). At 12 months, 68 (11%) participants in the intervention group received an emotional disorder diagnosis versus 72 (12%) in the control group [adjusted risk ratio 0.94 (95% confidence interval 0.70 to 1.28); p = 0.71]. Child and Adolescent Mental Health Services acceptance of the index referral [intervention 277 (45%) vs. control 262 (43%); risk ratio: 1.06 (95% confidence interval: 0.94 to 1.19)] or any referral by 18 months [intervention 374 (61%) vs. control 352 (58%); risk ratio: 1.06 (95% confidence interval: 0.97 to 1.16)] was similar between groups. There was no evidence of any differences between groups for any other secondary outcomes. The qualitative nested process evaluation identified a number of barriers and facilitators to the use of the development and well-being assessment during the trial, particularly at the assessment and diagnosis stages of the Child and Adolescent Mental Health Services pathway. Limitations: It was not possible to mask participants, clinicians or site researchers collecting source data to treatment allocation. Conclusions: We found no evidence that completion of the development and well-being assessment aided the detection of emotional disorders in this study. Using the development and well-being assessment in this way cannot be recommended for clinical practice. Future research: To determine longer-term service use outcomes and to investigate whether receipt of a clinical diagnosis makes a difference to clinical outcomes and care/intervention receipt. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 16/96/09.