Perspectives on clinical guidelines for severe behavioural problems in children across Europe: a qualitative study with mental health clinicians

Abstract

Clinical guidelines for severe behavioural problems (SBPs) in children have recently been developed in several European countries. However, questions emerged regarding their applicability to practice. Our study aimed to provide a first European insight into guidelines' fitness-for-purpose by exploring mental health clinicians' familiarity with, use and perceived value of guidelines for SBPs in children. Participants included 161 clinicians, primarily psychiatrists, from 24 countries. Clinicians completed a semi-structured qualitative questionnaire on existing SBPs guidelines and development of new guidelines where not available. Clinicians' responses were mapped against academic experts' perceptions on SBPs guidelines highlighted in a previous study (Gatej et al. in Eur Psychiatry 57:1-9, 2019). Under half of the clinicians reported being unaware of guidelines. Of these, 37.6% represented countries where guidelines were available according to experts. The remaining half of clinicians who were aware of guidelines on average reported being moderately familiar with their content, perceiving them as moderately useful and using them some of the time. Additionally, 60.8% clinicians agreed that SBPs guidelines need to be developed, as these would create a shared scientific knowledge base and common practice. Guideline improvements included taking a multifactorial approach, creating specific case recommendations, and dissemination efforts. The modest familiarity with and use of guidelines amongst practitioners may highlight guidelines poor fitness-for-purpose, or, alternatively, an underlying confusion around the meaning and purpose of guidelines. Moving forward, efforts should be directed at disseminating clearer definitions of guidelines, addressing existing challenges, and unifying efforts to further develop and audit application of international guidelines for SBPs.

Behavioural difficulties in early childhood and risk of adolescent injury

“…On the other hand, children with borderline disruptive behaviours may not get equivalent family support, parent training/family therapy and school behavioural support. Clinical guidelines for children with behavioural problems have been shown to be inconsistent and difficult to implement due to high caseloads, time pressure and lack of specialised staff 35. This may result in children with borderline problems not receiving adequate support with potential implications for persistence or worsening of their problems.…”

Multilevel barriers to guideline implementation - a nationwide multi- professional cross- sectional study within child and adolescent psychiatry

“…A challenge in guideline implementation is concerns about guideline usefulness and ability to account for real world complexity [47]. It is problematic since perceived utility also seems to be linked to use in the context of CAMHS [23,24]. In our study, clinicians held a positive view of the guideline as opposed to the results of the Westerlund study in which the NBHW guideline was perceived considerably less helpful, possibly because it was developed externally, not connected to the child mental health professional community, and without taking clinical expertise into account [24].…”

“…However, little is known about potential enablers and obstacles to guideline implementation in CAMHS, including any variation between profession, about the applicability of care guidelines, and how they are best implemented. Currently, only a handful of studies have been carried out to examine CAMHS clinicians' attitudes towards guidelines [5,[23][24][25]. In respect of depression, one of the most common primary and secondary conditions treated in CAMHS, most studies on depression guideline adoption have been qualitative and retrospective in nature, often involving small and/or non-representative samples, have not been able to study differences between professionals and take a pessimistic view [4,5,24].…”

Updated European guidelines for Tourette syndrome: and now use them!

“…A number of recently published studies have indeed highlighted subpar adherence to available guidelines. A study among mental health clinicians across Europe found that 46% of them were unaware of the existence of guidelines in their country for the treatment of severe behavioral problems in children, and of the ones who were aware, 37.6% did not use them in practice [8]. More than 40% of Dutch clinicians reported using ADHD guidelines only 'sometimes', or less [9].…”

“…The studies that we reviewed offer some clear clues. Foremost, awareness of the very existence of guidelines should be increased [8]. For this to happen, guideline training should be an essential component of (continuing) education programs for both medical and non-medical professions.…”