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Publication The challenges of eating out for young people with eating disorders: a thematic analysis of the perspectives of young people, parents and carers, and clinicians(Springer Nature, 2025-12-16) Shackshaft, Lydia; Chapman, Laura; Hook, Annabelle; Biddle, Lucy; Yardley, Lucy; Ford, Tamsin; Attwood, Angela; Penton-Voak, Ian; Slater, Mel; Rothwell, Emily; Reeves, Stella; Grant, Alys; Downs, James; Combe, Gillian; CLARK-STONE, Sam; Govender, Trinisha; Stewart, Anne; Moran, Paul; Bould, Helen; Clark-Stone, Sam; Govender, Trinisha; Bould, Helen; Nursing and Midwifery Registered; Medical and DentalBackground: Social eating is a key aspect of recovery for many individuals with an Eating Disorder (ED). To develop effective interventions to support recovery of social eating we need to understand the challenges that people with ED face when eating in public spaces. This study was conducted in the context of the development of a virtual reality graded-exposure café intervention for people with ED. The current analysis explores stakeholder perspectives on the challenges that people with ED face in café environments. Methods: People with lived experience of ED (n = 15), parents/carers (n = 4) and clinicians (n = 6) took part in semi-structured focus groups and 1:1 interviews. Transcripts were analysed thematically. Results: We identified six major themes: (1) Facing the unexpected and unknown; (2) Cafés elicit difficult emotions; (3) Challenges are highly individual; (4) Challenges relating to the physical café environment; (5) Challenges of social interactions in cafés; (6) Challenges of the process of choosing and consuming food and drink. Conclusions: This study highlights the challenges cafés present for people with ED, many of which also apply to other social eating scenarios. These findings will enable more targeted support and development of novel interventions to help people with ED return to social eating. Keywords: Adolescents; Eating disorders; Lived experience; Qualitative research; Social eating; Thematic analysis; Young adults.Publication Clinical and cost-effectiveness of a standardised diagnostic assessment for children and adolescents with emotional difficulties: the STADIA multi-centre RCT(NIHR Journals Library, 2025-11) Sayal, Kapil; Wyatt, Laura; Thomson, Louise; Holt, Grace; Ewart, Colleen; Bhardwaj, Anupam; Dubicka, Bernadka; Marshall, Tamsin; Gledhill, Julia; Lang, Alexandra; Sprange, Kirsty; Partlett, Christopher; Newman, Kristina; Moody, Sebastian; Bould, Helen; Upton, Clare; Keane, Matthew; Cox, Edward; James, Marilyn; Montgomery, Alan; Bould, Helen; Medical and DentalBackground: 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. Keywords: CHILD AND ADOLESCENT MENTAL HEALTH SERVICES (CAMHS); CHILDREN; CLINICIANS; COST EFFECTIVENESS; DAWBA; DIAGNOSIS; EMOTIONAL DISORDERS; HEALTH ECONOMICS; OUTCOMES; PARENTS/CARERS; RCT; REFERRAL ACCEPTANCE; STADIA; STANDARDISED DIAGNOSTIC ASSESSMENT; YOUNG PEOPLE.Publication The development of the Reflecting Team Utterances Framework: Process, reflections and applications(Wiley, 2021-07-30) Constable, Chloe; Delaney, Claire; Clutterham, Adam; Markiewicz, Abi; Constable, Chloe; Delaney, Claire; Clutterham, Adam; Markiewicz, Abi; Additional Professional Scientific and Technical; Additional Clinical Services; Admin and ClericalThe Reflecting Team (RT) has been a common companion of systemic practitioners since Tom Andersen first described its use (Andersen, 1987). Despite the widespread acceptance of such ideas in modern Systemic Practice, there is limited research into the RT method. We hoped to contribute to the broader research aim of exploring how and why reflecting team conversations lead to change by addressing the following question: is it possible to reliably categorise the utterances of the RT to form a framework? We used a content analysis to analyse and categorise over three hours of reflecting team conversations from four different clinical teams. This resulted in the identification of eleven discrete categories including: ‘they asked a question to you as a family’, ‘they highlighted something positive and they commented on their own emotions’. We go on to discuss potential applications of this Reflecting Team Utterances Framework and our reflections on the process.Publication Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: a UK-based birth cohort study(Springer Nature, 2021-12-03) Warne, Naomi; Heron, Jon; Mars, Becky; Kwong, Alex; Solmi, Francesca; Pearson, Rebecca; Moran, Paul; Bould, Helen; Bould, Helen; Medical and DentalBackground: Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk. Methods: In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May-July 2020) when participants were aged 27-29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April-May 2020) moderated these associations. Results: Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing. Conclusions: Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals. The aim of this project was to explore the mental health of young adults with disordered eating behaviours (such as fasting, vomiting/taking laxatives, binge-eating and excessive exercise) and self-harm during the COVID-19 pandemic. We analysed data from an established study that has followed children from birth (in 1991 and 1992) up to present day, including during the pandemic when participants were 28 years old. We looked at the relationship between disordered eating and/or self-harm behaviours from before the pandemic and mental health problems (symptoms of depression and anxiety) and mental wellbeing during the pandemic. We also explored whether there were any lifestyle changes (such as changes in sleep, exercise, visiting green space) that might be linked to better mental health and wellbeing in young adults with disordered eating and self-harm. We found that young adults with prior disordered eating and/or self-harm had more symptoms of depression and anxiety, and worse mental wellbeing than individuals without prior disordered eating or self-harm. However, lifestyle changes did not appear to affect mental health and wellbeing in these young adults. Our findings suggest that people with a history of disordered eating and/or self-harm were at high risk for developing mental health problems during the pandemic, and they will need help from mental health services.Publication Experiences of psychiatrists assessing under 18s on an “all age” rota. An evaluation of the current service(Cambridge University Press, 2021-06-18) Turtoi, Nicoleta; Ansell, Martin; Govender, Trinisha; Bould, Helen; Turtoi, Nicoleta; Ansell, Martin; Govender, Trinisha; Bould, Helen; Medical and DentalAims Gloucestershire Health Care Trust operates an “all age” out of hours on-call rota, staffed by Registrars and Consultants who cross-cover all psychiatric sub-specialities. Our aim was to understand the challenges faced by psychiatrists of different professional backgrounds when assessing under 18 year olds in a health-based Place of Safety (POS). Method We circulated a survey to all psychiatrists on the on-call rota, to gather quantitative and qualitative information on the challenges posed by assessments of under-18s in a POS and assess whether an under-18 specific policy was needed. Result Out of the 50 psychiatrists invited, 27 completed this survey (during February 2021). 33.3% of respondents reported that they had completed a POS assessment of an under 18-year-old when a Consultant Child and Adolescent Psychiatrist/Registrar was not available to join. 33.3% of respondents had been asked to complete such an assessment as the sole psychiatrist joining the AMHP, with 24% of those respondents reporting feeling uncomfortable doing these assessments without a second doctor present, and an additional 24% feeling comfortable only sometimes. 48.1% of the doctors surveyed did not invite parents or carers to take part in the assessment, despite this being considered best practice, citing reasons such as: being unaware that this was a possibility, assessments conducted at unsociable hours, safeguarding concerns involving the parents, and social distancing in the context of COVID-19. 41% of respondents had assessed vulnerable young people (children looked after or with a diagnosis of an autism spectrum condition) in the POS and reported that these assessments posed significant challenges to safe discharge planning and identifying appropriate placements. 81.5% felt that a tailored policy for young people was needed. Qualitative findings suggest psychiatrists think such a policy should include clear procedures (flowcharts), potential outcome scenarios/options for safe discharge, referral criteria for CAMHS, contact details for key staff members, a handover protocol. Respondents felt a shared policy with all stakeholders (AMHP service, Mental Health Services, police) was required. Conclusion Our survey highlights the challenges for non-CAMHS specialists assessing under 18s in a health-based POS and the need for an under-18 policy to support safe practice. Major themes will be further explored in a focus group to guide policy development.Publication Comorbidity of self-harm and disordered eating in young people: Evidence from a UK population-based cohort(Elsevier, 2021-01-07) Warne, Naomi; Heron, Jon; Mars, Becky; Moran, Paul; Stewart, Anne; Munafo, Marcus; Biddle, Lucy; Skinner, Andy; Gunnell, David; Bould, Helen; Bould, Helen; Medical and DentalBackground: Self-harm and eating disorders are often comorbid in clinical samples but their co-occurrence in the general population is unclear. Given that only a small proportion of individuals who self-harm or have disordered eating present to clinical services, and that both self-harm and eating disorders are associated with substantial morbidity and mortality, it is important to study these behaviours at a population level. Methods: We assessed the co-occurrence of self-harm and disordered eating behaviours in 3384 females and 2326 males from a UK population-based cohort: the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants reported on their self-harm and disordered eating behaviours (fasting, purging, binge-eating and excessive exercise) in the last year via questionnaire at 16 and 24 years. At each age we assessed how many individuals who self-harm also reported disordered eating, and how many individuals with disordered eating also reported self-harm. Results: We found high comorbidity of self-harm and disordered eating. Almost two-thirds of 16-year-old females, and two-in-five 24-year old males who self-harmed also reported some form of disordered eating. Young people with disordered eating reported higher levels of self-harm at both ages compared to those without disordered eating. Limitations: We were not able to measure whether participants identified their disordered eating as a method of self-harm. Conclusions: Self-harm and disordered eating commonly co-occur in young people in the general population. It is important to screen for both sets of difficulties to provide appropriate treatment.Publication Trajectories of autistic social traits in childhood and adolescence and disordered eating behaviours at age 14 years: A UK general population cohort study(Wiley, 2020-05-03) Solmi, Francesca; Bentivegna, Francesca; Bould, Helen; Mandy, William; Kothari, Rai; Skuse, David; Lewis, Glyn; Bould, Helen; Medical and DentalBackground Some people with eating disorders have difficulties with social communication. However, no longitudinal evidence regarding the direction of this association exists. We investigated trajectories of autistic social traits across childhood and adolescence in adolescents with and without disordered eating behaviours in early adolescence. Methods We used data from the Avon Longitudinal Study of Parents and Children. Our disordered eating measure indicated presence of any, monthly and weekly disordered eating (fasting, purging, dieting, binge eating) at age 14 years. Autistic social traits were reported by mothers using the Social and Communication Disorders Checklist (SCDC) at age seven, 11, 14 and 16 years. We modelled SCDC score trajectories using multilevel negative binomial models adjusting for a number of child- and maternal-level confounders. Results Of the 5,381 adolescents included in our sample, 421 (7.8%) experienced one or more disordered eating behaviours, and 148 (2.8%) weekly episodes. Adolescents with disordered eating had a 20% increase in SCDC scores (relative risk (RR) 1.23, 95% confidence interval (CI):1.14, 1.32) compared to those without disordered eating. This association was particularly apparent for those reporting weekly (RR 1.43, 95%CI: 1.27, 1.61) as opposed to monthly disordered eating (RR 1.12, 95%CI: 1.01, 1.22). Conclusions Greater autistic social traits in childhood could represent a risk factor for the development of disordered eating in adolescence. Although mechanisms of this association need to be elucidated, clinicians should be aware that autistic social traits could have predated the eating disorder when managing people with these conditions.Publication Association of Emotion Regulation Trajectories in Childhood With Anorexia Nervosa and Atypical Anorexia Nervosa in Early Adolescence(American Medical Association, 2021-07-07) Henderson, Mariella; Bould, Helen; Flouri, Eirini; Harrison, Amy; Lewis, Gemma; Lewis, Glyn; Srinivasan, Ramya; Stafford, Jean; Warne, Naomi; Solmi, Francesca; Bould, Helen; Medical and DentalKey Points Question Is emotion dysregulation in childhood associated with an increased risk of broad anorexia nervosa in adolescents? Findings In this cohort study of 15 896 participants from the Millennium Cohort Study, poor emotion regulation skills at 3 years of age were not associated with an increased risk of broad anorexia nervosa. However, lack of improvement in emotion regulation skills across childhood was associated with increased risk in this disorder. Meaning These findings suggest that failure to meet key emotional developmental milestones from 3 to 7 years of age could confer an increased risk for broad anorexia nervosa, and support with developing emotion regulation skills across childhood could be beneficial in preventing anorexia nervosa. Abstract Importance People with anorexia nervosa often experience difficulties regulating their emotions. There is no longitudinal evidence as to whether these differences are already present in childhood or when they begin to emerge. Objective To investigate the association between emotion regulation trajectories from 3 to 7 years of age and symptoms of anorexia nervosa and atypical anorexia nervosa in adolescence. Design, Setting, and Participants This cohort study included all children with complete exposure data in the Millennium Cohort Study, a UK general population birth cohort. Data were acquired from June 2001 to March 2016 and analyzed from June to November 2020. Exposures Mothers reported on their children’s emotion regulation skills at 3, 5, and 7 years of age using the Children’s Social Behavior Questionnaire. Multilevel models were used to derive early childhood emotion regulation scores (ie, predicted intercept) and within-child changes in emotion regulation scores from 3 to 7 years of age (ie, predicted slope). Main Outcome and Measures Symptoms consistent with a DSM-5 diagnosis of anorexia nervosa or atypical anorexia nervosa at 14 years of age, defined using a range of questions relative to body image, weight perception, and dieting behaviors (hereinafter referred to as broad anorexia nervosa). Univariable and multivariable logistic regression models tested the association between exposures and outcome. Regression models were adjusted for child and family sociodemographic and socioeconomic characteristics and mental health difficulties, prenatal and perinatal factors, child’s cognitive development, and maternal attachment. Results A total of 15 896 participants (85.7% of total sample; 51.0% boys; 84.5% White individuals) had complete data on the exposure and were included in the main analyses. Among those with complete exposure and outcome data (9912 of the analytical sample [62.4%]), 97 participants (1.0%; 86 [88.7%] girls and 85 [87.6%] White individuals) had symptoms consistent with a diagnosis of broad anorexia nervosa at 14 years of age. No evidence suggested that children with lower emotion regulation ability at 3 years of age had greater odds of later reporting symptoms of broad anorexia nervosa (odds ratio [OR], 1.21; 95% CI, 0.91-1.63). However, children whose emotion regulation skills did not improve over childhood and who had greater problems regulating emotions at 7 years of age had higher odds of having broad anorexia nervosa at 14 years of age (OR, 1.45; 95% CI, 1.16-1.83). Conclusions and Relevance These findings suggest that difficulties in developing age-appropriate emotion regulation skills in childhood are associated with experiencing broad anorexia nervosa in adolescence. Interventions to support the development of emotion regulation skills across childhood may help reduce the incidence of anorexia nervosaPublication Emotional dysregulation in childhood and disordered eating and self-harm in adolescence: prospective associations and mediating pathways(Wiley, 2022-12-21) Warne, Naomi; Heron, Jon; Mars, Becky; Solmi, Francesca; Biddle, Lucy; Gunnell, David; Hammerton, Gemma; Moran, Paul; Munafò, Marcus; Penton-Voak, Ian; Skinner, Andy; Stewart, Anne; Bould, Helen; Bould, Helen; Medical and DentalBackground: Emotional dysregulation may be a risk factor for disordered eating and self-harm in young people, but few prospective studies have assessed these associations long-term, or considered potential mediators. We examined prospective relationships between childhood emotional dysregulation and disordered eating and self-harm in adolescence; and social cognition, emotional recognition, and being bullied as mediators. Methods: We analysed Avon Longitudinal Study of Parents and Children data on 3,453 males and 3,481 females. We examined associations between emotional dysregulation at 7 years and any disordered eating and any self-harm at 16 years with probit regression models. We also assessed whether social cognition (7 years), emotional recognition (8 years) and bullying victimisation (11 years) mediated these relationships. Results: Emotional dysregulation at age 7 years was associated with disordered eating [fully adjusted probit B (95% CI) = 0.082 (0.029, 0.134)] and self-harm [fully adjusted probit B (95% CI) = 0.093 (0.036, 0.150)] at age 16 years. There was no evidence of sex interactions or difference in effects between self-harm and disordered eating. Mediation models found social cognition was a key pathway to disordered eating (females 51.2%; males 27.0% of total effect) and self-harm (females 15.7%; males 10.8% of total effect). Bullying victimisation was an important pathway to disordered eating (females 17.1%; males 10.0% of total effect), but only to self-harm in females (15.7% of total effect). Indirect effects were stronger for disordered eating than self-harm. Conclusions: In males and females, emotional dysregulation in early childhood is associated with disordered eating and self-harm in adolescence and may be a useful target for prevention and treatment. Mediating pathways appeared to differ by sex and outcome, but social cognition was a key mediating pathway for both disordered eating and self-harm.Publication Engaging Young People With Mental Health Needs and Exploring Outputs From a Resource Development Project: Qualitative Interview Study(JMIR Publications, 2025-08-25) Haime, Zoe; Carney, Charlotte; Linton, Myles-Jay; Bould, Helen; Biddle, Lucy; Bould, Helen; Medical and DentalBackground: Recommendations from professional bodies, including the Royal College of Psychiatrists, advise mental health practitioners to discuss problematic online use with children and young people. However, barriers such as knowledge gaps and low confidence in initiating discussions often prevent these conversations from happening. Objective: The Digital Dialogues project used a knowledge exchange approach, cocreating resources with young people, to support professionals in overcoming these challenges. This paper details the project design and reflects on the perspectives of the young people involved. Methods: The project was guided by the "children and young people have ownership" model of cocreation. A total of 11 participants were purposively sampled to take part in the Digital Dialogues Young Persons Group (DDYPG) and were actively involved in the study workshops, creative tasks, and resource design and development. In total, 6 (55%) DDYPG members took part in interviews, and 2 (18%) also completed an anonymous survey evaluating their time in the DDYPG. Thematic analysis was used to explore data from interviews and qualitative survey responses together. Results: The DDYPG successfully created several resources to support practitioners in addressing problematic online use with young people. Reflections from DDYPG members showed that creative engagement, meaningful involvement, and peer interactions were key motivators for participation and led to benefits, including feelings of empowerment and personal development. Anxiety, time demands, and potential exposure to triggering content could act as barriers. However, structured tasks, positive rapport with researchers, and flexible participation helped to mitigate these challenges. Conclusions: The findings highlight ethical considerations and potential strategies for involving young people in resource development research projects in the future. Keywords: children and young people; codevelopment; mental health; participatory research; qualitative; research design; resource development.Publication Guided Self‐Help Treatment for Children and Young People With Eating Disorders: A Proof‐Of‐Concept Pilot Study(Wiley, 2025-04-02) Davey, Emma; Bryant-Waugh, Rachel; Bennett, Sophie; Micali, Nadia; Baudinet, Julian; Konstantellou, Anna; CLARK-STONE, Sam; Green, Amelia; Shafran, Roz; Clark-Stone, Sam; Green, Amelia; Additional Professional Scientific and Technical; Admin and ClericalObjective: To conduct a proof‐of‐concept pilot study of a CBT guided self‐help intervention for children and young people witheating disorders. Method: Children and young people were recruited from two outpatient eating disorder services in England. They received aCBT guided self‐help intervention consisting of eight modules and weekly support sessions. Clinical outcomes (eating disorderpsychopathology and associated impairment, changes in %median BMI, depression, anxiety, and behavioural difficulties) wereassessed at baseline and post‐intervention (12 weeks). Qualitative data were collected for future intervention refinement. Results: Six female adolescents (aged 13–17) received the CBT guided self‐help intervention. All participants completed aminimum of six modules and six support sessions. Quantitative and qualitative feedback suggested that the intervention wasacceptable. From baseline to post‐intervention, there was a reduction in eating disorder psychopathology and impairment, alongwith an increase in %median BMI. Outcomes for depression, anxiety and behavioural difficulties were mixed. Conclusions: The CBT guided self‐help intervention was feasibly implemented, acceptable to participants, and showed potential to produce clinical benefits. While promising, these findings are preliminary and derived from a small, non‐randomisedsample of White female adolescents. More rigorous evaluation with a randomised design and a larger, representative sample iswarranted.Publication Developing good practice indicators to assist mental health practitioners to converse with young people about their online activities and impact on mental health: a two-panel mixed-methods Delphi study(BioMed Central, 2022-07-19) Biddle, Lucy; Rifkin-Zybutz, Raphael; Derges, Jane; Turner, Nicholas; Bould, Helen; Sedgewick, Felicity; Gooberman-Hill, Rachael; Moran, Paul; Linton, Myles-Jay; Bould, Helen; Medical and DentalBackground: Online activity has been linked to poor mental health in children and young people, particularly those with existing vulnerability who may inadvertently or otherwise access harmful content. It is suggested health and social care practitioners should address online activity during mental health consultations, but guidance about acceptable or effective ways to do this is lacking. This study sought to derive good practice guidance to support mental health practitioners to engage young people in conversations about their online activities and impact on mental health. Methods: A mixed-methods Delphi (consensus) study was conducted with a panel of mental health practitioners (n = 21) and a panel of young people (n = 22). Practitioners worked with children or young adults in the UK, mostly in statutory services (80.9%), in varied clinical roles, with 2 - 30 years of experience and most were female (87.5%). Young people were mostly female (77.3%), 13-22 years old, reported varied mental health diagnoses and had sought help from services. Across 3 rounds, panellists completed questionnaires which involved rating agreement with statements and answering open-ended questions. Iterative analysis informed subsequent questionnaire content. The percentage of participants rating their level of agreement with each statement was calculated. The threshold for inclusion as a good practice indicator (GPI) was 75% across both panels. Thematic analysis was used for free-text data. Results: Twenty-seven GPIs emerged covering 'who' (which young people) should be asked about online activities, 'when', 'what' should be discussed, and with what 'outcome'. Panels agreed conversations should be initiated with all young people from first meeting and regularly thereafter, with 'red flags' indicating a conversation may be pertinent. Core topics were identified with additional areas for patients presenting with disordered eating or self-harm. Panels emphasised conversations should be fluid, normalised, and encourage reflection and self-awareness. Conclusions: Mental health practitioners could empower young people to exercise agency in relation to online safety and capitalise on positive features. Findings also identify training needs for practitioners. Further research should explore real-world application of the GPIs and transferability to underrepresented groups within our panels, such as males and younger children. Ethnicity and deprivation were not recorded.Publication Quantifying the efficacy of an automated facial coding software using videos of parents(Frontiers Media, 2023-07-31) Burgess, Romana; Culpin, Iryna; Constantini, Ilaria; Bould, Helen; Nabney, Ian; Pearson, Rebecca; Bould, Helen; Medical and DentalIntroduction: This work explores the use of an automated facial coding software - FaceReader - as an alternative and/or complementary method to manual coding. Methods: We used videos of parents (fathers, n = 36; mothers, n = 29) taken from the Avon Longitudinal Study of Parents and Children. The videos-obtained during real-life parent-infant interactions in the home-were coded both manually (using an existing coding scheme) and by FaceReader. We established a correspondence between the manual and automated coding categories - namely Positive, Neutral, Negative, and Surprise - before contingency tables were employed to examine the software's detection rate and quantify the agreement between manual and automated coding. By employing binary logistic regression, we examined the predictive potential of FaceReader outputs in determining manually classified facial expressions. An interaction term was used to investigate the impact of gender on our models, seeking to estimate its influence on the predictive accuracy. Results: We found that the automated facial detection rate was low (25.2% for fathers, 24.6% for mothers) compared to manual coding, and discuss some potential explanations for this (e.g., poor lighting and facial occlusion). Our logistic regression analyses found that Surprise and Positive expressions had strong predictive capabilities, whilst Negative expressions performed poorly. Mothers' faces were more important for predicting Positive and Neutral expressions, whilst fathers' faces were more important in predicting Negative and Surprise expressions. Discussion: We discuss the implications of our findings in the context of future automated facial coding studies, and we emphasise the need to consider gender-specific influences in automated facial coding research.Publication The impact of routines on emotional and behavioural difficulties in children and on parental anxiety during COVID-19(Frontiers Media, 2023-12-13) Lees, Vera; Hay, Rosie; Bould, Helen; Kwong, Alex; Major-Smith, Daniel; Kounali, Daphne; Pearson, Rebecca; Lees, Vera; Hay, Rosie; Bould, Helen; Medical and DentalBackground: The Covid-19 pandemic and related public health measures, including lockdowns and school closures, have impacted on mental health of children. Aims and hypothesis: We hypothesised that there would be an association between maintaining a routine during lockdown and both lower emotional and behavioural difficulties in children and lower parental anxiety. Routine was taken as keeping to the same basic activities such as mealtimes and bedtimes. We also hypothesised that children of 'keyworker' parents would have fewer emotional and behavioural symptoms due to having maintained more normal routines. The key reason was that children of keyworkers still attended school or nursery and parents would have been getting up and coming home at the same times as pre-Covid. Keyworker status was defined as those whose work was essential to Covid-19 response, including work in health and social care and other key sectors. Methods: We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to explore associations between maintaining a routine, and emotional and behavioural difficulties in children, using linear regression models. All eligible ALSPAC-G2 participants were sent the survey and the responders are representative of the eligible G2 population. We included measures of parental anxiety. We separately explored associations with having a keyworker parent. We used the Carey Infant Temperament Questionnaire and the Revised Rutter Parent Scale for Preschool Children to establish levels of emotional and behavioural difficulties. The measures were chosen to match previous waves in multi-generations in ALSPAC where they had been shown to be predictive of later mental health in children. The scales measure emotional and behavioural problems. Results: Two hundred eighty-nine parents completed questionnaires about their 411 children. Keeping a routine was associated with emotional and behavioural difficulty scores 5.0 points lower (95% CI -10.0 to -0.1), p = 0.045 than not keeping a routine. Parents who reported keeping a routine had anxiety scores 4.3 points lower (95% CI -7.5 to -1.1), p = 0.009 than those who did not. Children of keyworkers tended to have lower emotional and behavioural difficulty scores [-3.1 (95%CI -6.26 to 0.08), p = 0.056] than children of non-keyworkers. All models were adjusted for relevant potential confounders. Conclusion: Maintaining a routine may be beneficial for both child emotional wellbeing and parental anxiety, although it is also possible that lower parental anxiety levels made maintaining a routine easier. Being the child of a keyworker parent during lockdown may have been protective for child emotional wellbeing.Publication Mental Health Practitioners' and Young People's Experiences of Talking About Social Media During Mental Health Consultations: Qualitative Focus Group and Interview Study(JMIR Publications, 2023-04-07) Derges, Jane; Bould, Helen; Gooberman-Hill, Rachael; Moran, Paul; Linton, Myles-Jay; Rifkin-Zybutz, Raphael; Biddle, Lucy; Bould, Helen; Medical and DentalBackground: Increasing concerns among mental health care professionals have focused on the impact of young people's use of digital technology and social media on their mental well-being. It has been recommended that the use of digital technology and social media be routinely explored during mental health clinical consultations with young people. Whether these conversations occur and how they are experienced by both clinicians and young people are currently unknown. Objective: This study aimed to explore mental health practitioners' and young people's experiences of talking about young people's web-based activities related to their mental health during clinical consultations. Web-based activities include use of social media, websites, and messaging. Our aim was to identify barriers to effective communication and examples of good practice. In particular, we wanted to obtain the views of young people, who are underrepresented in studies, on their social media and digital technology use related to mental health. Methods: A qualitative study was conducted using focus groups (11 participants across 3 groups) with young people aged 16 to 24 years and interviews (n=8) and focus groups (7 participants across 2 groups) with mental health practitioners in the United Kingdom. Young people had experience of mental health problems and support provided by statutory mental health services or third-sector organizations. Practitioners worked in children and young people's mental health services, statutory services, or third-sector organizations such as a university counseling service. Thematic analysis was used to analyze the data. Results: Practitioners and young people agreed that talking about young people's web-based activities and their impact on mental health is important. Mental health practitioners varied in their confidence in doing this and were keen to have more guidance. Young people said that practitioners seldom asked about their web-based activities, but when asked, they often felt judged or misunderstood. This stopped them from disclosing difficult web-based experiences and precluded useful conversations about web-based safety and how to access appropriate web-based support. Young people supported the idea of guidance or training for practitioners and were enthusiastic about sharing their experiences and being involved in the training or guidance provided to practitioners. Conclusions: Practitioners would benefit from structured guidance and professional development to enable them to support young people in feeling more willing to disclose and talk about their web-based experiences and their impact on their mental health. This is reflected in practitioners' desire for guidance to improve their confidence and skills to safely support young people in navigating the challenges of the web-based world. Young people want to feel comfortable discussing their web-based activities during their consultations with mental health practitioners, both in tackling the challenges and using the opportunity to discuss their experiences, gain support, and develop coping strategies related to web-based safety. Keywords: clinician and young people’s experiences; digital technology and social media; mental health consultations; young people.Publication The role of body image dissatisfaction in the relationship between body size and disordered eating and self-harm: complimentary Mendelian randomization and mediation analyses(Springer Nature, 2024-08-13) Power, Grace; Warne, Naomi; Bould, Helen; Casanova, Francesco; Jones, Samuel; Richardson, Tom; Tyrell, Jessica; Smith, George; Heron, Jon; Bould, Helen; Medical and DentalDisordered eating and self-harm commonly co-occur in young people suggesting potential for shared underlying causes. Body image dissatisfaction (BID) has been recognised as a psychological correlate of body size, associated with both disordered eating and self-harm. However, the investigation into etiological pathways early in the lifecourse to provide detail on how body size and BID may foster disordered eating and self-harm remains largely unexplored. Employing data from two large population-based cohorts, the UK Biobank and the Avon Longitudinal Study of Parents And Children (ALSPAC), we conducted bidirectional Mendelian randomization (MR) to determine the causal direction of effect between genetically predicted prepubertal body size and two measures of BID indicating (i) desire to be smaller, and (ii) desire to be larger. We then used multivariable regression followed by counterfactual mediation analyses. Bidirectional MR indicated robust evidence that increased genetically predicted prepubertal body size increased desire to be smaller and decreased desire to be larger. Evidence for the reverse causal direction was negligible. These findings remained very similar across sensitivity analyses. In females and males, multivariable regression analyses demonstrated that being overweight increased the risk of disordered eating (risk ratio (RR), 95% confidence interval (CI): 1.19, 1.01 to 1.40 and 1.98, 1.28 to 3.05, respectively) and self-harm (RR, 95% CI: 1.35, 1.04 to 1.77 and 1.55, 0.86 to 2.81, respectively), while being underweight was protective against disordered eating (RR, 95% CI: 0.57, 0.40 to 0.81 and 0.81, 0.38 to 1.73, respectively). There was weak evidence of an increase in the risk of self-harm among underweight individuals. Mediation analyses indicated that the relationship between being overweight and subsequent disordered eating was largely mediated by the desire to be smaller. Our research carries important public health implications, suggesting distinct risk profiles for self-harm and disordered eating in relation to weight and body image. In addition, a better understanding of genetically predicted prepubertal BID may be valuable in the prevention and treatment of disordered eating and self-harm in adolescence.Publication Mental Health Practitioners’ Training Needs and Preferences for Addressing Online Use with Children and Young People(Taylor and Francis Group, 2024-09-11) Haime, Zoe; Griffiths, Georgina; Linton, Myles-Jay; Bould, Helen; Biddle, Lucy; Bould, Helen; Medical and DentalBackground Digital technology use by children and young people (CYP) has been linked to mental health issues. Currently, mental health professionals (MHPs) lack clear guidance on addressing the impact of digital use on CYP mental health. Objectives This study aimed to identify the training needs and preferences of MHPs, in having these discussions with CYP. Method We conducted an online survey of MHPs from the UK and Ireland. The survey covered topics including, barriers encountered during discussions, and MHP training and resource needs. Descriptive statistics were used to analyze quantitative data, and content analysis was used to explore qualitative responses. Results A total of 133 MHPs responded: primarily female (79.7%), white (90.8%), working in secondary care services (69.2%), with extensive experience working with CYP (47.4% 10+yrs). Although nearly half reported frequently discussing online activity with CYP, the majority lacked adequate training and resources. Barriers included concerns about relevance, limited knowledge, and practical limitations. MHPs expressed interest in training on communication strategies and enhancing understanding of online risks. Additionally, they preferred resources co-created with CYP, featuring real-life examples and perspectives. Conclusions Gaps in MHPs’ readiness to address digital aspects of CYP mental health highlight the necessity for organizational-level changes and tailored training initiatives. Emphasizing collaborative efforts with CYP in resource development is crucial to create accessible and inclusive materials, that MHPs want to engage with. Further, MHPs prioritize the development of assessment tools, evidence-based interventions, and best practice guidelines to enhance approaches to these discussions, and limit disparities in quality of care.Publication Guided self-help treatment for children and young people with threshold and subthreshold eating disorders: A pilot study protocol(Public Library of Science, 2024-04-16) Davey, Emma; Bryant-Waugh, Rachel; Bennett, Sophie; Micali, Nadia; Baudinet, Julia; CLARK-STONE, Sam; Shafran, Roz; Clark-Stone, Sam; Nursing and Midwifery RegisteredBackground: Prompt access to evidence-based treatment for children and young people with eating disorders is important for outcomes, yet the gap in service provision remains pervasive. Record levels of young people are waiting for eating disorder treatment and access to care is limited. Guided self-help interventions that are brief and require minimal clinician support have the potential to meet the unprecedented demand for treatment quickly and effectively. Objective: To examine the feasibility, acceptability and proof of concept of a novel, CBT guided self-help intervention for children and young people with threshold and subthreshold eating disorders. Methods: A single-arm, proof-of-concept pilot study of the CBT guided self-help intervention will be conducted. Children and young people (aged 11-19) with threshold and subthreshold eating disorders will receive a self-help intervention covering the core components of CBT, supported by 8 weekly guidance sessions delivered remotely. Clinical outcomes (eating-related psychopathology and associated impairment, changes in weight, depression, anxiety, and behavioural difficulties) will be assessed at baseline and post-intervention (12 weeks). Feasibility and acceptability of the intervention will be measured using various outcomes, including adherence to, and engagement with the intervention, rates of recruitment and retention, measure completion and treatment satisfaction. Qualitative data will also be collected for future intervention refinement. Discussion: If the intervention is shown to produce clinical benefits in this pilot study, a fully powered randomised pilot study will be warranted with the ultimate goal of increasing access to psychological treatment for children and young people threshold and subthreshold eating disorders. Administrative information: This study protocol (S1 File) adheres to the guidelines outlined in the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist for trial protocols [1, 2] which can be found in S1 Checklist. The numbers in parentheses in this protocol correspond to the item numbers in the SPIRIT checklist. The order of items has been modified to group similar items.