Mark Tebbs: Hello and welcome to Mind the Kids podcast series. Today we're talking about the acceptability and effectiveness of standardized diagnostic assessment approaches in children and young people's mental health services. Standardized diagnostic assessments, SDAs are often used in children's mental health services to bring structure and consistency to how we understand young people's difficulties. They spark plenty of debate too. Do they really improve care or do they risk oversimplifying complex young lives? I'm Mark Tebbs, I'm your host for today. I've spent my whole career working in mental health from frontline service delivery to director of commissioning. So I'm delighted to be hosting this podcast. In each episode, we talk to researchers and practitioners and really try to bring the latest research to our listeners. I'm particularly interested in how we bring new evidence-based approaches to core issues. So how do we begin to address some of the issues facing children and young people's services like long waits, increasing demand. So it's really great to be speaking with Dr. Salah Bashir and Dr. Sue Fen Tan, who recently published their paper entitled A Review Article the acceptability and effectiveness of standardized diagnostic assessment approaches in children and young people's mental health services and updated systematic review. And this was published in ACAM's journal, The Child and Adolescent Mental Health. Salah Sue it's great to have you with us.
Dr. Salah Basheer: Thank you nice to meet you too.
Dr. Sue Fen Tan: Yes, thank you so much for having me
Mark Tebbs: So, let's start with some introductions. So, it'd great if you could tell us maybe a little bit about yourself, where you work, research interests, any collaborators that you worked with on the paper. It's a nice opportunity to give them a name check. maybe Salah, do want to start us off?
Dr. Salah Basheer: Hi, so I'm Salah. I'm an NIHR clinical lecturer. So I work in the University of Nottingham, where I do 50 % time of research and 50 % I'm doing clinical work. My research interests are mainly in terms of how to improve diagnostic assessments and also looking at how, in terms of ADHD, attention deficit, activity disorder, as well as the relation with sleep and mental health in those people who are suffering from ADHD. And so for this work, actually, along with Sue, I worked with Professor Kapil Sayal, who is the mentoring auditor on the work, who is also done quite a bit of research specifically looking at standardized diagnosis assessment, namely the Stadia trial, clinical trial, which looked specifically at this. Apart from Kapil Sayal this work also we had ⁓ other co-authors, Dr. Majumdar and ⁓ Dr. David who are all consultant child and psychiatrist who also collaborated with the work.
Dr. Sue Fen Tan: thank you so much for this opportunity to be here. I'm Sue. I'm one of the NIHR academic clinical fellows. So like Salah I split my time between clinical work and academic work and my research interest is around diagnostic assessments for children, young people. I've also recently completed a piece of work on looking at characteristics of young people with likely bipolar disorders, but recently I've shifted my research interest more into looking at neuromodulation for children and young people as a new type of mental health intervention.
Mark Tebbs: Great stuff. So let's dive in. It'd great to start with little bit of background, a little bit of context. So maybe Salah, you could start us off. So what was the original motivation behind the systematic review in standard diagnostic assessments? How does it build on some of the previous research in the area?
Dr. Salah Basheer: Yeah, so our motivation basically to look at in terms of how, what, whether the standardized diagnosis assessment are effective and are acceptable in real world child and adult mental health services was the fact was the topical situation where there is a lot of demand for CAMH services and there is, as you see in the news about increased waiting time and it was the thinking around it was about whether the standardized diagnosis tools will help in the situation in some way. And because of this topical reality, we wanted to do it systematically at this point in time because the previous system was quite a while back in 2013. So we wanted to know what new evidence has come through and to see if there is any new learnings that can be taken forward.
Mark Tebbs: Okay, brilliant. So before we dive into some of that detail, it'd good to just to maybe kind of set out some of the terms and definitions. So what is a standard diagnostic assessment tool? And I guess it'd be useful just to explain a little bit about how the use of those is kind of different to maybe traditional CAMH service referral processes.
Dr. Sue Fen Tan: Shall I take that one? So yes, SDAs are short for standardized or structured diagnostic assessment tools. They are actually questionnaires or interviews designed to systematically collect information about a young person's symptoms. And these tools ask consistent questions linked to diagnostic criteria, hence the term standardized. So it doesn't matter who administers it, you get asked the same set of questions whereas in traditional clinical assessment, I think that is a bit more flexible. It relies on the clinician's style of communication. You also get assessed and asked questions on diagnostic symptoms, but like I said, in a more flexible way and sometimes not all symptoms are covered for various reasons.
Mark Tebbs: Yeah, okay. So Salah, you mentioned the some of the demand pressures in CAMH services. So what the advantages of using SDAs and maybe what are some of the drawbacks or controversies of that approach?
Dr. Salah Basheer: Yeah, so that's a good question. What we think, again, in terms of how we expect that to work is where, for example, in a referral setting, what happens most times is that the CAMHS referral is signed by GP or by teacher or self. And then there is a problem in terms of incomplete clinical information that can happen. So if you have a STA tool which is being filled by the carer or the teacher or the parent, that could kind of give the information in a very systematic structured format to a clinician who is kind of deciding on whether to accept the referral or also where which services would kind of be appropriate for this child. So that could kind of help streamline the process a little bit in terms of referral. Apart from that, there is also possibilities where in terms of whether if STA tool is done in terms of specialist setting, for example, I have worked in certain specialist setting which uses these tools and what they do is they kind of do make this send these questionnaire to parent or carers before the clinical appointment. And what happens is during the clinical appointment, they go through this tool together to make sense about what happens. So that helps in kind of making the best use of time, I guess, in terms of that clinical appointment. And so that there is a clarity, which is quite essential in going forward. So that would be kind of benefits of it. The disadvantage in my perspective would be in terms of whether it would kind of lead to added workload on people, both the parent carers as well as the clinician, and also concerns about whether how the diagnostic label is interpreted or are we over pathologizing things by using such tools. So those kinds of concerns are the problems, guess.
Mark Tebbs: Okay so is it largely used as a like data gathering as part of the assessment process or is it often used as a screening tool so is it what part of the pathway does it sit within?
Dr. Salah Basheer: So, it can be used in multiple ways. So there are different kinds of tools and can be used in multiple ways. One of the things is we have to look at where it is used as well and where it would be more beneficial as well as well. So if you look at... Sometimes it's used, as I said, in referral screening just to get information for the referral screening, but it's also sometimes the same tool is used for as part of assessment by the clinician after they are accepted to CAMH service and they are being seen by CAMHS clinicians. So it can be used in multiple ways and so and one of the challenges we also looking at where it puts it best.
Mark Tebbs: Okay, so I don't know if you wanted to add anything from your experience around some of the kind pros and cons of the kind of use of the tools
Dr. Sue Fen Tan: Yeah, of course. So I think the main advantage is, you know, the thoroughness, the completeness and the consistency of the SDA itself. And just like Salah mentioned, you know, we can always rely on other sources of informants because in CAMHS, children, young people may not always be able to communicate their difficulties. Some of the drawbacks, I think, well, obviously the clinicians need proper training. And if we over rely on such as like SDA tool, then there's a risk that we might become a bit tick boxy in our assessment. And we lose that therapeutic relationship with clinicians that I personally feel is so vital and so unique to CAMHS.
Mark Tebbs: Yeah, okay, that's really helpful. And is it like used at all ages? Is there kind of like a cut off that is only applicable at a certain point in time?
Dr. Salah Basheer: So there are certain tools which can start from age two onwards. So there is as early as two, for example, Doba, which is one of the STL tools which has been used. So that can start from two to even adult ages there. But if you look at some other tool like MiniK.kSAT, it is a little later, six or eight. So there is difference in which tool can be, and it's based on how it has been standardized to.
Mark Tebbs: Okay, brilliant. So yeah, it'd good if you could unpack that a little bit more for us around which tools you looked at within this review and maybe what some of the differences are between them.
Dr. Salah Basheer: Yeah, so there are lots of tools in terms of SDA. There are multiple tools which are available out there. But from this review, what all studies we got when we looked at the literature out there, mainly it was three tools. One is DAWBA, then there was this Minikit and KSATS. So these were the three tools which came through. There are lot of similarities in the sense that it is, as Sue was saying, it is a way of comprehensively looking at a range of disorders. It tries to map the symptoms to diagnostic categories. And there are both online versions as well as paper version for all these tools, which can be sometimes useful as well because online versions are quite user-friendly these days. And many of them are, the access is also better in that sense. So these are the similarities, but when you come to some differences, subtle differences are as well. For example, Minikid is one of the shortest one out of the three. So it is quite structured as well. There is no way to kind of add in your description. There's no space for that for Minikid. So that's a difference. But the advantage there is that there is less time. You can use it in a faster way. When there is quite a busy clinic setting, can use that. But when you come to DAWBA, it's a semi-structured, where there is a lot of structure question, but there is also prompt where you can put in more details to it as well. So DAWBA in that way, that is advantageous in some sense, in some setting, maybe more useful as well. For example, in specialist assessments. The other unique thing about DAWBA is that it gives diagnostic probabilities. So it actually gives you from range from average to very high. So it's not like yes or no, this diagnosis is there or not. It's just what's the probability of this diagnosis being there. one of the useful, another one more advantage in terms of DAWBA is the fact that it actually, you can send that questionnaire online and that can be filled by them, by the parent, carer, teacher. So you don't have a lot of clinical involvement at the outset and that, that in certain settings like referral acceptance or before appointment assessment kind of thing. now coming to case ads, it's more clinical led when compared to DAWBA and it's also quite semi-structured in its format where there is structured questions, there are also open-ended prompts as well. But it is quite intensive, it's more clinical led. Sometimes it may be useful more in very specialized settings as well. So there are certain differences, subtle differences, but overall all these tools are quite comprehensively structured mapping onto diagnosis and helps avoid missing problems which a child may have.
Mark Tebbs: Okay brilliant so they've got some differences but fundamentally they're all about collecting comprehensive information, the accuracy of the diagnostic process and that kind of consistency between different clinicians. So okay that's really helpful. So what does the research say? Does it point to the use of those tools improving some of that kind referral process consistency and accuracy.
Dr. Salah Basheer: So the research from the review what we found was that STA tools do kind of help in kind of avoiding missing diagnosis because it's a quite comprehensive and that's been shown in terms of clinic setting. If you are using a STA tool it helps avoiding missing diagnosis and the there was in terms of evidence based in there is some there is evidence in terms of helping with the improving the referral decision accuracy as well. So it has been shown that you will be able to accept case children who have more needs compared if you don't use structured diagnostic assessment tool. Like for example, in this case, was DORBA which was shown to have that effect in terms of helping with the referral decisions. But ⁓ in terms of findings, what? came through us in terms of, there are certain barriers in terms of implementation, ⁓ in terms of which was discussed as well in terms of clinicians, worries about feasibility, worries about the use of diagnostic labels, so those kind of things came across. So this was just what I could describe in terms of the findings in the study.
Mark Tebbs: Could you expand on that little bit, particularly that drawback? What were activity concerns about the use of STAs?
Dr. Sue Fen Tan: Yeah, so I think in the review we found that some clinicians were quite concerned around diagnostic labels and the practicality in everyday practice. I think some clinicians worry that if we use these tools, they might push us into labeling children too quickly or we oversimplify their complex needs. So I think some of the clinicians feel that it's more important for children, young people to be able to access service and plan their treatment rather than be given a diagnosis. That there is a little bit of reluctance in terms of the CAMHS context to be, for children who have a diagnosis given so young and sometimes clinicians tend to use more like a vague diagnostic terminology because well, for various reasons, again, sometimes diagnosis can be stigmatizing. Sometimes this diagnosis follow the children, young people around into adulthood and few people have their diagnosis reviewed in later life. So that's why there's this real reluctance of assigning a diagnosis early on. So if the... you know, one of the strengths of the SDA tool is around diagnostic assignment, then clinicians who don't favor giving children diagnosis will be less inclined to use it. And I think sometimes in a very busy clinical setting, you know, to do your clinical interview and then top it up with an SDA, which might be a bit lengthy, isn't really the most activity thing. So I think there is a risk that with all these concerns, might be low uptake and low usage of these SDA tools, even if they are freely available in paper form or in online versions. So I think it's important to note that these tools are meant to ⁓ inform and complement clinical practice rather than ⁓ replace what is essentially a holistic and formulation-based practice.
Mark Tebbs: Yeah, okay, so that makes perfect sense. guess, is the uptake of the tools different in different kind of clinical professions? I guess the kind of the referral process is a multidisciplinary process. So is it more acceptable to certain professions than others?
Dr. Sue Fen Tan: Thank. Yes, that's actually a very interesting question. We found that in our review, psychiatrists and psychologists were more likely to use the SDA tools than other healthcare professionals like nurses, social care, support workers. And the hypothesis is that psychiatrists and psychologists are trained in diagnostic frameworks. So these tools already naturally fit into their way of working and practicing whereas other professionals may be more focused on relationships and how we get the young people to function again. So sometimes they might see less value in using a structured and a little inflexible way of ⁓ communication. And I think organizational factors also play a role. So sometimes certain professions may have better access to training, supervision, and the resources needed to implement these SDA tools.
Mark Tebbs: And is the research at a point where there is a balance of opinion in favour versus not in favour? I'm wondering, you you've described the kind of drawbacks and the potential kind of advantages. I just wondered whether there's like a growing clinical consensus on one approach over the other.
Dr. Salah Basheer: Yeah, I don't think at this point we have that consensus. For example, if you look at the guidelines, there are only one guideline in terms of NICE guidelines in UK, where they kind of recommend using this tool as an add-on to assessment in depression. And so at this point, there is no consensus, there is a lot of, at least from what our review is showing, is that there is a lot of promise. I think more work is already being undertaken to kind of see how this kind of fits, where it fits, as I said before, where it fits and how it fits and how to kind of address these challenges which are described in terms of clinch concerns using different solutions. once that comes through, I think there will be more clarity on how to go forward in terms of policy changes.
Mark Tebbs: Brilliant, thank you. So maybe what further research is needed to be able to kind of grow that consensus and build that evidence base?
Dr. Sue Fen Tan: Yeah, I think ⁓ if we think about, know, in terms of having more research on how it impact clinical outcomes and not just diagnostic accuracy, maybe we need to explore a little bit about the feasibility and cost effectiveness in an already stretched and resource constrained service. Obviously understanding the user's perspective, in terms of clinicians and children, young people and their families, so that we can refine the tools for real-world application. And then seeing how these SDA tools can support multidisciplinary teams and not just psychiatrists and psychologists. And see whether digital and hybrid delivery formats now with AI and all sorts of online tools Can this be more scalable and accessible to everyone?
Mark Tebbs: Okay, so, Salah is it a we're a point where the systematic review is adding to the body of evidence rather than, providing a definitive steer to that kind of policy could you let us know where we are in that journey?
Dr. Salah Basheer: Yeah, as I said before, we are still not at the point where we have kind of reached where we have, we can kind of make policy recommendations, but it actually adds to the literature at this point, adds to the growing literature and it kind of identifies kind of what the problem areas are in terms of where the research is lacking and where what kind of can help this move forward. So there is evidence in very specialized, kind of very isolated clinics and very specific clinics where there is some evidence where it helps with improving diagnostic assignments and not missing diagnosis. But when you look at CAMHS as a whole perspective, it's still not there yet in terms of evidence building. And as we were discussing, CAMHS is quite multidisciplinary in its nature. And we need to kind of look at what are the implementation challenges and then look at efficacy as well. Without getting that buy-in from clinicians and other stakeholders, it's very difficult to kind of really see how effective it is in terms of improving service outcomes like referral decisions or in terms of getting them into specific evidence-based treatments. So that's what we want really. It's not just about diagnosing. It's about kind of how can we get people in the right care at the right time. that's the aim. But I think it's just about sorting the implementation challenges as well. Also building more research which are real world setting.
Mark Tebbs: Yeah, brilliant. But we focus a lot on clinicians and the kind of evidence base. I'm kind of like wondering about families and young people themselves. what's the feedback in terms of children and young people? Do they like using it? You know, are they, involved in the development of it? What does what does it look like from the child or family's perspective?
Dr. Sue Fen Tan: Yeah, I think that is is ⁓ lacking when we try to do the review. I think it's important to understand that young people and service users and their family, they need to highlight when questions feel confusing, stigmatizing or irrelevant and see whether this is actually acceptable to them. Does it reflect real world language? some of the lingos that young people use, are they culturally sensitive and accessible across different age groups and literacy levels. I think if people feel like the tool makes sense to them, then they're more likely to engage with it meaningfully.
Dr. Salah Basheer: Yeah, I can just add there in terms of development of these tools, there is lots of involvement from young people when this is being developed, but more work needs to be done in terms of modernizing it, in terms of the new world with a of IT access and all. So there is... So yeah, so I just wanted to add that as well because there is scope for improvement, but there is some promise in terms of like for example, in the large study which was done by Professor Sayal, which is a state study trial, they had a lot of good uptake from parents and carers, many of them who were almost 80 % actually filled up the questionnaire. So there is a good uptake in that sense.
And even following this review, has been some qualitative work as part of the trial where they also, the young people and families really appreciated having access to such tool. They feeling a little bit of sense about what's happening, some clarity about what could be done. So I was feeling some that the problems are real for example. So those kinds of things have come through. But I think as Sue was saying, more works needs to be done in that area, at least from the previous literature where there was less studies looking specifically at this aspect.
Mark Tebbs: Yeah, I think for a lot of parents, can feel like the referral just goes into a black hole and they don't get a response. So I can imagine that people feeling like the assessment was progressing, felt like there was kind of progress and that the services were responding in some way. So I can imagine that, you know, there was some positive responses from families. You mentioned a little bit about emerging technologies. So I'm wondering about whether there's any thoughts around how SDAs could be used with AI, for example, to kind of like maybe address some of the resource challenges that you mentioned of kind of undertaking the assessments. is that being researched? or is that a little bit further ahead?
Dr. Sue Fen Tan: I think AI is everywhere now, whether we like it or not. And I think it has a potential sometimes to streamline assessments, maybe in terms of like personalizing recommendations and identify some of the patterns that might be missed in standard approaches.
Dr. Sue Fen Tan: So for example, ⁓ AI could adapt the style of questioning in like a real time manner. So ⁓ it reduces the length of and the number of questions that families need to complete. And it makes the assessment more efficient. But I think with AI, ⁓ there are some issues around data privacy, the bias in terms of its algorithm, and ⁓ not everyone can access AI and technology this might cause healthcare excess inequality in an already underrepresented population.
Mark Tebbs: Yeah, digital exclusion is such ⁓ a massive issue as these technologies take hold and become more prevalent. Salah, I'm just wondering, as researchers, what would you like to see next happen in this debate further?
Dr. Salah Basheer: Yeah, so as I alluded to earlier in terms of I'm already kind of involved in certain work where they're looking at where exactly this would fit in in camps, for example, and kind of building can be embedded in the system in the CAMPS practice. Is there some digital kind of solutions, like we are talking about AI, but even basic digital solutions where they can get some kind of flagging when these tools are completed so that when they are kind of going to the assessment process, they kind of are aware of it. So those kind of simple solutions can help. And so that we can kind of get those clinicians buying and also then look at how it is effective in terms of outcomes. So I think that could be the next step. And that is what the work is happening.
Dr. Sue Fen Tan: I think it'll be interesting to see what research comes out of SDA tools and how they can be applied successfully in a canned setting.
Mark Tebbs: Brilliant. Cool. We're coming to the end of the podcast. It's been really super interesting talking to you both. I just wonder whether each of you have got like a final take home message for our listeners. Maybe Salah, do want to go first and then we'll hear from Sue?
Dr. Salah Basheer: Yeah, of course. So what I would want to emphasize to the listeners is that we are not talking about a state tool kind of replacing clinical practice. We are kind of talking about whether we can kind of help, whether it can use an add-on. And so that's what we're talking about. And we are not talking about replacing clinical practice. And what we want, what we hope is that this would kind of be beneficial in some way and whether we can kind of build on the work done so far so that we can get the clinician buy-in before we kind of discuss this in terms of routine practice.
Dr. Sue Fen Tan: Yeah, and well. I think a tool is only as good as the buy-in, the actual application. And if people don't find it user-friendly and they don't want to use it, then the tool won't be good in real-world setting. And like Salah said, I just want to echo that you know, the human touch in a clinic setting, that empathy, that shared decision making, that's not something that the SDA tool can replace.
Mark Tebbs: Yeah, brilliant. So lots of opportunity, but also some more work to be able to overcome some of those kind of barriers and streamline processes so that it's a more user friendly tool. Brilliant. Thank you so much for this conversation. It's been really, really interesting. If listeners have enjoyed the podcast, then it'd be great if you could leave a review in your platform. And thank you for listening.
Dr. Sue Fen Tan: Thank you for listening.
Dr. Salah Basheer: Thank you.