We are the Association for Child and Adolescent Mental Health or ACAM for short. And this is ACAM Learn. Hello and welcome to Mind the Kids podcast series. Today we're talking about the acceptability and effectiveness of standardised diagnostic assessment approaches in children and young people's mental health services. Standardised 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, increase in demand. So it's really great to be speaking with Dr. Salah Basheer and Dr. Sue Fen Tan, who recently published their paper entitled A Review Article, The Acceptability and Effectiveness of Standardised Diagnostic Assessment Approaches in Children and Young People's Mental Health Services, An Updated Systematic Review. And this was published in ACAM's journal of the Child and Adolescent Mental Health. Salah, Sue, it's great to have you with us. Thank you. Nice to meet you, too. Thank you so much for having us. Look, let's start with some introductions. It'd be 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. So maybe, Salah, do you want to start us off? So I'm Salah, 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 hyperactivity disorder, as well as the relation with sleep and mental health in those people who are suffering from ADHD. And so for this work, I actually a part of-- with Sue, I worked with Professor Kapil Sayal, who is the mentoring author on this work, who has also done quite a bit of research, specifically looking at standardised diagnostic assessment, namely the STADIA clinical trial, which looked specifically at this. Apart from Kapil Sayal, this work also, we had other co-authors, Dr. Majumder and Dr. David, who are all consultant child and adult psychiatrist, who also collaborated with the work. 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. Great stuff. So look, let's dive in. It'd be great to start with a 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? So our motivation, basically, to look at in terms of whether the standardised diagnostic assessment are effective and are acceptable in real-world child and adolescent mental health services. 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 the thinking around it was about whether the standardised diagnostic assessment tools, will it help in the situation in some way? And because of this topical reality, we wanted to do a systematic review at this point in time because the previous systematic review was quite a while back, in 2013. So we wanted to know what new evidence have come through and to see if there is any new learnings that can be taken forward. Brilliant. So before we dive into some of that detail, it'd be good to just to maybe 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 different to maybe traditional CAMH service referral process. Shall I take that one? So yes, SDAs are short for standardised 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 standardised. 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 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. So, Salah, you mentioned there came the demand pressures in CAMH services. So what are the advantages of using SDAs, and maybe what are some of the drawbacks or controversies of that approach? So that's a good question. What we think, again, in terms of how we expect that to work is where, for example, if in a referral setting, what happens most times is that a CAMHS referral is sent by a 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 SDA tool which is being filled by the carer or the teacher or the parent, that could give information in a very systematic, structured format to a clinician who is deciding on whether to accept the referral and also where which services would be appropriate for this child. So that could help streamline the process a little bit in terms of referral. Apart from that, there is also possibilities where in terms of whether if a SDA is done in terms of specialist setting, for example, I have worked in certain specialist settings, which uses these tools, and what they do is they send this questionnaire to parents 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 making the best use of time, I guess, in terms of that clinical appointment. So that there is a clarity, which is quite essential in going forward. So that would be the benefits of it. The disadvantage in my perspective would be in terms of whether it could 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 kind of concerns are the problems, I guess. So is it largely used as a data gathering, as part of the assessment process, or is it often used as a screening tool? What part of the pathway does it sit within? So this question, it can be used in multiple ways. So there are different kinds of tools, and it can be used in multiple ways. One of the thing is we have to look at where it is used as well and where it would be more beneficial as well. So if you look at-- sometimes it's used, as I said, in referral screening, just to get information for 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 clinician. So it can be used in multiple ways. And one of the challenges, we'd be also looking at where it would fit best. Sue, I don't know if you wanted to add anything from your experience around some of the pros and cons of using tools. Yeah, of course. So I think the main advantage is the thoroughness, the completeness, and the consistency of the SDA itself. And just like Salah mentioned, 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, were obviously the clinicians need proper training. And if we over rely on such as 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. That's really helpful. And is it like, you use it at all ages? Is there a cutoff that is only applicable at a certain point in time? So there are certain tools which can start from age 2 onwards. So there's as early as 2, for example, DAWBA, which is one of the tools which are being used. So that can start from 2 to even adult ages there. But if you look at some other tool, like MINI-KID, KSADS, it is a little later at 6 or 8. So there is difference in which tool can be, and it's based on how it has been standardised, too. Brilliant. So it's be 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. 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 was three tools. One is DAWBA. Then there was this MINI-KID and KSADS. So these were the three tools which came through. There are a 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 has 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 there as well. For example, MINI-KID is one of the shortest one out of the three. So it is quite structured as well. There is no way to add in your description. There is no space for that for MINI-KID, 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 be used that. But when you come to DAWBA, it's a semi-structured, where there is a lot of structured question, but there is also a prompt where you can put in more details to it as well. So DAWBA, in that way, that is advantages. In some sense, in some setting, it may be 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 in terms of DAWBA is the fact that 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 helps in setting like referral acceptance or before appointment assessment kind of thing. So now coming to KSADS, it's more clinical 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 specialised setting as well. So there are certain differences, subtle differences. But overall, all these tools are quite comprehensive, very structured, mapping onto diagnosis, and helps avoid missing problems with the child or a child may have. Brilliant. So they've got some differences, but fundamentally, they're all about collecting comprehensive information, the accuracy of the diagnostic process and that consistency between different clinicians. That's really helpful. So what does the research say? Does it point to the use of those tools improving some of that kind of referral process' consistency and accuracy? So the research from the review, what we found was that SDA tools do help in avoiding missing diagnosis because it's quite comprehensive, and that's been shown in terms of clinic setting. If you are using a SDA tool, it helps avoiding missing diagnosis. And there was, in terms of evidence base, there is evidence in terms of helping with 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, it was DAWBA, which was shown to have that effect in terms of helping with the referral decisions. But in terms of findings, what came through was 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. Sue, could you expand on that a little bit, just particularly those drawbacks? So what were the practical concerns about the use of SDAs? So I think in the review, we found that some clinicians were quite concerned around diagnostic labels and the practicality in everyday practise. I think some clinicians worry that if we use these tools, they might push us into labelling children too quickly, or we oversimplify their complex needs. So I think some of the clinicians feel that it's more important for children and young people to be able to access services 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 to have a diagnosis given so young. And sometimes clinicians tend to use a vague diagnostic terminology because, well, for various reasons, again, sometimes diagnoses can be stigmatising. Sometimes this diagnosis follow the children, young people around into adulthood, and a few people have their diagnosis reviewed in later life. So that's why there's this real reluctance of assigning a diagnosis early on. One of the strengths of the SDA tool is around diagnostic assignment, then clinicians who don't favour giving children diagnoses will be less inclined to use it. And I think sometimes in a very busy clinical setting, to do your clinical interview and then top it up with an SDA, which might be a bit lengthy, isn't really the most practical thing. So I think there's a risk that with all these concerns, there 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 practise rather than replace what is essentially a holistic information-based practise. So that makes perfect sense. I guess, is the uptake of the tools different in different clinical professions? I guess, the referral process is a multidisciplinary process. So is it more acceptable to certain professions and others? 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 health 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 organisational 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. Is the research at a point where there's a balance of opinion in favour versus not in favour? You've described the drawbacks and the potential advantages. I just wondered whether there's a growing clinical consensus on one approach over the other. 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 recommend using this tool as an add-on to assessment in depression. 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 see how this fits, where it fits-- as I said before, where it fits and how it fits and how to address these challenges, which are described in terms of clinicians' concerns using different solutions. So once that comes through, I think there will be more clarity on how to go forward in terms of policy changes. Brilliant. Thank you. Sue, maybe what further research is needed to be able to grow that consensus and build that evidence base. I think if we think about 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, both 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? Salah, are we at 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? As I said before, we are still not at the point where we have reached where we can make policy recommendations. But it actually adds to the literature. At this point, it adds to the growing literature. And it identifies what the problem areas are in terms of where the research is lacking and what can help this move forward. So there is evidence in very specialised, very isolated clinics, and very specific clinics where there is some evidence where it helps with improving diagnostic assignments and not missing diagnoses. 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 nature. And we need to 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 really say 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 how can we get people in the right care at the right time. So 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. Brilliant. We focus a lot on clinicians and the evidence base. I'm wondering about families and young people themselves. What's the feedback in terms of children and young people? Do they like using it? Are they involved in the development of it? What does it look like from the child or family? I think it's where [AUDIO OUT], which is lacking where 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, stigmatising, or irrelevant and see whether this is actually acceptable to them. Does it reflect real-world language? Some of the lingo 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. 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 modernising it in terms of the new world with a lot of IT access and all. So there is-- so I just wanted to add that as well because there is scope for improvement. But there is some promise in terms of, for example, in the larger study which was done by Professor Sayal, which is STADIA 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, there has been some qualitative work as a part of the trial, where they also, the young people and families, really appreciated having access to such tool, feeling a little bit of sense about what's happening, some clarity about what could be done. So I was feeling that the problems are real for some. So those kind of things have come through. But I think, as Sue was saying, more work needs to be done in that area, at least from previous literatures where there was less studies looking specifically at this aspect. I think for a lot of parents, it 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 progress, and that the services were responding in some way. So I can imagine that 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 maybe address some of the resource challenges that you mentioned of undertaking the assessments. Is that being researched, or is that a little bit further ahead? I think AI is everywhere now, whether we like it or not. And I think it has the potential sometimes to streamline assessments, maybe in terms of personalising recommendations and identify some of the patterns that might be missed in standard approaches. So for example, AI could adapt the style of questioning in a real-time manner. So it reduces the length 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 access inequality in an already underrepresented population. 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? So as I alluded to earlier, in terms of I'm already involved in certain work where they're looking at where exactly this would fit in in CAMHS, for example, and it can be embedded in the system, in the CAMHS practise. Is there some digital kind of solutions? We are talking about AI, but even basic digital solutions where they can get some flagging when these tools are completed so that when they are going through the assessment process, they are aware of it. So those simple solutions, can that help, so that we can get those clinician buy in and also then look at how it is effective in terms of outcomes. So I think that would be the next step. And that is what the work is already happening. I think it will be interesting to see what research comes out of SDA tools and how they can be applied successfully in the CAMHS setting. 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 a final take-home message for our listeners. Maybe, Salah, do you want to go first, and then we'll hear from Sue? Yeah, of course. So what I would want to emphasise to the listeners is that we are not talking about SDA tool replacing clinical practise. We are talking about whether we can help, whether it can be used as an add-on. And so that's what we are talking about. And we are not talking about replacing clinical practise. And what we want-- what we hope is that this would be beneficial in some way and whether we can build on the work done so far so that we can get the clinician buy in before we discuss this in terms of routine practise. 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 the human touch in a clinic setting, that empathy, that shared decision-making, that's not something that the SDA tool can replace. Brilliant. So lots of opportunity, but also some more work to be able to overcome some of those 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. Thank you for listening. Thank you. [MUSIC PLAYING]