Investigating the expectations and reality of child and adolescent mental health: considering treatment outcomes, outcome expectancy and illness belief models for anxiety and depression and the role of clinicians in management

The primary aims of this thesis were to investigate the outcomes achieved by young people with anxiety and depression following treatment by specialist child and adolescent mental health services, the treatment outcome expectancies and illness belief models of young people, and how clinicians are currently managing outcome measurement and treatment outcome expectancies in practice. Study 1 consists of a systematic review and meta-analysis, which investigates the outcomes of routine specialist mental health care for young people with anxiety and depression. Results indicate that only approximately 38% of young people who access specialist mental health treatment show measurable improvement. Study 2 used qualitative methods to explore young people’s expectations of treatment outcomes and beliefs about their anxiety and depression, assessed across the dimensions outlined in the Self-Regulatory Model (Leventhal, Meyer, & Nerenz, 1980). Illness perceptions were multifactorial and highly idiosyncratic, suggesting the need to develop a valid and reliable tool to measure illness perceptions in this group. Study 3 aimed to address this by using mixed methods to develop modified, anxiety and depression specific versions of the revised illness perceptions questionnaire (IPQ-R) (Moss-Morris et al., 2002). Item development and modifications, along with the psychometric properties of the new measures, are reported. Overall, results suggest that the IPQ-Anxiety (IPQ-A) and IPQ-Depression (IPQ-D) are valid and reliable tools for measuring illness perceptions. Study 4 aimed to explore illness perceptions and mental health variables as predictors of treatment outcome expectancy among young people with a history of anxiety and depression. Young people’s cognitive representations of anxiety and depression differed across domains, highlighting that although the conditions co-occur, they are experienced and perceived independently. Results also indicated that greater treatment control beliefs and religious and spirituality beliefs were associated with more positive treatment outcome expectations in youth with history of both anxiety and depression. Study 5 used quantitative methods to investigate CAMHS professionals’ attitudes to routine outcome measurement (ROM) and the barriers to implementation in practice according to the theoretically derived dimensions and the Capability, Opportunity, and Motivation Model of Behaviour COM-B (COM-B) (Michie, Van Stralen, & West, 2011). ROM can serve as a useful clinical tool to monitor outcomes and manage expectations, providing both the practitioner and the young person with some degree of objective feedback about the degree of change. The findings of this study suggest that there are several psychological, motivational and structural barriers to usage, which map on to a number of intervention functions. Study 6 used a qualitative approach to better understand child and adolescent mental health practitioners’ views, feelings and experiences in relation to managing treatment when outcomes have not improved. This is the first study, to date, to utilise the COM-B Model within this context. Results highlight that practitioners face several key challenges in practice, including pervasive resource constraint and an obligation to manage ongoing risk. The results of this thesis can inform evidence-based communication between young people, families and practitioners to facilitate young people’s involvement in shared decision-making and choice regarding their own treatment