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. 2025 Nov;29(61):1–34. doi: 10.3310/GJKS0519

Clinical and cost-effectiveness of a standardised diagnostic assessment for children and adolescents with emotional difficulties: the STADIA multi-centre RCT.

Kapil Sayal, Laura Wyatt, Louise Thomson, Grace Holt, Colleen Ewart, Anupam Bhardwaj, Bernadka Dubicka, Tamsin Marshall, Julia Gledhill, Alexandra Lang, Kirsty Sprange, Christopher Partlett, Kristina Newman, Sebastian Moody, Helen Bould, Clare Upton, Matthew Keane, Edward Cox, Marilyn James, Alan Montgomery
PMCID: PMC12641346  PMID: 41239894

Abstract

BACKGROUND

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.

Plain language summary

Emotional difficulties are common in children and young people, and many may be referred to Child and Adolescent Mental Health Services. Referrals are sometimes rejected because of insufficient information. Even if the referral is accepted, a clinical diagnosis is often not reached. A correct diagnosis is vital so that the right help can be offered. We investigated whether a standardised online information-gathering package (development and well-being assessment) helps with the assessment and diagnosis process in Child and Adolescent Mental Health Services. We invited children and young people and their families, following a routine (non-urgent) referral into Child and Adolescent Mental Health Services, from eight National Health Services Trusts across England. One thousand two hundred and twenty-five (1225) families took part – half received usual care (control group), and half received usual care and were also asked to complete the development and well-being assessment (development and well-being assessment group). Families also completed questionnaires about the child’s/young person’s mental health at the beginning of the study and then 6 and 12 months later. Child and Adolescent Mental Health Services clinical records were reviewed 12 and 18 months after joining the study to look at what care was offered and received through Child and Adolescent Mental Health Services. We also interviewed a range of young people, family members and staff in Child and Adolescent Mental Health Services about their views and experience of using the development and well-being assessment and the summary development and well-being assessment report. At 12-month follow-up, there was no difference in the number receiving an emotional disorder diagnosis; 11% in the development and well-being assessment group and 12% in the control group. The same was found at 18 months (14% vs. 15%). There was no difference between the groups in the time taken to reach a diagnosis or to offer or start treatment, nor was there any significant impact on whether Child and Adolescent Mental Health Services accepted the referral. The interviews showed that young people and families found the development and well-being assessment and report to be useful; however, the development and well-being assessment report was not used consistently, as intended, by clinicians during assessments to aid diagnosis. These findings show that completing the development and well-being assessment after referral into Child and Adolescent Mental Health Services did not have any impact on whether a diagnosis was made by Child and Adolescent Mental Health Services or on the care received.

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