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A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques

A systematic review of shared decision making interventions in child and youth mental health:... Reviews around interventions to improve shared decision making (SDM) for child and youth mental health have produced inconclusive findings on what approaches increase participation. Importantly, the previous reviews did not explore the use of theory, as well as mechanisms of change (intervention functions) and active units of change (behaviour change techniques). The aim of this review was to explore these factors and ascertain how, if at all, these contribute to SDM. Five databases were searched up until April 2020. Studies met inclusion criteria if they were: (a) an intervention to facilitate SDM; (b) aimed at children, adolescence, or young people aged up to 25, with a mental health difficulty, or their parents/guardians; and (c) included a control group. Data were extracted on patient characteristics, study design, intervention, theoretical background, intervention functions, behaviour change techniques, and SDM. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Eight different interventions met inclusion criteria. The role of theory to increase SDM remains unclear. Specific intervention functions, such as ‘education’ on SDM and treatment options and ‘environmental restructuring’ using decision aids, are being used in SDM interventions, as well as ‘training’ for clinicians. Similarly, behaviour change techniques linked to these, such as ‘adding objects to the environ‑ ment’, ‘discussing pros/cons’, and clinicians engaging in ‘behavioural practice/rehearsal’. However, as most studies scored low on the quality assessment criteria, as well as a small number of studies included and a low number of behaviour change techniques utilised, links between behaviour change techniques, intervention functions and increased participation remain tentative. Intervention developers and clinicians may wish to consider specific intervention functions and behaviour change techniques to facilitate SDM. Keywords Shared decision making · Child mental health · Youth mental health · Behaviour change · Interventions Introduction The last 50 years have seen a shift from the paternalistic model of health, towards one, where patients are actively * Daniel Hayes involved in shaping and developing healthcare [1]. This [email protected] can occur across different levels of the healthcare system 1 including service redesign, where patients play a role in Evidence Based Practice Unit, University College London reviewing and developing interventions, through to treat‑ and Anna Freud National Centre for Children and Families, 4‑8 Rodney Street, London N1 9JH, England ment decision making [1]. This concept, referred to a shared decision making (SDM), acknowledges that both clinicians Child Attachment and Psychological Therapies Research Unit (ChAPTRe), University College London and Anna and patients have expertise which is important [2]. In the Freud National Centre for Children and Families, 4‑8 Rodney context of making decisions around an individuals’ own care Street, London N1 9JH, England and treatment, the clinician brings their professional knowl‑ Health Services and Population Research Department, edge and clinical experience, whilst the patient brings a lived King’s College London Institute of Psychiatry, Psychology experience of their illness and what would fit with their life‑ and Neuroscience, De Crespigny Park, London SE5 8AF, style [3]. Through joint communication, understanding and England Vol.:(0123456789) 1 3 European Child & Adolescent Psychiatry deliberation, both parties should arrive at an option for care Second, grouping interventions by overarching approach and treatment which they deem acceptable [4]. neglects the unique features within each, which may cause More recently, the concept of SDM has been applied to individuals to behave in different ways. If, as models and children and young people [5]. Involvement in such decisions experts suggest, SDM is a set of behaviours or skills that can is enshrined in the United Nations Convention on the Rights be taught to stakeholders [10, 23–26], then it is important, of the Child [6]. Here, articles 12 and 13 are particularly rel‑ within each approach, to understand the specific ways in they evant to care and treatment decisions, outlining that the views attempt to change behaviours to facilitate SDM. and opinions of the child should be given consideration in line The behaviour change wheel is an amalgamation of 132 with their age and maturity. In treatment decisions, whilst different behaviour change constructs and is an ideal lens in this may not mean that the child or young person has ultimate which to explore SDM behaviour [16]. Within this, interven‑ decisionmaking po ‑ wer, it does highlight that at a minimum, tions may be broken down into both intervention functions they should be allowed to express their own views and opin‑ and behaviour change techniques [27]. Identification func‑ ions and have these taken into consideration [7]. tions refer to the underlying causal mechanisms of change Models have been developed to try and better facilitate responsible for changing behaviour. Nine different interven‑ SDM in clinical practice [4, 8–11]. These conceptualise dif‑ tion functions exist: ‘Education’, ‘Persuasion’ ‘Incentivisa‑ ferent aspects of SDM as skills, competencies and behaviours tion’, ‘Coercion’, ‘Enablement’, ‘Training’, ‘Modelling’, that can be taught to those involved in the decision‑making ‘Environmental Restructuring’, and ‘Restriction’. In the con‑ process. One of the most widely cited models, an integrative text of SDM, ‘Education’ could refer to increasing patient model of SDM, identified 13 elements which should be pre‑ knowledge around options, whilst ‘Training’ could be where sent, as well as 10 general qualities which clinicians should clinicians are taught how to elicit preferences. have [10]. However, this model was developed from literature Further to the nine intervention functions, 93 behaviour mainly situated in adult physical health, meaning that key change techniques also exist. These refer to the smallest aspects may have been missed when involving children and components of behaviour change interventions that, on young people with mental health difficulties. their own and in favourable circumstances, can bring about In the field of child and youth mental health, both generic change [27]. For SDM, examples of these could be incorpo‑ [12, 13] and context specific [14, 15], models have been rating the use of a decision aid into the clinical encounter; developed. Many have core overlapping features, such as dis‑ which would correspond to the behaviour change technique cussing values, preferences, and options, as well as arrang‑ ‘adding objects to the environment’. Whilst the comparison ing follow up [16]. However, differences also exist, such of different options on the decision aid would map onto the as whether they are aimed at parents/guardians or young behaviour change technique ‘pros/cons’. people, and whether there needs to be explicit agreement A recent study drawing on secondary data analysis from among all stakeholders prior to a decision being made [16]. a 2014 Cochrane review [28] has explored the role of behav‑ In addition to models, a number of interventions to facilitate iour change techniques in SDM [29]. In the 87 included SDM in child and youth mental health have been developed. interventions, 7 different intervention functions and 32 These have been categorised into six overarching approaches: behaviour change techniques were identified. Within this, therapeutic techniques, psychoeducational information, deci‑ the most common intervention function used was ‘educa‑ sion aids, action planning or goal setting, discussion prompts, tion’ and the most common behaviour change technique was and mobilising patients to engage [17]. Reviews exploring the ‘information about health consequences. Whilst this is use‑ effectiveness of approaches have produced inconsistent results, ful in providing an initial framework, there were no included with some interventions being effective in improving partici‑ interventions in child and youth mental health. Given the pation in decision making in certain circumstances [17, 18]. unique properties of this population, such as multiple stake‑ Two important limitations exist which may account for holders and capacity due to age and having a mental health these differences in effectiveness of different approaches difficulty[ 30], establishing behaviour change techniques [16] First, whether the interventions used theory was not within this population is needed. examined. The use of theory is important as it not only Inspecting intervention functions and behaviour change allows for the identification of causal determinants of change techniques may allow researchers and intervention develop‑ and mediators, but also allows a space in which theories can ers to better understand the drivers of change that are present be tested and evaluated [19]. Reviews of interventions across in tools that facilitate SDM for care and treatment decisions. healthcare settings indicate that the use of theory can lead to Given the above, this study will undertake a review of the more effective outcomes [20, 21]. Within the field of SDM, literature and explore the impact of theory, intervention there is tentative support for this notion, where computerised functions, and behaviour change techniques on SDM around decision aids underpinned by theory were more likely to lead patient treatment decisions in child and youth mental health. to increases in participation [22]. Specific research questions: 1 3 European Child & Adolescent Psychiatry Table 1 Inclusion/exclusion criteria Inclusion criteria Exclusion criteria Population A child or young person (up to the age of 25) with a diagnosa‑ Studies where the presenting difficulty is physical health ble or non‑diagnosed mental health difficulty, or their parent/ guardian Intervention Any intervention, approach or tool (e.g., online decision aids, Interventions whose primary aim is not facilitate in care and mobile applications and training) aimed at facilitating deci‑ treatment decisions sion making around care and treatment Comparator Studies where an there is an intervention and control arm. This Studies where there is no control arm can include non‑randomised control studies Outcome Includes a measure examining the process of SDM (e.g., using Includes only an outcome measure related to SDM (e.g., the SDM‑Q‑9 (Kriston et al., 2010) or CollaboRATE (Elwyn decisional conflict) without also including a process meas‑ et al., 2013). Unvalidated measures will be included. Out‑ ure. This is because measuring decision outcome is not a comes can be reported by any individual (e.g., child/ young meaningful indicator of quality, as the eventual outcome can person, parent/guardian, healthcare professional) be dependent upon many external factors (Elwyn, Elwyn, & Miron‑Shatz, 2009) Study Design Randomised and clinical control studies Qualitative studies and case studies. Studies not reported in English. Conference presentations will be excluded as these have been found to differ substantially from peer ‑reviewed papers on outcome metrics (Balshem et al., 2013) Other English language Language other than English Any date/timeframe N/A 1) What theory is being used to facilitate SDM in child and is included in the supplementary material. Eligibility criteria youth mental health? are outlined in Table 1 and were developed in line with the 2) What intervention functions are being used to facilitate research questions. Studies were limited to English language SDM in child and youth mental health? and peer reviewed publications. Database searching was not 3) What behaviour change techniques are being used to limited to a particular timeframe. facilitate SDM in child and youth mental health? To identify additional records, reference checking of 4) Does the inclusion of the above aspects lead to increased the following articles was undertaken: (a) those at sec‑ SDM in child and youth mental health? ond stage screening that focused on SDM and children and young people but had no evaluation (n = 234) and (b) those that met full inclusion criteria. In addition, consul‑ tation with researchers in the field of SDM via an online Method Facebook group and at the International Shared Decision‑ Making (ISDM) conference during a child and youth mental A team of individuals with a knowledge of SDM in child and health panel. The study selection was completed using a youth mental health was convened. Expertise and knowl‑ two‑stage process by two researchers (DH, RT). The first edge included winning bids and writing papers on SDM in stage involved screening article titles and abstracts, during child and youth mental health (DH, JEC, MW), develop‑ which all records were screened by the first author (DH) and ing models of SDM in child and youth mental health (DH, 10% by the second author (RT) and any results that were MW), advising on child and youth mental health service not relevant were excluded. The second stage consisted of transformation, where SDM is a central component (DH, full‑text screening by both authors. A good inter ‑rater reli‑ JEC, MW), delivering training to clinicians on SDM practice ability was found at both first‑ and second‑stage screening (DH, RT, MW), and developing decision aids and tools to (0.78 and 0.87), respectively. The exclusion of papers at each facilitate SDM in child and youth menta health (DH, JEC, stage is highlighted in Fig. 1. For each included article, data RT, MW, NM). were extracted independently by the same two researchers Five research databases were searched up until April reading articles and available documentation line by line 2020—PsycINFO, EMBASE, Medline/PubMed, Web and extracting data using a template. This included author, of Science and Cochrane Libraries. The search strategy year and publication date, participant details, study design, included three concepts: ‘SDM’, ‘child, adolescent, or intervention, theoretical background, intervention functions young person (up to the age of 25, or their parent/guardian), and who they were aimed at, behaviour change techniques and ‘mental health’ (including both diagnosable and non‑ and who they were aimed at, as well as any SDM process diagnosable menta health difficulties). The search strategy measures. For behaviour change techniques and intervention 1 3 European Child & Adolescent Psychiatry Fig. 1 PRIMSA flowchart Addional records idenfied Database search (n = 4) (n = 9,006) Total records included for screening (n = 9,010) Total records excluded at this stage (n =8,092) Reasons Title and abstract screening (n = Not SDM resource (n = 6,765) (9,010) Physical Health (n = 1,160) Adult populaon (n = 135) No comparator (n=32) Total records excluded at this stage Full-text records assessed for (n = 910) eligibility Reasons (n = 918) Not SDM resource (n = 407) No evaluaon (n = 234) Physical Health (n = 178) Adults (n = 74) No comparator (n = 10) No process measure (n = 5) Conference abstract (n = 2) Records included in review (n = 8) functions, both researchers involved in the data extraction functions and behaviour change techniques were submitted process completed an online training (https://w ww.b ct ‑taxon to two research psychologists working in behaviour change. omy. com/). From this, one additional behaviour change technique, ‘cred‑ Authors and intervention developers of resources and ible source’, was included on some records. papers deemed acceptable for inclusion were contacted to Studies were quality assessed using the Effective Pub‑ establish whether any further information on the intervention lic Health Practice Project (EPHPP) Quality Assessment component was available (e.g., a manual or protocol). For Method [31] which is acceptable for examining both ran‑ extracted intervention functions and behaviour change tech‑ domised and non‑randomised studies [ 32]. This explores niques, a good level of agreement was obtained between the the risk of bias within studies on the following domains: researchers extracting data (Kappa = 0.81 and 0.90, respec‑ selection bias, study design, confounding variables, blind‑ tively). Any discrepancies were resolved by discussion and ing, data collection methods, and withdrawal and drop out. agreed upon by the researchers. The finalised intervention Each section is given a rating: strong, moderate or weak, 1 3 Included Eligibility Screening Idenficaon European Child & Adolescent Psychiatry and from this an overall rating is calculated. Each study that ODSF and IPDAS guidelines in intervention development met inclusion criteria was quality assessed independently [34]. by two researchers (DH & RT). A good level of agreement was obtained between the researchers (Kappa = 0.82). Any Behaviour change techniques used in SDM discrepancies were resolved by discussion and changes were interventions in child and youth mental health agreed upon by both researchers. Overall, 18 behaviour change techniques were identified across the eight interventions. The number of different Results behaviour change techniques per intervention ranged from two to 11, with a median of 7 (IQR = 5–7.5). The most fre‑ Database and hand searching returned 9010 articles. The quently used behaviour change technique was ‘pros/cons’ screening of titles and abstracts (first stage screening) which appeared in seven interventions and refers to the resulted in the exclusion of 8092 records. Next, full‑text weighing up of different options with the clinician or using screening (second stage screening) resulted in the exclusion a decision aid [33–35, 38–40, 52]. This was followed by of 910 results. A total of eight studies met the inclusion cri‑ ‘credible source’, which appeared across six interventions teria for this review. Their characteristics, including behav‑ and refers to the clinician, peer worker, or coach, provid‑ iour change techniques, intervention functions, process, and ing advice based on their expertise [33, 34, 36, 38, 40, 52]. outcome measures, are shown in Table 2. Similarly, ‘adding objects to the environment’ appeared in Of the eight interventions designed to increase SDM in six interventions. This included the use a decision aid in five child and youth mental health settings, four were aimed for instances and the use of a visualisation aid in the remaining young people as the decision maker [33–36], three for par‑ intervention [33–35, 38, 39, 52]. ents/guardians [37–39], and one for both parents/guardian The three ‘Behavioural practice/rehearsal’, ‘habit forma‑ and young people [40]. In terms of overarching approaches tion’, and ‘instructions on how to perform the behaviour’ to facilitate SDM, five interventions included decision aids each appeared in five interventions and refer to a clinician, [33–35, 39, 41] and three were therapeutic approaches [36, peer worker, or coach learning about and practicing using 38, 40]. Three papers came from the United States (US) [36, the decision aid or the therapeutic approach [33, 34, 36, 40, 40, 41], two from Australia [34, 39], one from the United 52]. ‘Information about health consequences’ appeared in Kingdom (UK) [35], one from the Netherlands [38], and one three interventions and refers to the decision aid or clinician from Japan [33]. In terms of presenting difficulties, three facilitating SDM by providing the risks or side effects of SDM approaches were not specific to a particular difficulty options [33, 40, 41]. ‘Problem solving’ appeared three times [34, 36, 38], two focused on Attention deficit hyperactivity when there was explicit discussion between stakeholders in disorder (ADHD) [40, 41], one focused on self‑harm [35], identifying patient difficulties [36, 38, 40], whilst both ‘goal one focused on depressive symptoms [33], and one focused setting’ and ‘reviewing outcome goals’ appeared twice [36, on autism [39]. 40]. The theory used in interventions to facilitate SDM Intervention functions used in SDM interventions in child and youth mental health in child and youth mental health None of the interventions explicitly outlined using one spe‑ Across the eight interventions, five different intervention cific theoretical framework. One intervention [38] followed functions were identified. These included: ‘Education’, the Ottawa Decision Support Framework (ODSF), which is ‘training’, environmental restructuring’, ‘modelling’, and a framework that incorporates multiple theories [42]. For ‘enablement’. Per intervention, the number of intervention the ODSF, this includes: expected utility theory [43], deci‑ functions ranged from three to five, with a median of 3.00 sion analysis [44], prospect theory [45], the conflict theory (IQR = 3.5–4.25). model of decision making [46], the theory of reasoned The most frequent intervention function was ‘education’, action [47], self‑efficacy [48], and factors related to social which was identified across all interventions and refers to support [49, 50]. Three interventions [33, 39, 41] specified patients receiving information about options and risks and that they had used the International Patient Decision Aids clinicians learning about SDM and how to facilitate it during Standards (IPDAS) guidelines for developing interventions. appointments. ‘Enablement’ was also identified across all The IPDAS guidelines draw on some theory to ensure that eight interventions. This refers to focusing on setting goals relevant content is included when developing decision aids and exploring clinician and patient beliefs. [51], including expected utility theory [43] and prospect ‘Training’ was found in six interventions and refers to theory [45]. One intervention outlined the use of both the clinicians, peer workers and coaches learning SDM skills 1 3 European Child & Adolescent Psychiatry ‑ ‑ ‑ ‑ ‑ ‑ 1 3 Table 2 Characteristics of interventions included in the final review Included arti Author, year of publica N Comparison and design Intervention and theo Intervention function(s) Behaviour change Process measure: deci Results cle number tion, and country retical background techniques sion making/involve ment/ participation ^ Ø 1 Aoki et al., (2020), 88 young people with a Intervention vs usual Three decision aid With young people With young people SDM (COMRADE; Duration of consultation Japan mood (depression or practice booklets (depression, ‘Enablement’ 5.1 ‘Information about Edwards et al., 2003: (Researcher rated) bipolar) disorder Randomised control trial bipolar disorder, and With healthcare workers health consequences’ YP rated) Satisfaction (YP rated) medication treatment) ‘Training’ 9.1 ‘Credible source’ Looked up treatment No theoretical back With both 9.2 ‘Pros/cons’ after (YP rated) ground specified ‘Education’ For healthcare workers Discussed options with Followed IPDAS ‘Environmental restruc 4.1 ‘Instruction on how others outside clinic turing’ to perform behaviour’ (YP rated) 8.1 ‘Behavioural prac Depressive symptoms tice/rehearsal’ at 3 and 6 months (YP 8.3 ‘Habit formation’ rated) Both young people and Persistence of treatment healthcare workers (audit records) 12.5 ‘Adding objects to Medication adherence the environment’ (YP rated) 2 Brinkman (2013), US 44 parents/guardians Intervention vs usual Preencounter cards, With healthcare workers With healthcare workers ˄ SDM (Option Scale; Knowledge (P/G rated) of young people with practice booklet, DA, and Training’ 6.1 ‘Demonstration of Elwyn et al., 2005: O Decisional conflict* (P/G ADHD, 7 paediatri Controlled clinical trial healthcare worker ‘Modelling’ behaviour’ rated) rated) cians training Both parents/guardians 7.1 ‘Prompts/cues’ Follow up calls and visits No theoretical back and healthcare workers With parents/guardians (audit records) ground specified ‘Environmental restruc 1.3 ‘Goal setting (out Prescriptions written Followed IPDAS turing’ come)’ (audit records) ‘Enablement’ 4.1 ‘Instruction on how Behavioural ratings (P/G ‘Education’ to perform behaviour’ and T rated) 5.1 ‘Information about Titration of medication health consequences’ audit records) 9.1 ‘Credible source’ Number of days covered 9.2 ‘Pros/cons’ (audit records) with Both parents/guardians medication and healthcare workers Physician satisfaction 12.5 ‘Adding objects to with choice (C rated) environment’ Ø # Ø 3 Grant (2016), Australia 81 parents/guardians Intervention vs usual An online decision aid With parents/guardians With parents/guardiansDecisional conflict Parental Sense of Com of young people with practice outlining treatments ‘Education’ 9.2 ‘Pros/cons’ (Support subscale: petency Scale (PSOC) autism for Autism ‘Enablement’ 12.5 Adding objects to P/G rated) [42] (P/G rated) No theoretical back ‘Environmental restruc the environment ground specified turing’ Followed IPDAS European Child & Adolescent Psychiatry ‑ ‑ ‑ ‑ ‑ ‑ ‑ 1 3 Table 2 (continued) Included arti Author, year of publica N Comparison and design Intervention and theo Intervention function(s) Behaviour change Process measure: deci Results cle number tion, and country retical background techniques sion making/involve ment/ participation ^ ^ 4 Hogue et al. (2016), US 3 MIP therapists and Intervention vs historical A therapeutic approach With young people and With young people and Family decision making Psychiatric evaluation 35 young people with control (MIP) promoting parents/guardians parents/guardians (O rated) completion (audit ADHD and their Controlled clinical trial family decisions about ‘Education’ 1.2 ‘Problem solving’ Non validated measure records) parents/guardians medication ‘Enablement’ 1.3 ‘Goal setting (out Prescribed any medica No theoretical back With healthcare workers come)’ tion (audit records) ground specified ‘Education’ 1.5 ‘Review behavioural Prescribed ADHD (audit ‘Training’ goals’ records) medication 1.7 ‘Review outcome Days on ADHD medica goals’ tion (audit records) 5.1 ‘Information about health consequences’ 5.3 ‘Information about social/environmental consequences’ 9.1 ‘Credible source’ 9.2 ‘Pros/cons’ 13.2 ‘Framing/ refram ing’ With healthcare workers 4.1 ‘Instruction on how to perform behaviour’ 8.1 ‘Behavioural prac tice/rehearsal’ 8.3 ‘Habit formation’ Ø # Ø 5 Rowe et al., (2018) UK 23 young people with Intervention vs usual An online decision aid With young people: With young people Decisional conflict Intended help seeking self harm practice for selfharm support ‘Education’ 9.2 ‘Pros/cons’ (Support subscale: YP (YP rated) Randomised Control No theoretical back ‘Enablement’ 12 5 ‘Adding objects to rated) Actual help seeking (YP Trial ground specified ‘Environmental restruc the environment’ rated) turing’ ^ Ø 6 Simmons et al., (2017) 149 young people ages Intervention vs historical Peer support worker and With young people and With young people SDM (SDMQ9[43] Decisional conflict (YP Australia 16–25 (presenting dif control decision support tool healthcare workers 3.1 ‘Social support (YP rated) rated) ficulty not specific), Controlled clinical trial No theoretical back : (unspecified) Satisfaction with service ground specified ‘Education’ 9.1 ‘Credible source’ (YP rated) Followed ODSF and ‘Enablement’ 9.2 ‘Pros/cons’ IPDAS ‘Environmental restruc 12.5 ‘Adding objects to turing’ the environment’ For healthcare workers For healthcare workers ‘Training’ 4.1 ‘Instruction on how ‘ to perform behaviour’ 8.1 ‘Behavioural prac tice/rehearsal’ 8.3 ‘Habit formation’ 9.1 ‘Credible source’ 12.5 ‘Adding objects to the environment’ European Child & Adolescent Psychiatry ‑ ‑ ‑ ‑ 1 3 Table 2 (continued) Included arti Author, year of publica N Comparison and design Intervention and theo Intervention function(s) Behaviour change Process measure: deci Results cle number tion, and country retical background techniques sion making/involve ment/ participation ^ ^ 7 Walker et al., (2017). US 55 high risk young Intervention vs usual A wraparound service With young people With young people Participation Youth Participation in people with mental practice for young people ‘Enablement’ 1.2 ‘Problem solving’ Youth Participation in planning (YPP) Prepa health difficulties (not Randomised Control aimed at increasing With healthcare workers 1.3 ‘Goal setting (out Planning Scale (YPP; ration (YP rated) specific). Involved in Trial collaboration and ‘Education’ come)’ Walker and Powers YPP Planning at least two systems participation in care ‘Training’ 1.7 ‘Review outcome 2007) (YP rated) YPP accountability (YP designed to support No theoretical back goals’ rated) young people (mental ground specified 3.2 ‘Social support Working Alliance Inven health and child (practical)’ tory (WAI; Horvath and welfare) 9.1 ‘Credible source’ Greenberg 1989) (YP With healthcare workers rated) 4.1 ‘Instruction on how to perform behaviour’ 8.1 ‘Behavioural prac tice/rehearsal’ 8.3 ‘Habit formation’ ^ Ø 8 Westermann et al., 71 parents/guard SDM vs usual practice: Counselling in Dialogue With healthcare workers With healthcare workers Satisfaction with Decisional conflict (C (2013). Netherlands ians of young people Randomised Control No theoretical back ‘Training’ 8.1 ‘Behavioural prac participation in shared rated) (presenting difficulty Trials ground specified ‘Modelling’ tice/rehearsal’ decision making ˄ Decision made with not specific), and 20 Followed the ODSF Both healthcare workers 8.3 ‘Habit formation’ (mothers) accurate information therapists and parents/guardians With parents/guardians (P/G rated) ‘Environmental restruc 9.1 ‘Credible source’ ˄ Accepting recommended turing’ Both parents/guardians treatment (P/G rated) ‘Education and healthcare workers Consensus on diagnostic Enablement’ 1.2 ‘Problem solving’ formulation (P/G and 9.2 ‘Pros/cons’ C rated) 12.5 ‘Adding objects to the environment’ ^ ˅ Ø 1 Measure increased, Measure decreased, No change on measure, International Patient Decision Aid Standards (IPDAS) 2 $ Ottawa Decision Support Framework, *Authors report this finding as significant at p < 0.06, Parents/guardians were allocated to choose a treatment of their choice, or be randomly allocated a treatment (no choice). The decisional conflict scale (O’Connor, 1995) is both a process and outcome measure for SDM [44]. YP rated young person rated, P/G rated parent/guardian rated, O rated observer rated, T rated teacher rated, C rated clinician rated European Child & Adolescent Psychiatry [33, 34, 36, 38, 40, 41]. ‘Environmental restructuring’ was Therapeutic approaches also present in six interventions and refers to the use of deci‑ sion aids or visual aids [33–35, 38, 39, 52]. ‘Modelling’ All therapeutic approaches improved participation in SDM was found in two interventions and refers to clinicians being [38, 40, 41]. Those that were used the most frequently shown how to use tools or approaches and then attempting between stakeholders, and provided the most evidence for to replicate that behaviour [38, 41]. increasing SDM (indicated by a statistically significant increase in the process measure utilised), included ‘problem Relationships between intervention functions, solving’, ‘pros/cons’, and ‘credible source’. For clinicians behaviour change techniques, and SDM in child and peer workers, ‘behavioural practice/rehearsal’ and ‘habit and youth mental health formation’ also showed promise. The next section explores the relationship between interven‑ Intervention functions and increased participation tion functions, behaviour change techniques, and SDM. Sup‑ in decision making in child and youth mental health plementary Tables 1 and 2 indicate the intervention func‑ tions and behaviour change techniques present within each Decision aids study and whether an increase in SDM was found. The heterogeneity of process measures and populations For decision aids, the intervention functions ‘education’, precluded the pooling of results for meta‐analysis. Six inter‑ ‘environmental restructuring’, and ‘enablement’, aimed for ventions reported a statistically significant increase for par‑ young people, parents/guardians and clinicians/peer work‑ ticipation in decision making [33, 34, 36, 38, 40, 41], whilst ers, were found to increase SDM when also paired with two did not [35, 39]. As only two different intervention ‘training’ for clinicians and peer workers. approaches were identified, each approach will be explored to see if specific behaviour change techniques, intervention Therapeutic approaches functions, and theory impact on participation in SDM. For therapeutic approaches, ‘education’ and ‘enablement’ Behaviour change techniques and increased used with all stakeholders involved in the decision‑making participation in decision making in child and youth process facilitated SDM. ‘Training’ for clinicians and the mental health health coaches also had evidence for increasing SDM. Decision aids Linking participation with wider outcomes For decision aids, the behaviour change techniques ‘add‑ The wide range of outcome measures employed and dif‑ ing objects to the environment’, ‘pros/cons’, and ‘credible ferences in whether interventions increased participation source’ showed the most promise in facilitating SDM (indi‑ in shared decision making makes drawing further conclu‑ cated by a statistically significant increase in the process sions difficult. One metric common across two studies was measure utilised). However, these techniques were only whether the young person was satisfied with treatment [33, successful when used in conjunction with other behaviour 34]. In both these instances, significant increases in shared change techniques [33, 34, 41]. These will be described decision making were found; however, neither resulted in below: increased satisfaction. Similarly, another metric, again found For young people or parents/guardians, these behaviour in two studies, was prescriptions written [40, 41]. Similar change techniques included: ‘information about health con‑ to the previous example, whilst increased participation in sequences’, ‘information about social/environment conse‑ decision making was found, this did not translate through a quences’, and ‘goal setting’ [33, 34, 41]. Whilst for clinicians change in prescriptions written. or peer workers using decision aids, these included: ‘instruc‑ tions on how to perform the behaviour’, ‘behavioural prac‑ Quality assessment for risk of bias tice/rehearsal’, and ‘habit formation’ appeared to enhance SDM when used in conjunction with ‘adding objects to the The results from the EPHPP quality assessment are depicted environment’, ‘pros/cons’, and ‘credible source’. in Supplementary Table 3. Of the eight studies, one was rated strong overall, as indicated by no weak ratings across any of the EPHPP criteria. Two were rated as moderate overall, as indicated by one weak rating across all quality assessment criteria. Finally, five studies were rated as weak Statistical significance set at p < 0.05. overall as they scoring two or more weak ratings in total. 1 3 European Child & Adolescent Psychiatry The categories ‘study design’ and ‘data collection meth‑ a wider range of behaviour change techniques may be ods’ received the highest frequency of strong ratings, whilst expected. ‘controlling for confounding variables’ and ‘making sure Of the behaviour change techniques found in this review, outcome assessors were blinded’ received the highest fre‑ some explicitly map onto the integrative framework of quency of weak ratings. SDM [10], such as ‘pros/cons’, whilst others overlap with constructs in the integrative framework, such as ‘credible source’, which corresponds with ‘professional knowledge’. Conclusions and discussion In addition, behaviour change techniques, such as adding ‘objects to the environment ‘, whilst not appearing in such The aim of this review was to explore the impact of theory, frameworks, lend themselves well to SDM, as young peo‑ intervention functions, and behaviour change techniques on ple and parents/guardians often report a lack of appropriate SDM in child and youth mental health. sources to help facilitate decision making [59, 60]. In the previous review exploring behaviour change tech‑ Use of theory in interventions niques [29], the most frequently used behaviour change tech‑ nique used was ‘information about health consequences’. In Two interventions, both which were therapeutic approaches, this review, the most common behaviour change technique were not underpinned by theory. One therapeutic approach was ‘pros/cons’. This difference could highlight the impor ‑ was underpinned by the ODSF, four decision aids utilised tance of other factors, beyond pure health outcomes when the IPDAS guidelines [51], and one decision aid used both making a decision in child and youth mental health. For the IPDAS and ODSF. Whilst both frameworks are described example, research suggests that other factors, such as finan‑ as being underpinned by theory, the degree to which the cial, educational and social, are important to the patients IPDAS is completely theoretically informed has been ques‑ and families [61], as well as their goals, values and prefer‑ tioned by some [53, 54]. In particular, critics have stated that ences [10]. However, it is important to note that whilst iden‑ the documentation related to the IPDAS guidelines section, tified behaviour change techniques differ in frequency, there ‘presenting probabilities in an unbiased and understandable appears to be considerable overlap between common behav‑ way’, is ill‑defined, not conceptually clear, and lacking in iour change techniques used in both reviews (e.g., ‘dem‑ both theoretical and empirical support [53]. These concerns onstration of behaviour’ for healthcare professionals). This have been echoed by others, with academics suggesting that may reinforce the potential of a core taxonomy of behaviour the IPDAS guidelines should be considered critically from change techniques common to SDM. both theoretical and empirical perspectives [54]. Of interest is the use of three behaviour change tech‑ If the IPDAS guidelines are included as a theory‑led niques: ‘adding objects to the environment’, ‘pros/cons’, and framework, the proportion of interventions reported here ‘credible source’ When these techniques were incorporated that incorporate theory is higher than in the previous into decision aids and used by young people and parents/ research [22, 55, 56]. However, unlike the previous reviews, guardians outside the clinical appointment, they did not no individual theories were used to develop tools to facilitate appear to increase involvement in SDM. This highlights the SDM. This may highlight the growing recognition of the expertise of both patients/carers and those within clinical theory–practice gap, which states that relying on an individ‑ settings and the importance of arriving at a joint decision ual theory will neglect other factors, such as cognition, the via discussion. Whilst factors, such as time, have been high‑ environment, or the tools themselves [57]. The ODSF is one lighted as an issue by clinicians when it comes to SDM [62, solution to this, as it incorporates multiple theories. How‑ 63], providing tools for use outside of the clinical session ever, the Theoretical Domains Framework [58] should also may not be preferable if these tools are not subsequently be considered, as it incorporates a greater number of theories discussed in the clinic. and may be used flexibly to change SDM behaviour through targeting capability, opportunity, and motivation [16]. Intervention functions Behaviour change techniques Five intervention functions were identified as having Overall, 18 out of 93 possible behaviour change techniques the potential to increase SDM. The most frequently used were identified in SDM interventions in child and youth intervention functions in this review were ‘education’ and mental health. This is less than the 32 found in the previous ‘enablement’. This suggests that intervention developers review [29]; however, as the previous review did not limit may think individuals lack the knowledge and motivation itself to any specific presenting difficulty nor population, required to participate engage in SDM and require support in overcoming these barriers. 1 3 European Child & Adolescent Psychiatry In the previous review exploring intervention functions caution should be taken when translating interventions into [29], education was the most common, followed by ena‑ UK settings, particularly as most of these interventions were blement, the discovery that ‘education’ was an intervention developed in the US and Australia, which place a greater function linked to increased participation in decision mak‑ emphasis on insurance within healthcare. This is evident in ing is supported by previous reviews of patient behaviour resources, such as the decision choice cards, in which cost change interventions [64]. Moreover, there is support in the has its own card and prices are outlined for each treatment wider literature for educating and enabling individuals as a [41]. method of increasing participation in SDM. For example, a Cochrane review of the use of decision aids across health‑ Strengths and limitations care settings found that these tools educated and enabled individuals in the following ways: they improved patients’ This is the first study to examine theory, intervention func‑ knowledge of treatment options, they helped patients under‑ tions, and behaviour change techniques for SDM approaches stand what mattered most to them, they provided patients in child and youth mental health. A strength of this study is with more accurate expectations of the risks and benefits that it examines the intervention functions and behaviour for options, and they helped patients to participate more in change techniques that are used within the decision‑making decision making [65]. process, as well as how these may increase participation in The previous review also identified training, usually with SDM. clinicians, as a common intervention function [29]. The use A further strength of this study is the use of two research‑ of training to bring about behaviour change is also frequently ers to extract the data from the papers and to conduct the reported in the literature when designing interventions [64]. quality assessments. This mitigates the risk of systematic Indeed, findings from clinicians in child and youth mental bias at data extraction stage whilst also decreasing the total health services who have tried to incorporate new SDM tools number of errors in data extraction and quality assessment and techniques into the doctor–patient encounter report feel‑ [69]. With respect to the data extraction, online training ing apprehension at the start of the process [66]. Clinicians was completed by both researchers to ensure consistency also reported that prior to SDM tools being incorporated in identifying and recording behaviour change techniques. into their practice, there was a stage of ‘feeling clunky’ [66]. High levels of agreement were obtained, indicating strong This could suggest that further training, as well as model‑ inter‑rater reliability. ling, may be useful in expediting the acceptance of tools and A limitation of this review is that not all records were techniques in clinical practice. double screened, thus, whilst a high interrater reliability was reached, some articles may have been missed. A further Wider findings limitation of this review is that studies did not report on the fidelity to the model or approach they were implementing. It is too early to establish how participation in decisionmak ‑ ‑ Thus, we cannot say the degree to which behaviour change ing links with wider outcomes. This is due to a very small techniques outlined in the papers were actually followed. sample of overlapping outcomes, both of which tentatively As implementation has been found to affect outcomes [70], suggest that increased participation in decision making future studies into SDM interventions should report fidelity had no effect on satisfaction or prescriptions written. This to the approach/model. In addition, most studies gave little fits with the wider literature in adult mental health, where or no information about the control group, which meant that research on this topic is also inconclusive [67]. Whether the behaviour change techniques used here were often left or not shared decision making results in additional positive unexamined. These studies also did not examine the skill benefits, it is important to remember that many young people of the clinician, or the amount of time they had been in the feel powerless and left out of care and treatment decisions, profession, which may also affect findings. Limitations of and that any intervention that facilitates this should be wel‑ the EPHPP tool [31] also exist. Whilst it allows for com‑ comed, as their right for involvement enshrined in the UN parison between randomised and non‑randomised studies, rights of the child [6]. some areas of bias, such as performance, assessment, and Previous reviews have highlighted that the majority of publication bias are not included. This could change the approaches and evaluations to facilitate SDM focus on dif‑ quality assessment ratings of studies if they were able to be ficulties, such as ADHD and autism [ 17, 18]. Within this taken into account. Finally, whilst information is provided on review, the range of difficulties targeted by interventions whether the interventions produced a statistically significant appears to be more diverse, as it includes self‑harm and change in SDM, this does not explain if the interventions depressive symptoms. This is a welcome development as were clinically effective. Missing information in some man‑ research suggests that lower levels of SDM may be related to uscripts precluded the author’s ability to explore relation‑ the severity rather than type of difficulty [16, 68]. However, ships between effect size and intervention characteristics. 1 3 European Child & Adolescent Psychiatry 8. Entwistle VA, Watt IS (2006) Patient involvement in treatment Researchers should consider providing information regard‑ decision‑making: the case for a broader conceptual framework. ing effect sizes in published manuscripts in the future. Patient Educ Couns 63:268–278. https:// doi. org/ 10. 1016/j. pec. 2006. 05. 002 9. Elwyn G, Frosch D, Thomson R, Joseph‑ Williams N, Lloyd A, Conclusion Kinnersley P et al (2012) Shared decision making: a model for clinical practice. J Gen Intern Med 27:1361–1367. https://doi. or g/ To increase participation in decision making, intervention 10. 1007/ s11606‑ 012‑ 2077‑6 developers may wish to consider drawing on specific inter ‑ 10. Makoul G, Clayman M (2006) An integrative model of shared decision making in medical encounters. Patient Educ Couns vention functions and behaviour change techniques when 60:301–312. https:// doi. org/ 10. 1016/j. pec. 2005. 06. 010 working with stakeholders involved in the decision‑making 11. Liverpool S, Hayes D, Edbrooke‑ Childs J (2021) An affective ‑ process. However, as most of the studies included in this appraisal approach for parental shared decision making in children review scored low on the EPHPP quality assessment, there and young people’s mental health settings: a qualitative study. Front Psychiatry 12:1–12. https:// doi. org/ 10. 3389/ fpsyt. 2021. is only tentative support for which behaviour change tech‑ niques and intervention function may increase participation 12. Common Room Consulting. Open Talk 2017. http:// www. opent in decision making when it comes to child and youth mental alk. info/. Accessed 28 Dec 2017 health. Future research may wish to examine findings out‑ 13. Wolpert M, Hoffman J, Abrines N, Feltham A, Baird L, Law D et al (2014) Closing the gap: Shared decision making in CAMHs. lined here, using more robust methods, including blinding Final report for closing the gap through changing relationship. where possible and purposefully selecting samples. Health Foundation, London 14. Langer D, Mooney T, Wills C (2015) Shared decision‑making for Supplementary Information The online version contains supplemen‑ treatment planning in mental health care: theory, evidence, and tary material available at https://doi. or g/10. 1007/ s00787 021‑ 01782‑ x‑ . tools. Oxford Handbooks, Oxford 15. Crickard EL, O’Brien MS, Rapp CA, Holmes CL (2010) Devel‑ oping a framework to support shared decision making for youth Declarations mental health medication treatment. Community Ment Health J 46:474–481. https:// doi. org/ 10. 1007/ s10597‑ 010‑ 9327‑z Conflict of interest The authors declare no conflict of interest. 16. Hayes D (2018) Developing an intervention to promote shared decision making in child and youth mental health: integrating Open Access This article is licensed under a Creative Commons Attri‑ theory, research and practice. University College London, London bution 4.0 International License, which permits use, sharing, adapta‑ 17. Cheng H, Hayes D, Edbrooke‑Childs J, Martin K, Chapman L, tion, distribution and reproduction in any medium or format, as long Wolpert M (2017) What approaches for promoting shared decision as you give appropriate credit to the original author(s) and the source, making are used in child mental health? A scoping review. Clin provide a link to the Creative Commons licence, and indicate if changes Psychol Psychother 24:O1495–O1511 were made. The images or other third party material in this article are 18. Liverpool S, Pereira B, Hayes D, Wolpert M, Edbrooke‑Childs J included in the article’s Creative Commons licence, unless indicated (2020) A scoping review and assessment of essential elements of otherwise in a credit line to the material. If material is not included in shared decision‑making of parent‑involved interventions in child the article’s Creative Commons licence and your intended use is not and adolescent mental health. 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Am J Community Psy ‑ interventions for people with mental health conditions. Cochrane chol 41:327 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Child & Adolescent Psychiatry Springer Journals

A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques

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Abstract

Reviews around interventions to improve shared decision making (SDM) for child and youth mental health have produced inconclusive findings on what approaches increase participation. Importantly, the previous reviews did not explore the use of theory, as well as mechanisms of change (intervention functions) and active units of change (behaviour change techniques). The aim of this review was to explore these factors and ascertain how, if at all, these contribute to SDM. Five databases were searched up until April 2020. Studies met inclusion criteria if they were: (a) an intervention to facilitate SDM; (b) aimed at children, adolescence, or young people aged up to 25, with a mental health difficulty, or their parents/guardians; and (c) included a control group. Data were extracted on patient characteristics, study design, intervention, theoretical background, intervention functions, behaviour change techniques, and SDM. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Eight different interventions met inclusion criteria. The role of theory to increase SDM remains unclear. Specific intervention functions, such as ‘education’ on SDM and treatment options and ‘environmental restructuring’ using decision aids, are being used in SDM interventions, as well as ‘training’ for clinicians. Similarly, behaviour change techniques linked to these, such as ‘adding objects to the environ‑ ment’, ‘discussing pros/cons’, and clinicians engaging in ‘behavioural practice/rehearsal’. However, as most studies scored low on the quality assessment criteria, as well as a small number of studies included and a low number of behaviour change techniques utilised, links between behaviour change techniques, intervention functions and increased participation remain tentative. Intervention developers and clinicians may wish to consider specific intervention functions and behaviour change techniques to facilitate SDM. Keywords Shared decision making · Child mental health · Youth mental health · Behaviour change · Interventions Introduction The last 50 years have seen a shift from the paternalistic model of health, towards one, where patients are actively * Daniel Hayes involved in shaping and developing healthcare [1]. This [email protected] can occur across different levels of the healthcare system 1 including service redesign, where patients play a role in Evidence Based Practice Unit, University College London reviewing and developing interventions, through to treat‑ and Anna Freud National Centre for Children and Families, 4‑8 Rodney Street, London N1 9JH, England ment decision making [1]. This concept, referred to a shared decision making (SDM), acknowledges that both clinicians Child Attachment and Psychological Therapies Research Unit (ChAPTRe), University College London and Anna and patients have expertise which is important [2]. In the Freud National Centre for Children and Families, 4‑8 Rodney context of making decisions around an individuals’ own care Street, London N1 9JH, England and treatment, the clinician brings their professional knowl‑ Health Services and Population Research Department, edge and clinical experience, whilst the patient brings a lived King’s College London Institute of Psychiatry, Psychology experience of their illness and what would fit with their life‑ and Neuroscience, De Crespigny Park, London SE5 8AF, style [3]. Through joint communication, understanding and England Vol.:(0123456789) 1 3 European Child & Adolescent Psychiatry deliberation, both parties should arrive at an option for care Second, grouping interventions by overarching approach and treatment which they deem acceptable [4]. neglects the unique features within each, which may cause More recently, the concept of SDM has been applied to individuals to behave in different ways. If, as models and children and young people [5]. Involvement in such decisions experts suggest, SDM is a set of behaviours or skills that can is enshrined in the United Nations Convention on the Rights be taught to stakeholders [10, 23–26], then it is important, of the Child [6]. Here, articles 12 and 13 are particularly rel‑ within each approach, to understand the specific ways in they evant to care and treatment decisions, outlining that the views attempt to change behaviours to facilitate SDM. and opinions of the child should be given consideration in line The behaviour change wheel is an amalgamation of 132 with their age and maturity. In treatment decisions, whilst different behaviour change constructs and is an ideal lens in this may not mean that the child or young person has ultimate which to explore SDM behaviour [16]. Within this, interven‑ decisionmaking po ‑ wer, it does highlight that at a minimum, tions may be broken down into both intervention functions they should be allowed to express their own views and opin‑ and behaviour change techniques [27]. Identification func‑ ions and have these taken into consideration [7]. tions refer to the underlying causal mechanisms of change Models have been developed to try and better facilitate responsible for changing behaviour. Nine different interven‑ SDM in clinical practice [4, 8–11]. These conceptualise dif‑ tion functions exist: ‘Education’, ‘Persuasion’ ‘Incentivisa‑ ferent aspects of SDM as skills, competencies and behaviours tion’, ‘Coercion’, ‘Enablement’, ‘Training’, ‘Modelling’, that can be taught to those involved in the decision‑making ‘Environmental Restructuring’, and ‘Restriction’. In the con‑ process. One of the most widely cited models, an integrative text of SDM, ‘Education’ could refer to increasing patient model of SDM, identified 13 elements which should be pre‑ knowledge around options, whilst ‘Training’ could be where sent, as well as 10 general qualities which clinicians should clinicians are taught how to elicit preferences. have [10]. However, this model was developed from literature Further to the nine intervention functions, 93 behaviour mainly situated in adult physical health, meaning that key change techniques also exist. These refer to the smallest aspects may have been missed when involving children and components of behaviour change interventions that, on young people with mental health difficulties. their own and in favourable circumstances, can bring about In the field of child and youth mental health, both generic change [27]. For SDM, examples of these could be incorpo‑ [12, 13] and context specific [14, 15], models have been rating the use of a decision aid into the clinical encounter; developed. Many have core overlapping features, such as dis‑ which would correspond to the behaviour change technique cussing values, preferences, and options, as well as arrang‑ ‘adding objects to the environment’. Whilst the comparison ing follow up [16]. However, differences also exist, such of different options on the decision aid would map onto the as whether they are aimed at parents/guardians or young behaviour change technique ‘pros/cons’. people, and whether there needs to be explicit agreement A recent study drawing on secondary data analysis from among all stakeholders prior to a decision being made [16]. a 2014 Cochrane review [28] has explored the role of behav‑ In addition to models, a number of interventions to facilitate iour change techniques in SDM [29]. In the 87 included SDM in child and youth mental health have been developed. interventions, 7 different intervention functions and 32 These have been categorised into six overarching approaches: behaviour change techniques were identified. Within this, therapeutic techniques, psychoeducational information, deci‑ the most common intervention function used was ‘educa‑ sion aids, action planning or goal setting, discussion prompts, tion’ and the most common behaviour change technique was and mobilising patients to engage [17]. Reviews exploring the ‘information about health consequences. Whilst this is use‑ effectiveness of approaches have produced inconsistent results, ful in providing an initial framework, there were no included with some interventions being effective in improving partici‑ interventions in child and youth mental health. Given the pation in decision making in certain circumstances [17, 18]. unique properties of this population, such as multiple stake‑ Two important limitations exist which may account for holders and capacity due to age and having a mental health these differences in effectiveness of different approaches difficulty[ 30], establishing behaviour change techniques [16] First, whether the interventions used theory was not within this population is needed. examined. The use of theory is important as it not only Inspecting intervention functions and behaviour change allows for the identification of causal determinants of change techniques may allow researchers and intervention develop‑ and mediators, but also allows a space in which theories can ers to better understand the drivers of change that are present be tested and evaluated [19]. Reviews of interventions across in tools that facilitate SDM for care and treatment decisions. healthcare settings indicate that the use of theory can lead to Given the above, this study will undertake a review of the more effective outcomes [20, 21]. Within the field of SDM, literature and explore the impact of theory, intervention there is tentative support for this notion, where computerised functions, and behaviour change techniques on SDM around decision aids underpinned by theory were more likely to lead patient treatment decisions in child and youth mental health. to increases in participation [22]. Specific research questions: 1 3 European Child & Adolescent Psychiatry Table 1 Inclusion/exclusion criteria Inclusion criteria Exclusion criteria Population A child or young person (up to the age of 25) with a diagnosa‑ Studies where the presenting difficulty is physical health ble or non‑diagnosed mental health difficulty, or their parent/ guardian Intervention Any intervention, approach or tool (e.g., online decision aids, Interventions whose primary aim is not facilitate in care and mobile applications and training) aimed at facilitating deci‑ treatment decisions sion making around care and treatment Comparator Studies where an there is an intervention and control arm. This Studies where there is no control arm can include non‑randomised control studies Outcome Includes a measure examining the process of SDM (e.g., using Includes only an outcome measure related to SDM (e.g., the SDM‑Q‑9 (Kriston et al., 2010) or CollaboRATE (Elwyn decisional conflict) without also including a process meas‑ et al., 2013). Unvalidated measures will be included. Out‑ ure. This is because measuring decision outcome is not a comes can be reported by any individual (e.g., child/ young meaningful indicator of quality, as the eventual outcome can person, parent/guardian, healthcare professional) be dependent upon many external factors (Elwyn, Elwyn, & Miron‑Shatz, 2009) Study Design Randomised and clinical control studies Qualitative studies and case studies. Studies not reported in English. Conference presentations will be excluded as these have been found to differ substantially from peer ‑reviewed papers on outcome metrics (Balshem et al., 2013) Other English language Language other than English Any date/timeframe N/A 1) What theory is being used to facilitate SDM in child and is included in the supplementary material. Eligibility criteria youth mental health? are outlined in Table 1 and were developed in line with the 2) What intervention functions are being used to facilitate research questions. Studies were limited to English language SDM in child and youth mental health? and peer reviewed publications. Database searching was not 3) What behaviour change techniques are being used to limited to a particular timeframe. facilitate SDM in child and youth mental health? To identify additional records, reference checking of 4) Does the inclusion of the above aspects lead to increased the following articles was undertaken: (a) those at sec‑ SDM in child and youth mental health? ond stage screening that focused on SDM and children and young people but had no evaluation (n = 234) and (b) those that met full inclusion criteria. In addition, consul‑ tation with researchers in the field of SDM via an online Method Facebook group and at the International Shared Decision‑ Making (ISDM) conference during a child and youth mental A team of individuals with a knowledge of SDM in child and health panel. The study selection was completed using a youth mental health was convened. Expertise and knowl‑ two‑stage process by two researchers (DH, RT). The first edge included winning bids and writing papers on SDM in stage involved screening article titles and abstracts, during child and youth mental health (DH, JEC, MW), develop‑ which all records were screened by the first author (DH) and ing models of SDM in child and youth mental health (DH, 10% by the second author (RT) and any results that were MW), advising on child and youth mental health service not relevant were excluded. The second stage consisted of transformation, where SDM is a central component (DH, full‑text screening by both authors. A good inter ‑rater reli‑ JEC, MW), delivering training to clinicians on SDM practice ability was found at both first‑ and second‑stage screening (DH, RT, MW), and developing decision aids and tools to (0.78 and 0.87), respectively. The exclusion of papers at each facilitate SDM in child and youth menta health (DH, JEC, stage is highlighted in Fig. 1. For each included article, data RT, MW, NM). were extracted independently by the same two researchers Five research databases were searched up until April reading articles and available documentation line by line 2020—PsycINFO, EMBASE, Medline/PubMed, Web and extracting data using a template. This included author, of Science and Cochrane Libraries. The search strategy year and publication date, participant details, study design, included three concepts: ‘SDM’, ‘child, adolescent, or intervention, theoretical background, intervention functions young person (up to the age of 25, or their parent/guardian), and who they were aimed at, behaviour change techniques and ‘mental health’ (including both diagnosable and non‑ and who they were aimed at, as well as any SDM process diagnosable menta health difficulties). The search strategy measures. For behaviour change techniques and intervention 1 3 European Child & Adolescent Psychiatry Fig. 1 PRIMSA flowchart Addional records idenfied Database search (n = 4) (n = 9,006) Total records included for screening (n = 9,010) Total records excluded at this stage (n =8,092) Reasons Title and abstract screening (n = Not SDM resource (n = 6,765) (9,010) Physical Health (n = 1,160) Adult populaon (n = 135) No comparator (n=32) Total records excluded at this stage Full-text records assessed for (n = 910) eligibility Reasons (n = 918) Not SDM resource (n = 407) No evaluaon (n = 234) Physical Health (n = 178) Adults (n = 74) No comparator (n = 10) No process measure (n = 5) Conference abstract (n = 2) Records included in review (n = 8) functions, both researchers involved in the data extraction functions and behaviour change techniques were submitted process completed an online training (https://w ww.b ct ‑taxon to two research psychologists working in behaviour change. omy. com/). From this, one additional behaviour change technique, ‘cred‑ Authors and intervention developers of resources and ible source’, was included on some records. papers deemed acceptable for inclusion were contacted to Studies were quality assessed using the Effective Pub‑ establish whether any further information on the intervention lic Health Practice Project (EPHPP) Quality Assessment component was available (e.g., a manual or protocol). For Method [31] which is acceptable for examining both ran‑ extracted intervention functions and behaviour change tech‑ domised and non‑randomised studies [ 32]. This explores niques, a good level of agreement was obtained between the the risk of bias within studies on the following domains: researchers extracting data (Kappa = 0.81 and 0.90, respec‑ selection bias, study design, confounding variables, blind‑ tively). Any discrepancies were resolved by discussion and ing, data collection methods, and withdrawal and drop out. agreed upon by the researchers. The finalised intervention Each section is given a rating: strong, moderate or weak, 1 3 Included Eligibility Screening Idenficaon European Child & Adolescent Psychiatry and from this an overall rating is calculated. Each study that ODSF and IPDAS guidelines in intervention development met inclusion criteria was quality assessed independently [34]. by two researchers (DH & RT). A good level of agreement was obtained between the researchers (Kappa = 0.82). Any Behaviour change techniques used in SDM discrepancies were resolved by discussion and changes were interventions in child and youth mental health agreed upon by both researchers. Overall, 18 behaviour change techniques were identified across the eight interventions. The number of different Results behaviour change techniques per intervention ranged from two to 11, with a median of 7 (IQR = 5–7.5). The most fre‑ Database and hand searching returned 9010 articles. The quently used behaviour change technique was ‘pros/cons’ screening of titles and abstracts (first stage screening) which appeared in seven interventions and refers to the resulted in the exclusion of 8092 records. Next, full‑text weighing up of different options with the clinician or using screening (second stage screening) resulted in the exclusion a decision aid [33–35, 38–40, 52]. This was followed by of 910 results. A total of eight studies met the inclusion cri‑ ‘credible source’, which appeared across six interventions teria for this review. Their characteristics, including behav‑ and refers to the clinician, peer worker, or coach, provid‑ iour change techniques, intervention functions, process, and ing advice based on their expertise [33, 34, 36, 38, 40, 52]. outcome measures, are shown in Table 2. Similarly, ‘adding objects to the environment’ appeared in Of the eight interventions designed to increase SDM in six interventions. This included the use a decision aid in five child and youth mental health settings, four were aimed for instances and the use of a visualisation aid in the remaining young people as the decision maker [33–36], three for par‑ intervention [33–35, 38, 39, 52]. ents/guardians [37–39], and one for both parents/guardian The three ‘Behavioural practice/rehearsal’, ‘habit forma‑ and young people [40]. In terms of overarching approaches tion’, and ‘instructions on how to perform the behaviour’ to facilitate SDM, five interventions included decision aids each appeared in five interventions and refer to a clinician, [33–35, 39, 41] and three were therapeutic approaches [36, peer worker, or coach learning about and practicing using 38, 40]. Three papers came from the United States (US) [36, the decision aid or the therapeutic approach [33, 34, 36, 40, 40, 41], two from Australia [34, 39], one from the United 52]. ‘Information about health consequences’ appeared in Kingdom (UK) [35], one from the Netherlands [38], and one three interventions and refers to the decision aid or clinician from Japan [33]. In terms of presenting difficulties, three facilitating SDM by providing the risks or side effects of SDM approaches were not specific to a particular difficulty options [33, 40, 41]. ‘Problem solving’ appeared three times [34, 36, 38], two focused on Attention deficit hyperactivity when there was explicit discussion between stakeholders in disorder (ADHD) [40, 41], one focused on self‑harm [35], identifying patient difficulties [36, 38, 40], whilst both ‘goal one focused on depressive symptoms [33], and one focused setting’ and ‘reviewing outcome goals’ appeared twice [36, on autism [39]. 40]. The theory used in interventions to facilitate SDM Intervention functions used in SDM interventions in child and youth mental health in child and youth mental health None of the interventions explicitly outlined using one spe‑ Across the eight interventions, five different intervention cific theoretical framework. One intervention [38] followed functions were identified. These included: ‘Education’, the Ottawa Decision Support Framework (ODSF), which is ‘training’, environmental restructuring’, ‘modelling’, and a framework that incorporates multiple theories [42]. For ‘enablement’. Per intervention, the number of intervention the ODSF, this includes: expected utility theory [43], deci‑ functions ranged from three to five, with a median of 3.00 sion analysis [44], prospect theory [45], the conflict theory (IQR = 3.5–4.25). model of decision making [46], the theory of reasoned The most frequent intervention function was ‘education’, action [47], self‑efficacy [48], and factors related to social which was identified across all interventions and refers to support [49, 50]. Three interventions [33, 39, 41] specified patients receiving information about options and risks and that they had used the International Patient Decision Aids clinicians learning about SDM and how to facilitate it during Standards (IPDAS) guidelines for developing interventions. appointments. ‘Enablement’ was also identified across all The IPDAS guidelines draw on some theory to ensure that eight interventions. This refers to focusing on setting goals relevant content is included when developing decision aids and exploring clinician and patient beliefs. [51], including expected utility theory [43] and prospect ‘Training’ was found in six interventions and refers to theory [45]. One intervention outlined the use of both the clinicians, peer workers and coaches learning SDM skills 1 3 European Child & Adolescent Psychiatry ‑ ‑ ‑ ‑ ‑ ‑ 1 3 Table 2 Characteristics of interventions included in the final review Included arti Author, year of publica N Comparison and design Intervention and theo Intervention function(s) Behaviour change Process measure: deci Results cle number tion, and country retical background techniques sion making/involve ment/ participation ^ Ø 1 Aoki et al., (2020), 88 young people with a Intervention vs usual Three decision aid With young people With young people SDM (COMRADE; Duration of consultation Japan mood (depression or practice booklets (depression, ‘Enablement’ 5.1 ‘Information about Edwards et al., 2003: (Researcher rated) bipolar) disorder Randomised control trial bipolar disorder, and With healthcare workers health consequences’ YP rated) Satisfaction (YP rated) medication treatment) ‘Training’ 9.1 ‘Credible source’ Looked up treatment No theoretical back With both 9.2 ‘Pros/cons’ after (YP rated) ground specified ‘Education’ For healthcare workers Discussed options with Followed IPDAS ‘Environmental restruc 4.1 ‘Instruction on how others outside clinic turing’ to perform behaviour’ (YP rated) 8.1 ‘Behavioural prac Depressive symptoms tice/rehearsal’ at 3 and 6 months (YP 8.3 ‘Habit formation’ rated) Both young people and Persistence of treatment healthcare workers (audit records) 12.5 ‘Adding objects to Medication adherence the environment’ (YP rated) 2 Brinkman (2013), US 44 parents/guardians Intervention vs usual Preencounter cards, With healthcare workers With healthcare workers ˄ SDM (Option Scale; Knowledge (P/G rated) of young people with practice booklet, DA, and Training’ 6.1 ‘Demonstration of Elwyn et al., 2005: O Decisional conflict* (P/G ADHD, 7 paediatri Controlled clinical trial healthcare worker ‘Modelling’ behaviour’ rated) rated) cians training Both parents/guardians 7.1 ‘Prompts/cues’ Follow up calls and visits No theoretical back and healthcare workers With parents/guardians (audit records) ground specified ‘Environmental restruc 1.3 ‘Goal setting (out Prescriptions written Followed IPDAS turing’ come)’ (audit records) ‘Enablement’ 4.1 ‘Instruction on how Behavioural ratings (P/G ‘Education’ to perform behaviour’ and T rated) 5.1 ‘Information about Titration of medication health consequences’ audit records) 9.1 ‘Credible source’ Number of days covered 9.2 ‘Pros/cons’ (audit records) with Both parents/guardians medication and healthcare workers Physician satisfaction 12.5 ‘Adding objects to with choice (C rated) environment’ Ø # Ø 3 Grant (2016), Australia 81 parents/guardians Intervention vs usual An online decision aid With parents/guardians With parents/guardiansDecisional conflict Parental Sense of Com of young people with practice outlining treatments ‘Education’ 9.2 ‘Pros/cons’ (Support subscale: petency Scale (PSOC) autism for Autism ‘Enablement’ 12.5 Adding objects to P/G rated) [42] (P/G rated) No theoretical back ‘Environmental restruc the environment ground specified turing’ Followed IPDAS European Child & Adolescent Psychiatry ‑ ‑ ‑ ‑ ‑ ‑ ‑ 1 3 Table 2 (continued) Included arti Author, year of publica N Comparison and design Intervention and theo Intervention function(s) Behaviour change Process measure: deci Results cle number tion, and country retical background techniques sion making/involve ment/ participation ^ ^ 4 Hogue et al. (2016), US 3 MIP therapists and Intervention vs historical A therapeutic approach With young people and With young people and Family decision making Psychiatric evaluation 35 young people with control (MIP) promoting parents/guardians parents/guardians (O rated) completion (audit ADHD and their Controlled clinical trial family decisions about ‘Education’ 1.2 ‘Problem solving’ Non validated measure records) parents/guardians medication ‘Enablement’ 1.3 ‘Goal setting (out Prescribed any medica No theoretical back With healthcare workers come)’ tion (audit records) ground specified ‘Education’ 1.5 ‘Review behavioural Prescribed ADHD (audit ‘Training’ goals’ records) medication 1.7 ‘Review outcome Days on ADHD medica goals’ tion (audit records) 5.1 ‘Information about health consequences’ 5.3 ‘Information about social/environmental consequences’ 9.1 ‘Credible source’ 9.2 ‘Pros/cons’ 13.2 ‘Framing/ refram ing’ With healthcare workers 4.1 ‘Instruction on how to perform behaviour’ 8.1 ‘Behavioural prac tice/rehearsal’ 8.3 ‘Habit formation’ Ø # Ø 5 Rowe et al., (2018) UK 23 young people with Intervention vs usual An online decision aid With young people: With young people Decisional conflict Intended help seeking self harm practice for selfharm support ‘Education’ 9.2 ‘Pros/cons’ (Support subscale: YP (YP rated) Randomised Control No theoretical back ‘Enablement’ 12 5 ‘Adding objects to rated) Actual help seeking (YP Trial ground specified ‘Environmental restruc the environment’ rated) turing’ ^ Ø 6 Simmons et al., (2017) 149 young people ages Intervention vs historical Peer support worker and With young people and With young people SDM (SDMQ9[43] Decisional conflict (YP Australia 16–25 (presenting dif control decision support tool healthcare workers 3.1 ‘Social support (YP rated) rated) ficulty not specific), Controlled clinical trial No theoretical back : (unspecified) Satisfaction with service ground specified ‘Education’ 9.1 ‘Credible source’ (YP rated) Followed ODSF and ‘Enablement’ 9.2 ‘Pros/cons’ IPDAS ‘Environmental restruc 12.5 ‘Adding objects to turing’ the environment’ For healthcare workers For healthcare workers ‘Training’ 4.1 ‘Instruction on how ‘ to perform behaviour’ 8.1 ‘Behavioural prac tice/rehearsal’ 8.3 ‘Habit formation’ 9.1 ‘Credible source’ 12.5 ‘Adding objects to the environment’ European Child & Adolescent Psychiatry ‑ ‑ ‑ ‑ 1 3 Table 2 (continued) Included arti Author, year of publica N Comparison and design Intervention and theo Intervention function(s) Behaviour change Process measure: deci Results cle number tion, and country retical background techniques sion making/involve ment/ participation ^ ^ 7 Walker et al., (2017). US 55 high risk young Intervention vs usual A wraparound service With young people With young people Participation Youth Participation in people with mental practice for young people ‘Enablement’ 1.2 ‘Problem solving’ Youth Participation in planning (YPP) Prepa health difficulties (not Randomised Control aimed at increasing With healthcare workers 1.3 ‘Goal setting (out Planning Scale (YPP; ration (YP rated) specific). Involved in Trial collaboration and ‘Education’ come)’ Walker and Powers YPP Planning at least two systems participation in care ‘Training’ 1.7 ‘Review outcome 2007) (YP rated) YPP accountability (YP designed to support No theoretical back goals’ rated) young people (mental ground specified 3.2 ‘Social support Working Alliance Inven health and child (practical)’ tory (WAI; Horvath and welfare) 9.1 ‘Credible source’ Greenberg 1989) (YP With healthcare workers rated) 4.1 ‘Instruction on how to perform behaviour’ 8.1 ‘Behavioural prac tice/rehearsal’ 8.3 ‘Habit formation’ ^ Ø 8 Westermann et al., 71 parents/guard SDM vs usual practice: Counselling in Dialogue With healthcare workers With healthcare workers Satisfaction with Decisional conflict (C (2013). Netherlands ians of young people Randomised Control No theoretical back ‘Training’ 8.1 ‘Behavioural prac participation in shared rated) (presenting difficulty Trials ground specified ‘Modelling’ tice/rehearsal’ decision making ˄ Decision made with not specific), and 20 Followed the ODSF Both healthcare workers 8.3 ‘Habit formation’ (mothers) accurate information therapists and parents/guardians With parents/guardians (P/G rated) ‘Environmental restruc 9.1 ‘Credible source’ ˄ Accepting recommended turing’ Both parents/guardians treatment (P/G rated) ‘Education and healthcare workers Consensus on diagnostic Enablement’ 1.2 ‘Problem solving’ formulation (P/G and 9.2 ‘Pros/cons’ C rated) 12.5 ‘Adding objects to the environment’ ^ ˅ Ø 1 Measure increased, Measure decreased, No change on measure, International Patient Decision Aid Standards (IPDAS) 2 $ Ottawa Decision Support Framework, *Authors report this finding as significant at p < 0.06, Parents/guardians were allocated to choose a treatment of their choice, or be randomly allocated a treatment (no choice). The decisional conflict scale (O’Connor, 1995) is both a process and outcome measure for SDM [44]. YP rated young person rated, P/G rated parent/guardian rated, O rated observer rated, T rated teacher rated, C rated clinician rated European Child & Adolescent Psychiatry [33, 34, 36, 38, 40, 41]. ‘Environmental restructuring’ was Therapeutic approaches also present in six interventions and refers to the use of deci‑ sion aids or visual aids [33–35, 38, 39, 52]. ‘Modelling’ All therapeutic approaches improved participation in SDM was found in two interventions and refers to clinicians being [38, 40, 41]. Those that were used the most frequently shown how to use tools or approaches and then attempting between stakeholders, and provided the most evidence for to replicate that behaviour [38, 41]. increasing SDM (indicated by a statistically significant increase in the process measure utilised), included ‘problem Relationships between intervention functions, solving’, ‘pros/cons’, and ‘credible source’. For clinicians behaviour change techniques, and SDM in child and peer workers, ‘behavioural practice/rehearsal’ and ‘habit and youth mental health formation’ also showed promise. The next section explores the relationship between interven‑ Intervention functions and increased participation tion functions, behaviour change techniques, and SDM. Sup‑ in decision making in child and youth mental health plementary Tables 1 and 2 indicate the intervention func‑ tions and behaviour change techniques present within each Decision aids study and whether an increase in SDM was found. The heterogeneity of process measures and populations For decision aids, the intervention functions ‘education’, precluded the pooling of results for meta‐analysis. Six inter‑ ‘environmental restructuring’, and ‘enablement’, aimed for ventions reported a statistically significant increase for par‑ young people, parents/guardians and clinicians/peer work‑ ticipation in decision making [33, 34, 36, 38, 40, 41], whilst ers, were found to increase SDM when also paired with two did not [35, 39]. As only two different intervention ‘training’ for clinicians and peer workers. approaches were identified, each approach will be explored to see if specific behaviour change techniques, intervention Therapeutic approaches functions, and theory impact on participation in SDM. For therapeutic approaches, ‘education’ and ‘enablement’ Behaviour change techniques and increased used with all stakeholders involved in the decision‑making participation in decision making in child and youth process facilitated SDM. ‘Training’ for clinicians and the mental health health coaches also had evidence for increasing SDM. Decision aids Linking participation with wider outcomes For decision aids, the behaviour change techniques ‘add‑ The wide range of outcome measures employed and dif‑ ing objects to the environment’, ‘pros/cons’, and ‘credible ferences in whether interventions increased participation source’ showed the most promise in facilitating SDM (indi‑ in shared decision making makes drawing further conclu‑ cated by a statistically significant increase in the process sions difficult. One metric common across two studies was measure utilised). However, these techniques were only whether the young person was satisfied with treatment [33, successful when used in conjunction with other behaviour 34]. In both these instances, significant increases in shared change techniques [33, 34, 41]. These will be described decision making were found; however, neither resulted in below: increased satisfaction. Similarly, another metric, again found For young people or parents/guardians, these behaviour in two studies, was prescriptions written [40, 41]. Similar change techniques included: ‘information about health con‑ to the previous example, whilst increased participation in sequences’, ‘information about social/environment conse‑ decision making was found, this did not translate through a quences’, and ‘goal setting’ [33, 34, 41]. Whilst for clinicians change in prescriptions written. or peer workers using decision aids, these included: ‘instruc‑ tions on how to perform the behaviour’, ‘behavioural prac‑ Quality assessment for risk of bias tice/rehearsal’, and ‘habit formation’ appeared to enhance SDM when used in conjunction with ‘adding objects to the The results from the EPHPP quality assessment are depicted environment’, ‘pros/cons’, and ‘credible source’. in Supplementary Table 3. Of the eight studies, one was rated strong overall, as indicated by no weak ratings across any of the EPHPP criteria. Two were rated as moderate overall, as indicated by one weak rating across all quality assessment criteria. Finally, five studies were rated as weak Statistical significance set at p < 0.05. overall as they scoring two or more weak ratings in total. 1 3 European Child & Adolescent Psychiatry The categories ‘study design’ and ‘data collection meth‑ a wider range of behaviour change techniques may be ods’ received the highest frequency of strong ratings, whilst expected. ‘controlling for confounding variables’ and ‘making sure Of the behaviour change techniques found in this review, outcome assessors were blinded’ received the highest fre‑ some explicitly map onto the integrative framework of quency of weak ratings. SDM [10], such as ‘pros/cons’, whilst others overlap with constructs in the integrative framework, such as ‘credible source’, which corresponds with ‘professional knowledge’. Conclusions and discussion In addition, behaviour change techniques, such as adding ‘objects to the environment ‘, whilst not appearing in such The aim of this review was to explore the impact of theory, frameworks, lend themselves well to SDM, as young peo‑ intervention functions, and behaviour change techniques on ple and parents/guardians often report a lack of appropriate SDM in child and youth mental health. sources to help facilitate decision making [59, 60]. In the previous review exploring behaviour change tech‑ Use of theory in interventions niques [29], the most frequently used behaviour change tech‑ nique used was ‘information about health consequences’. In Two interventions, both which were therapeutic approaches, this review, the most common behaviour change technique were not underpinned by theory. One therapeutic approach was ‘pros/cons’. This difference could highlight the impor ‑ was underpinned by the ODSF, four decision aids utilised tance of other factors, beyond pure health outcomes when the IPDAS guidelines [51], and one decision aid used both making a decision in child and youth mental health. For the IPDAS and ODSF. Whilst both frameworks are described example, research suggests that other factors, such as finan‑ as being underpinned by theory, the degree to which the cial, educational and social, are important to the patients IPDAS is completely theoretically informed has been ques‑ and families [61], as well as their goals, values and prefer‑ tioned by some [53, 54]. In particular, critics have stated that ences [10]. However, it is important to note that whilst iden‑ the documentation related to the IPDAS guidelines section, tified behaviour change techniques differ in frequency, there ‘presenting probabilities in an unbiased and understandable appears to be considerable overlap between common behav‑ way’, is ill‑defined, not conceptually clear, and lacking in iour change techniques used in both reviews (e.g., ‘dem‑ both theoretical and empirical support [53]. These concerns onstration of behaviour’ for healthcare professionals). This have been echoed by others, with academics suggesting that may reinforce the potential of a core taxonomy of behaviour the IPDAS guidelines should be considered critically from change techniques common to SDM. both theoretical and empirical perspectives [54]. Of interest is the use of three behaviour change tech‑ If the IPDAS guidelines are included as a theory‑led niques: ‘adding objects to the environment’, ‘pros/cons’, and framework, the proportion of interventions reported here ‘credible source’ When these techniques were incorporated that incorporate theory is higher than in the previous into decision aids and used by young people and parents/ research [22, 55, 56]. However, unlike the previous reviews, guardians outside the clinical appointment, they did not no individual theories were used to develop tools to facilitate appear to increase involvement in SDM. This highlights the SDM. This may highlight the growing recognition of the expertise of both patients/carers and those within clinical theory–practice gap, which states that relying on an individ‑ settings and the importance of arriving at a joint decision ual theory will neglect other factors, such as cognition, the via discussion. Whilst factors, such as time, have been high‑ environment, or the tools themselves [57]. The ODSF is one lighted as an issue by clinicians when it comes to SDM [62, solution to this, as it incorporates multiple theories. How‑ 63], providing tools for use outside of the clinical session ever, the Theoretical Domains Framework [58] should also may not be preferable if these tools are not subsequently be considered, as it incorporates a greater number of theories discussed in the clinic. and may be used flexibly to change SDM behaviour through targeting capability, opportunity, and motivation [16]. Intervention functions Behaviour change techniques Five intervention functions were identified as having Overall, 18 out of 93 possible behaviour change techniques the potential to increase SDM. The most frequently used were identified in SDM interventions in child and youth intervention functions in this review were ‘education’ and mental health. This is less than the 32 found in the previous ‘enablement’. This suggests that intervention developers review [29]; however, as the previous review did not limit may think individuals lack the knowledge and motivation itself to any specific presenting difficulty nor population, required to participate engage in SDM and require support in overcoming these barriers. 1 3 European Child & Adolescent Psychiatry In the previous review exploring intervention functions caution should be taken when translating interventions into [29], education was the most common, followed by ena‑ UK settings, particularly as most of these interventions were blement, the discovery that ‘education’ was an intervention developed in the US and Australia, which place a greater function linked to increased participation in decision mak‑ emphasis on insurance within healthcare. This is evident in ing is supported by previous reviews of patient behaviour resources, such as the decision choice cards, in which cost change interventions [64]. Moreover, there is support in the has its own card and prices are outlined for each treatment wider literature for educating and enabling individuals as a [41]. method of increasing participation in SDM. For example, a Cochrane review of the use of decision aids across health‑ Strengths and limitations care settings found that these tools educated and enabled individuals in the following ways: they improved patients’ This is the first study to examine theory, intervention func‑ knowledge of treatment options, they helped patients under‑ tions, and behaviour change techniques for SDM approaches stand what mattered most to them, they provided patients in child and youth mental health. A strength of this study is with more accurate expectations of the risks and benefits that it examines the intervention functions and behaviour for options, and they helped patients to participate more in change techniques that are used within the decision‑making decision making [65]. process, as well as how these may increase participation in The previous review also identified training, usually with SDM. clinicians, as a common intervention function [29]. The use A further strength of this study is the use of two research‑ of training to bring about behaviour change is also frequently ers to extract the data from the papers and to conduct the reported in the literature when designing interventions [64]. quality assessments. This mitigates the risk of systematic Indeed, findings from clinicians in child and youth mental bias at data extraction stage whilst also decreasing the total health services who have tried to incorporate new SDM tools number of errors in data extraction and quality assessment and techniques into the doctor–patient encounter report feel‑ [69]. With respect to the data extraction, online training ing apprehension at the start of the process [66]. Clinicians was completed by both researchers to ensure consistency also reported that prior to SDM tools being incorporated in identifying and recording behaviour change techniques. into their practice, there was a stage of ‘feeling clunky’ [66]. High levels of agreement were obtained, indicating strong This could suggest that further training, as well as model‑ inter‑rater reliability. ling, may be useful in expediting the acceptance of tools and A limitation of this review is that not all records were techniques in clinical practice. double screened, thus, whilst a high interrater reliability was reached, some articles may have been missed. A further Wider findings limitation of this review is that studies did not report on the fidelity to the model or approach they were implementing. It is too early to establish how participation in decisionmak ‑ ‑ Thus, we cannot say the degree to which behaviour change ing links with wider outcomes. This is due to a very small techniques outlined in the papers were actually followed. sample of overlapping outcomes, both of which tentatively As implementation has been found to affect outcomes [70], suggest that increased participation in decision making future studies into SDM interventions should report fidelity had no effect on satisfaction or prescriptions written. This to the approach/model. In addition, most studies gave little fits with the wider literature in adult mental health, where or no information about the control group, which meant that research on this topic is also inconclusive [67]. Whether the behaviour change techniques used here were often left or not shared decision making results in additional positive unexamined. These studies also did not examine the skill benefits, it is important to remember that many young people of the clinician, or the amount of time they had been in the feel powerless and left out of care and treatment decisions, profession, which may also affect findings. Limitations of and that any intervention that facilitates this should be wel‑ the EPHPP tool [31] also exist. Whilst it allows for com‑ comed, as their right for involvement enshrined in the UN parison between randomised and non‑randomised studies, rights of the child [6]. some areas of bias, such as performance, assessment, and Previous reviews have highlighted that the majority of publication bias are not included. This could change the approaches and evaluations to facilitate SDM focus on dif‑ quality assessment ratings of studies if they were able to be ficulties, such as ADHD and autism [ 17, 18]. Within this taken into account. Finally, whilst information is provided on review, the range of difficulties targeted by interventions whether the interventions produced a statistically significant appears to be more diverse, as it includes self‑harm and change in SDM, this does not explain if the interventions depressive symptoms. This is a welcome development as were clinically effective. Missing information in some man‑ research suggests that lower levels of SDM may be related to uscripts precluded the author’s ability to explore relation‑ the severity rather than type of difficulty [16, 68]. However, ships between effect size and intervention characteristics. 1 3 European Child & Adolescent Psychiatry 8. Entwistle VA, Watt IS (2006) Patient involvement in treatment Researchers should consider providing information regard‑ decision‑making: the case for a broader conceptual framework. ing effect sizes in published manuscripts in the future. 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Am J Community Psy ‑ interventions for people with mental health conditions. Cochrane chol 41:327 1 3

Journal

European Child & Adolescent Psychiatry – Springer Journals

Published: Feb 1, 2023

Keywords: Shared decision making; Child mental health; Youth mental health; Behaviour change; Interventions

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