Bijlage 2 Evidence statements NICE guideline

Nr.

Evidence statement

ES1

Effectiveness of transition support models for young people leaving care

For this population, there is evidence from 2 reviews (1 of moderate and 1 of good quality) that independent living programmes, where care leavers are supported to remain in foster care for longer, can improve the transition into adult life (Everson-Hock et al. 2011 ++/+; Morris and Stein 2009 +/+). This was supported by a low-quality evaluation (Munro et al. 2011 -/+). There is evidence from 1 small study of good quality (Powers et al. 2012 +/+) that a combination of coaching and mentoring can improve young people’s quality of life, and uncertain evidence that this intervention did not impact on their engagement in the transition planning. There is evidence from 1 US study of good quality (Nesmith and Christophersen 2014 +/+) that a combination of training for all parties, and young people’s leadership of their own transition planning meetings, can increase young people’s satisfaction with the transition process.

ES2

Effectiveness of transition support models for young people with disabilities, when the transition lead is within education

For this population in this setting, there is evidence from 1 good quality systematic review that student-focused planning increases their participation in planning meetings by a moderate degree (Cobb and

Alwell 2009 +/+). There is evidence from 1 small study of low quality

(Hagner et al. 2012 -/+) that student-focused planning does not impact students’ self-determination. There is evidence from 1 study of good quality that a particular type of reading technology (Rocket Reader) can have a small impact on students’ ‘self-determination’ in advance of transition (Lee et al. 2011 +/+).

ES3

Effectiveness of transition support models for young people in transition from CAMHS to AMHS

This evidence statement is based on findings from 2 reviews (1 of moderate and 1 of good quality) about transition from CAMHS to AMHS (Paul et al 2014 ++/++; Swift et al. 2013 +/++). Neither review found evidence on the effectiveness of transition support in regard to particular diagnoses. One high quality review (Paul et al. 2014 ++/++) identified 3 studies relevant to questions about the effectiveness of transition planning or support. All 3 studies evaluated packages of care which included input from AMHS, and all 3 studies found positive impact from these programmes, but due to study quality and design the reviewers were unable to provide a conclusion. The evidence from these reviews therefore indicates a clear need for further research on the effectiveness of providing purposeful and planned transition from CAMHS to AMHS.

ES4

Effectiveness of transition clinics for young people in transition from paediatric to adult health services

We found mixed quality evidence from 4 systematic reviews (Bloom et al. 2012 ++/+; Crowley et al. 2011 -/++; Doug et al. 2011 +/++; Kime et al.

2013 +/++) and from 1 individual study (Prestidge et al. 2012 -/++) that transition clinics can improve condition-specific outcomes for young people transitioning from paediatric to adults’ services, although some studies evaluating transition clinics have not found any impact on condition-specific outcomes, and so this is an area of uncertainty.

There is mixed quality evidence from 4 systematic reviews (Bloom et al. 2012 ++/+; Crowley et al. 2011, -/++; Doug et al. 2011 +/++; Kime et al. 2013 +/++), 1 individual randomised study (Huang et al. 2014 ++/+) and 4 retrospective comparison studies (Bent et al. 2002 +/++; Cadario et al. 2009 -/++; Nakhla et al. 2009 -/++; Prestidge et al. 2012 -/++) that principles of good practice include coordination and planning, for example by a transition coordinator, and written and verbal communication.

There is evidence from 1 good quality systematic review (Kime et al. 2013 +/++) that transition planning should be person-centred, include collaboration between paediatric and adults’ services and include self- management training for young people. It is, however, worth noting that 2 good quality RCTs (Betz et al. 2010 +/+; Mackie et al. 2014 +/+) found no impact from one-off training interventions.

ES5

Effectiveness of communication technologies to support transition between paediatrics and adult services

There is evidence from 1 good quality study (Huang et al. 2014 ++/+) that a combination of web-based instruction and text-based reminders can improve self-management of long-term conditions during transition into adults’ services.

ES6

Cost-effectiveness of services to support transition from children’s to adults’ services

There is limited evidence from 1 UK study (Bent et al. 2002 +/++) with good applicability and minor limitations in economic methodological

quality that multidisciplinary services rather than ‘ad hoc’ services are marginally cost-saving and can improve participation in society and reduce activity limitations for individuals with physical disabilities who have multiple service needs. However, the analysis measures only community health and social care services and not acute or respite social care services and assumes no differences between groups in utilisation of those services.

There is very limited evidence from 1 non-UK study (Prestidge et al. 2012 -/++) with good applicability and some limitations in economic methodological quality that transition clinics compared to ‘standard’ services for individuals with renal failure have the potential to be cost- saving and cost-effective from a healthcare perspective, on the assumption that the intervention prevents adverse dialysis and transplant-related events.

ES7

How can adults’ services support effective transition for young people in transition?

There were no high quality studies identified by our search that had direct relevance to social care and mental health interventions and adults’ services, despite the criteria to include non-UK studies. There is a lack of robust evaluation of interventions in adults’ services aimed at young people in transition. As with other questions in this topic, there is a lack of robust research that responds to our question, especially in relation to social care and mental health services, but the expertise of the guideline committee can respond to these gaps with examples of practice from their experience and/or invitation of expert witnesses.

ES8

Factors that help the implementation of effective transition strategies and practice in children’s and adults’ services

One good quality systematic review (Kime et al. 2013 +/++) and 2 individual studies (1 of good quality, Kingsnorth et al. 2010 ++ and, 1 of moderate quality, Sloper et al. 2011 +/++) found that clarity of roles, and clear communication between organisations, paired with strong leadership, contributed to the successful implementation of transition protocols and practice, and similarly that the lack of this can hinder it.

The qualitative study (Kingsnorth et al. 2010 ++) further found that this was enhanced by an emphasis on equity between all organisations involved, and that this needed to be implemented in terms of all organisations being involved in hosting meetings, co-branding, shared accountability and mission statements. There is evidence from the survey (Sloper et al. 2011 +/++) that the involvement of young people and carers can help with implementation of transition strategies and approaches, and this study also suggested that there should be a dedicated transition team.

ES9

Factors that prevent the implementation of effective transition strategies and practice in children’s and adults’ services

There is evidence from 1 moderate quality study (Sloper et al. 2011

+/++) that the lack of joint funding streams and lack of services can hinder successful implementation of transition strategies. There is evidence from 1 good quality qualitative study (Kingsnorth et al. 2010

++) that barriers to implementation are different information-sharing protocols across different agencies and sectors, lack of staff expertise in how to support transitions, high staff turnover and difficulties in establishing new roles when there is no previous experience. There is evidence from 1 moderate quality systematic review (Kime et al. 2013

+/++) that professionals in children’s services may hinder young people’s transition into adults’ services because they are concerned about the different culture and provision there.

ES10

Paucity of research into the provision of transition support for people supported by a combination of services

Overall, there is a need for further research to understand how best to provide transition support for those receiving a combination of different services. We have found 6 studies which are very different in design and focus, and none of which directly address our question.

ES11

Planning support for young people – support by a combination of services

There is evidence from 3 moderate quality mixed methods studies (Beresford et al. 2013 +; Burgess 2007 +/+; Sloper et al. 2011 +) and 1 good quality qualitative study (Hamdani et al. 2014 +/+) that person- centred planning can be a good way of managing the transition into adults’ services for those using a combination of different services.

ES12

Young people with learning difficulties supported by a combination of services

There is evidence from 1 poor quality US evaluation (Certo et al. 2003 -

/+) and 1 qualitative case study (Noyes et al. 2004 -/++) that for young people with learning disabilities transition planning should be jointly funded across sectors (mental health, social care and education), that the planning should start at the beginning of young people’s last year in school/college, with gradual transfer to adult services, and have an emphasis on providing young people with employment or further education immediately after leaving school. Elements of these recommendations are supported by other studies, with 2 moderate quality mixed methods studies (Beresford et al. 2013 +; Sloper et al.

2011 +) supporting the emphasis on long-term planning when transitioning young people with disabilities or high functioning autism or Asperger’s syndrome, and in particular in relation to education and employment. Findings from 1 good quality qualitative study (Hamdani et al. 2014 ++/++) also supported joint funding arrangements across sectors and institutions, and the early start for planning the transfer into adults’ services.

ES13

Information at point of transition

There is evidence from 2 good quality mixed methods studies (Beresford et al. 2014 +; Sloper et al. 2011 +), that young people who receive multiagency transition support need good quality information, and that this should be provided in different formats, including experiential information where young people can visit potential services

or meet providers. These 2 studies also found that financial advice

should be considered as part of the pre-transition training, and for some families transition could coincide with a loss in income from benefits.

ES14

Remit of transition support

There is evidence from 2 good quality mixed methods studies (Beresford et al. 2014 +; Sloper et al, 2011, +) that transition support for young people using a combination of different services should go beyond service transition and include considerations of developmental transitions and participation in social life, such as relationships and leisure activities. This might include, for example, facilitating social interaction with other young people undergoing similar experiences, given that there is evidence from 1 good quality mixed methods study (Beresford et al. 2014 +) that for high-functioning young people small levels of support can make a big difference (e.g. opportunities to meet others with the same condition).

ES15

Support for young people who do not meet criteria for adults’ services

There is evidence from 1 good quality mixed methods study (Beresford et al. 2014 +) that community mental health services are important during transition for young people transitioning out of children’s services who do not meet the eligibility criteria for adults’ services.

ES16

Views of care leavers supported by social care services: consistency of support

There is evidence from 1 moderate quality and 3 good quality studies (Barn et al. 2006; ++Hiles et al. 2013, +/++; Hiles et al. 2014 ++; Munro et al. 2012 ++), 1 of which is a systematic review (Hiles et al. 2014

+/++), that young people leaving care appreciate consistent and ongoing support during transition. This is particularly true for those who have experienced multiple placements or have mental health needs.

ES17

Views of care leavers supported by social care services: support to make contact with birth families

There is evidence from 1 moderate quality systematic review (Hiles et

al. 2014 +/++) that leaving care is a period when many care leavers want to regain contact with their birth families, and some will need emotional support with this.

ES18

Views of care leavers supported by social care services: practical support to become independent

There is good quality evidence from 1 moderate quality and 3 good quality studies (Barn et al. 2006 ++; Hiles et al. 2013 +/++; Hiles et al. 2014 ++; Munro et al. 2012 ++,), 1 of which is a systematic review (Hiles et al. 2014 +/++), that young people leaving care would like high levels of practical support in relation to their accommodation, education, employment and general practical issues which arise when moving to independence.

ES19

Views of young people with learning disabilities and their parents/carers, supported by social care services

Across 7 mixed quality studies (Broadhurst et al. 2012 +; Children’s Workforce Development Council 2010 -; Cowen 2010 -; Kelly 2013 ++; Newman et al. 2009 ++; Pilnick et al. 2011 +) and supported by the good quality study by Beresford et al. (2012 +), all reviewed for the question on multiple services, there is evidence that transition planning should be personalised and involve young people in the planning.

Young people’s participation is challenged when they have learning disabilities, in that services sometimes continue to talk to their parents only.

ES20

Views on parent or carer involvement in transition planning

There is strong evidence from 6 studies – 4 of which are moderate quality, 2 of which are good quality (Bhaumik et al. 2011 +/++; Broadhurst et al. 2012 +; Kelly 2013 ++; Milner 2008 +; Newman et al. 2009 ++; Pilnick et al. 2011 +) – and 1 low quality study (Cowen 2010 -), that it is essential that parents (or someone else with primary caring responsibility or in a primary relationship role) are involved in young people’s transition planning. This was also supported by Beresford et al. (2012 +), reviewed for the question on multiple services. While the role of parents might change during this period, depending on the young person’s capacities, most young people will continue to have a close relationship to their parents as they grow into adulthood. Balancing young people’s need for increased independence with the parents’ role can be difficult, but is nevertheless something which needs to be considered when planning the transition out of children’s services.

ES21

Views on the information and information support need for young people with learning disabilities before and during transition

There is strong evidence from 3 moderate quality and 2 good quality studies (Bhaumik et al. 2011 +/++; Broadhurst et al. 2012 +; Kelly 2013

++; Milner 2008 +; Newman et al. 2009 ++) and 2 of low quality (Children’s Workforce Development Council 2010 -; Cowen, 2010 -) that young people with learning difficulties and their families need substantial information in advance of and during transition, and help with interpreting the information. This was also found when reviewing for question 4.5.7 (multiple services). For example, while independent budgets has been found to be helpful by 2 mixed quality studies (Newman et al. 2009 ++; Cowen 2010 -) there is evidence from 1 good quality study here (Kelly 2013 ++) that some parents did not know how to manage budgets or how to self-commission ‘services’ using these.

Information is needed on the transition process, what to expect after

transfer, and what happens after equipment is returned to children’s services.

ES22

Views on the role of a keyworker during transition

There is strong evidence from 3 moderate and 2 good quality studies (Bhaumik et al. 2011 +/++; Broadhurst et al. 2012 +; Kelly 2013 ++; Newman et al. 2009 ++; Pilnick et al. 2011 +) and 1 low quality study (Cowen 2010 -) that young people and their parents value the support of a keyworker, as long as this is consistently provided.

ES23

Views on the support needs of young people with learning difficulties making transition

There is evidence from 1 good quality study (Newman et al. 2009 ++) that transition planning for young people with learning disabilities should include concerns about their work or education opportunities, social needs and housing. This was also supported by evidence from a moderate quality study by Beresford et al. (2012 +), reviewed for the question on multiple services.

ES24

Lack of structured transitions programmes as hindrance to transition

There is moderate quality evidence from 4 systematic reviews (Binks et al. 2007 +/+; Jordan et al. 2013 +/+; Kime et al. 2013 +/++; Watson et al. 2011 -/++) and 3 individual studies (Care Quality Commission 2014 overall assessment ++; Por et al. 2004 +/++; Shaw et al. 2004, +/++) that the absence of a structured transition programme can hinder effective transition.

ES25

Poor inter- and intra-agency communication and coordination

Poor inter- and intra-agency coordination, gaps in levels of integration between sectors, lack of communication between paediatric and adult physicians and other adult care services in the community can hinder transitions, according to moderate quality evidence from 3 systematic reviews (Binks et al. 2007 +/+; Jordan et al. 2013 +/+; Kime et al. 2013

+/++), and 4 individual studies (Allen et al. 2012 +/++; Care Quality Commission 2014 overall assessment ++; Por et al. 2004 +/++; Shaw et al. 2004 +/++).

ES26

Lack of information as hindrance to transition

There is moderate quality evidence from 2 systematic reviews (Jordan et al. 2013 +/+; Kime et al. 2013 +/++) and 4 individual studies (Beresford et al. 2014 overall assessment +; Care Quality Commission 2014 overall assessment ++; Por et al. 2004 +/++; Shaw et al. 2004 +/++) that insufficient information to young people and their parents/carers about transition and what it will entail will hinder transitions.

ES27

Factors related to adult service culture and involvement

There is moderate quality evidence from 3 systematic reviews (Binks et al. 2007 +/+; Jordan et al. 2013 +/+; Kime et al. 2013 +/++), and 2 individual studies (Beresford et al. 2014 overall assessment +; Garvey et al. 2013 ++/+) that illustrates factors related to adults’ services can hinder transition. Specifically, these include the culture, approach, differences in care provided, lack of involvement, lack of preparation, lack of training and resources in adults’ services.

ES28

Limited access to specialist support in adult health services

Lack of access to specialist and allied health professionals due to age limit, or higher eligibility criteria in adults’ services was identified as a factor which hinders transition by 1 good quality systematic review (Kime et al. 2013 +/++).

ES29

Resource and time limitations

There is moderate quality evidence from 1 systematic review (Kime et al. 2013 +++) and 3 individual studies (Care Quality Commission 2014 overall assessment ++; Sebastian et al. 2012 +/++; Shaw et al. 2004

+/++) That lack of adequate resources and time hinder transitions.

ES30

Professionals’ and young people’s preference for staying in paediatrics

Resistance from paediatric care providers to ‘letting go’ of their long- standing relationships with young patients and distrust of adult-centred health services can hinder transitions, as can the preference of young people and their parents to remain in paediatric services. This comes from moderate quality evidence from 2 systematic reviews by Kime et al. (2013 +/++) and Binks et al. (2007 +/+).

ES31

Limiting policies and protocols

Rigid policies and protocols can hinder transitions, according to moderate evidence from 3 systematic reviews (Binks et al. 2007 +/+; Kime et al. 2013 +/++; Watson et al. 2011 -/++).

ES32

Parental involvement as a barrier to transition

Parental involvement has been identified by professionals as a barrier to transition. Conversely, lack of parental involvement has been identified by young people as a barrier to transition. This is based on good quality evidence in 1 systematic review (Kime et al. 2013 +/++), and 3 individual studies (Beresford et al. 2014 overall assessment +; Por et al. (2004

+/++; Shaw et al. 2004 +/++).

ES33

Opportunity to experience adult services pre-transition

Meeting adult providers and visiting adult facilities in advance of transitioning can help transition. This is based on moderate quality evidence supported by 4 systematic reviews (Binks et al. 2007 +/+; Bloom et al. 2012 ++/+; Crowley et al. 2011 -/++; Jordan et al. 2013 +/+), and 3 individual studies (Beresford et al. 2014 overall assessment +; Kipps et al. 2002 -/++; Por et al. 2004 +/++). Related to this, there is low quality evidence from 1 systematic review (Binks et al. 2007 +/+), and 1 study (Por et al. 2004 +/++) that indicates early transition planning can help transition.

ES34

Transition plans that address health and lifestyle factors broadly, and involvement of GPs

Transition plans that address lifestyle changes such as sexual health and drugs and which can be personalised to the young person’s needs can help transition (low quality evidence from 1 systematic review – Kime et al. 2013 +/++), as can involvement of GPs in the transition (according to low quality evidence from 1 good quality report by the Care Quality Commission 2014 overall assessment ++).

ES35

Importance of consistent provision

There is moderate quality evidence from 2 good quality individual studies that a gap over 6 months from the transfer from paediatrics to the first adult clinic appointment is a barrier to successful transition (Downing et al. 2013 +/+; Garvey et al. 2013 ++/+).

ES36

Factors that help and hinder transitions for specific conditions

There is moderate quality evidence from a good quality systematic review by Binks et al. (2007 +/+) that the barriers to transition experienced by young people with spina bifida and cerebral palsy are similar to those experienced by young people with other complex health conditions. Similarly, the recommendations for young people with sickle cell disease, made by a systematic review of good quality (Jordan et al.

2013 +/+) are the same as those found in other reviews for all young people with long-term conditions and transition in healthcare settings. However, as identified in previous research reviewed for other questions, young people with autism appear to be at risk of a poorer transition than those with more or with less complex needs (Cheak- Zamora et al. 2013 +/+). And 1 individual study found that young people with multiple conditions (comorbid medial conditions) were more likely to transfer successfully (Reid et al. 2004 +/++). The same study found that young people with substance misuse problems were more likely to not transfer successfully to adult care. There is moderate quality evidence from 1 good quality systematic review that there are particular barriers for young people with HIV when transitioning to adult care, related to increased stigma, difficulty with adherence to medication regimen, difficulty with adolescent sexuality and the young people often coming from disorganised social environments (Kime et al. 2013 +/++).

ES37

Distance between clinic and home as a barrier to transition

There is low quality evidence from 2 individual studies that the longer the distance from a young person’s home to the adult clinic the less likely it is that the young person will transition successfully (Andemariam et al.

2014 -/+; Reid et al. 2004 +/++).

ES38

Evidence on effective transition interventions/programmes

One systematic review concluded that a lack of service evaluations and agreed process and outcome measures for transition hinder opportunities for comparing different service models and guide service development. This included a lack of formal evaluation of the experience of users against any outcome measures. Many of the reported service models highlight that young people have different individual experiences of transitional care and recognise the need for flexibility when supporting transfer of clinical care. It is important to be able to record these experiences in a systematic way (Watson et al. 2011 -/++).

ES39

Factors helping transition out of care

There is evidence from 1 good quality systematic review and 4 good quality individual studies that factors which help young people transition out of care relate to the process of independence being flexible, gradual and supported by professionals and carers.

There is evidence from 2 good quality individual studies that the current system of care can hinder successful transitions, due to lack of resources and time for professionals to work with young people in-depth and long-term to address these factors.

ES40

Long-term planning of post-school support for young people in out-of- authority residential school placements

An important factor that helps transition for young people placed in out- of-authority residential schools is early long-term planning of what will happen after they leave the school. This is evidenced by findings from 2 high quality qualitative studies (Beresford and Cavet 2009 overall assessment ++; Heslop and Abbott 2007 overall assessment ++). It may be that the SEND pathfinder approach will improve this situation (Craston et al. 2013 ++/+).

ES41

Factors that hinder transition for young people in out-of-authority residential schools

Factors that hinder transition for young people placed in out-of-authority residential schools are evidenced by 1 high quality qualitative study (Beresford and Cavet 2009 overall assessment ++):

·           geographical distance between the school and home authority

·           the independent nature of schools which means they do not need to collaborate on transition planning

·           competing business interest of some independent schools and adult placements for young people, against local authority guidelines which stipulate that 1 long-term goal is for the young people to return to their original home authority

·           complex health care needs which were present at the time of referral to the residential school are still there at the time of transition, and so the needs for moving out of authority are still in place

·           institutionalisation of young people who have spent a long time in residential schools, leading to challenges in terms of preparation for independence

·           moving from the residential school might result in loss of friendships and present challenges in terms of moving back to a family they no longer ‘know’.

ES42

Factors that hinder healthcare transition for young people in out-of- authority residential schools

Factors that hinder successful healthcare transitions for young people placed in out-of-authority residential schools, evidenced by 1 high quality qualitative study (Beresford and Cavet 2009 overall assessment ++):

·           structural arrangements which hinder health professionals in visiting young people out of authority, and which hinder transfer of young people from 1 authority to another (e.g. changing GP)

·           funding discussions in terms of which sector/agency is in charge of which part of the overall care package.

Factors which hinder transition for this group of young people, and which are similar for all young people with a disability and across health and social care:

·           lack of transition plan or model

·           lack of integrated information-sharing between agencies and sectors

·           involving young people who have communication challenges in their transition planning.

These factors were identified by a range of studies reviewed for this question, and conducted in healthcare settings, and were also identified by 1 high quality study for this population (Beresford and Cavet 2009 overall assessment ++).

ES43

Transition protocol or plan

Having a transition protocol or plan is a factor that helps young people with learning disabilities transition into adult services, here evidenced by 2 good quality studies (Craston et al. 2013 ++/+; Mills et al. 2013 overall assessment +).

ES44

Self-directed support

If good practice in transition is seen to include self-directed support to young people, there is evidence from 1 good quality qualitative study

(Mitchell 2012 overall assessment +) that young people like the idea, but that its implementation might be hindered by adults’ concerns about young people’s capacity.

ES45

Factors that hinder purposeful and planned transitions

Time and resource pressures were found to be another factor which hinders transitions for this group, also identified for other groups and in other settings, and here evidence by 1 high quality study from Northern Ireland (Kelly 2013 overall assessment ++).

The same study (Kelly 2013 overall assessment ++) also mirrored the finding that different cultures in children’s and adults’ services can be a factor that hinders purposeful and planned transitions.

It is the experience of social care practitioners, evidenced here by 1 high quality study (Kelly 2013 overall assessment ++) that parents’ concerns about young people’s vulnerability is a factor that makes transition planning challenging.

ES46

Overall factors that impact on mental health transitions

Overall, factors identified as hindering or helping the transition of young people from CAMHS to AMHS mirrored many of those identified for other settings.

Lack of young adult-friendly services was found by 1 high quality systematic review by Paul et al. (2014 ++/++) and 1 high quality study by Richards and Vostanis (2004 overall assessment ++).

Lack of integration with other services, and poor communication, both between other services and between children’s and adults’ services, found by 2 systematic reviews (Paul et al. 2014 ++/++; Swift et al. 2013

++/+) and 1 high quality qualitative study (Richards and Vostanis 2004 overall assessment ++). One high quality qualitative study found that CAMHS staff felt unclear about the social care transition and isolated from general health and social care transition processes (Kaehne 2011 overall assessment ++).

As for some physical health conditions for which there is now increased survival into adulthood, there is also for some mental health conditions a lack of services due to the conditions being considered limited to childhood and adolescence. This was evidenced by 3 systematic reviews (Montano and Young 2012 -/-; Paul et al. 2014 ++/++; Swift et al. 2013 ++/+), and 1 individual study (Singh et al. 2010 overall assessment ++).

ES47

Eligibility thresholds

Specific to some young people using CAMHS, a factor which hinders their transition into adults’ services is that they are not deemed eligible due to high service thresholds. This was identified by all included studies (2 high quality and 1 low quality systematic review, and 3 high quality individual studies).

ES48

The impact of being on medication or hospitalised

Specific to some young people using CAMHS, a factor which helps their transition into adults’ services is if they have a severe condition which has resulted in them being on medication or being hospitalised. This is supported by 2 high quality systematic reviews (Paul et al. 2014 ++/++; Swift et al. 2013 ++/+) and 2 high quality individual studies (Kaehne 2011 overall assessment ++; Richards and Vostanis 2004 overall assessment ++).