The heterogeneity of emotion skills curricular studies makes direct comparisons difficult. However, all controlled trials showed positive outcomes, suggesting the importance and effectiveness of 'other-directed' emotion skills training. No specific recommendations about curricular amount and frequency, timing and pedagogy can be made.

Background and objectivesServices have variable practices for identifying and providing interventions for ‘severe attachment problems’ (disorganised attachment patterns and attachment disorders). Several government reports have highlighted the need for better parenting interventions in at-risk groups. This report was commissioned to evaluate the clinical effectiveness and cost-effectiveness of parenting interventions for children with severe attachment problems (the main review). One supplementary review explored the evaluation of assessment tools and a second reviewed 10-year outcome data to better inform health economic aspects of the main review.Data sourcesA total of 29 electronic databases were searched with additional mechanisms for identifying a wide pool of references using the Cochrane methodology. Examples of databases searched include PsycINFO (1806 to January week 1, 2012), MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to December week 4, 2011) and EMBASE (1974 to week 1, 2012). Searches were carried out between 6 and 12 January 2012.Review methodsPapers identified were screened and data were extracted by two independent reviewers, with disagreements arbitrated by a third independent reviewer. Quality assessment tools were used, including quality assessment of diagnostic accuracy studies – version 2 and the Cochrane risk of bias tool. Meta-analysis of randomised controlled trials (RCTs) of parenting interventions was undertaken. A health economics analysis was conducted.ResultsThe initial search returned 10,167 citations. This yielded 29 RCTs in the main review of parenting interventions to improve attachment patterns, and one involving children with reactive attachment disorder. A meta-analysis of eight studies seeking to improve outcome in at-risk populations showed statistically significant improvement in disorganised attachment. The interventions saw less disorganised attachment at outcome than the control (odds ratio 0.47, 95% confidence interval 0.34 to 0.65;p < 0.00001). Much of this focused around interventions improving maternal sensitivity, with or without video feedback. In our first supplementary review, 35 papers evaluated an attachment assessment tool demonstrating validity or psychometric data. Only five reported test–retest data. Twenty-six studies reported inter-rater reliability, with 24 reporting a level of 0.7 or above. Cronbach’s alphas were reported in 12 studies for the comparative tests (11 with α > 0.7) and four studies for the reference tests (four with α > 0.7). Three carried out concurrent validity comparing the Strange Situation Procedure (SSP) with another assessment tool. These had good sensitivity but poor specificity. The Disturbances of Attachment Interview had good sensitivity and specificity with the research diagnostic criteria (RDC) for attachment disorders. In our supplementary review of 10-year outcomes in cohorts using a baseline reference standard, two studies were found with disorganised attachment at baseline, with one finding raised psychopathology in adolescence. Budget impact analysis of costs was estimated because a decision model could not be justifiably populated. This, alongside other findings, informed research priorities.LimitationsThere are relatively few UK-based clinical trials. A 10-year follow-up, while necessary for our health economists for long-term sequelae, yielded a limited number of papers.ConclusionsMaternal sensitivity interventions show good outcomes in at-risk populations, but require further research with complex children. The SSP and RDC for attachment disorders remain the reference standards for identification until more concurrent and predictive validity research is conducted. A birth cohort with sequential attachment measures and outcomes across different domains is recommended with further, methodologically sound randomised controlled intervention trials. The main area identified for future work was a need for good-quality RCTs in at-risk groups such as those entering foster care or adoption.Study registrationThis study is registered as PROSPERO CRD42011001395.FundingThe National Institute for Health Research Health Technology Assessment programme.

BackgroundBusy emergency departments (EDs) are not the optimum environment for assessment of patients in mental health crisis. The Psychiatric Decisions Unit (PDU) was developed by the Birmingham and Solihull Mental Health Foundation Trust as an enhanced assessment service to ensure patients in mental health crisis receive optimal care.AimsTo evaluate the activities of the PDU and its impact on the frequency of ED presentations and inpatient admissions, and to explore patient satisfaction.MethodsData were collected over a 6-month period during 2015 regarding patient demographics, referral sources, length of stay, and frequency of mental health-related ED presentations and inpatient psychiatric admissions. Comparison group data were used to evaluate the impact of the PDU. Patient satisfaction was measured using the ‘Friends and Family Test’ and structured feedback forms.ResultsIn total, 385 patients were referred to the PDU during the study period. Implementation of the PDU was associated with a 39% decrease in the number of patients taken to the ED by Street Triage and a 26% fall in inpatient psychiatric admissions via the Trusts’ in-hospital liaison psychiatry team. Ninety-eight per cent of patients surveyed felt that they were treated with respect and understanding, and 94% reported that they were likely or extremely likely to recommend the service to friends and family.ConclusionsImplementation of the PDU was associated with a reduction in the frequency of ED presentations and inpatient psychiatric admissions. This study suggests that patients are satisfied with the care provided at the PDU.

The complexity and variability of data reporting, likely contributing factors and outcomes make cerebellar mutism difficult to predict in incidence and the degree of impact that may ensue. A clear and accepted universal definition would help improve reporting, as would the application of agreed outcome measures. Clear and consistent reporting of surgical technique remains absent. Recommendations for practice are provided.