What can we learn from an expensive but futile trial of interventions to improve child mental health?

My recent post at PLOS blogs Mind the Brain recent post at PLOS blogs Mind the Brain  concerned an Expression of Interest from the UK  Department for Education (DfE) for a large randomized trial comparing three preventive mental health interventions for promoting well-being among primary school children.

My first reaction was why is there no outcry from evidence-oriented mental health services researchers and policymakers against this waste of scarce resources? Is it no independent critical voice in the UK? Is this not a time for public engagement?

If we cannot depend on professionals to bring their expertise into the discussion, how about informed citizen-scientists parents who demand evidence for programs to which their children will be exposed and further evidence that the resources are not being squandered?

After all, the expensive initiative is being implemented when there is serious underfunding of both primary schools and child mental health programs. Many children with pressing mental health needs are not in a situation to obtain receiving treatment, and those who do obtain services are after an intolerably long wait. There are no prospects for substantial increases in funding in the future.

Maybe I don’t understand British understatement, but press coverage in the leading UK media outlets involved only the most muted of criticism and a lot of praise from those who will financially benefit from the opportunities that come with implementing and evaluating these interventions and the associated training that will be needed.

Some of the claims of the enormous potential benefit of these interventions were simply ludicrous.

Clearly there is an emphasis on expertise conferred by self proclamation or social status, not by demonstrated commitment to evidence. I recognized one of the individuals who wascited as an authority as someone who has repeatedly pointed to involvement in video games as responsible for the decline of Western civilization.

I detect a note of cynicism in calling for interventions that are delivered “lite,” with small amounts of time for week in which they are delivered by teachers who have been provided with minimal training.

I also find it cynical that the outcomes include not only self-report surveys, but improvements in classroom behavior and academic achievement. The schools and their teachers are set up to fail and to be blamed for not achieving these outcomes in the face of substantial underfunding.

I can envision a further initiative targeting the poor performance of teachers failing to meet important educational goals.

The three trialed interventions – mindfulness, protective behaviours, and breathing and relaxation training – lack sufficient evidence that they can improve these “harder” outcomes when delivered in the full form, much less when delivered “lite.”

There is a otential for harm to existing delivery of services from these programs. They create the illusion that something is being done. They tie up teacher time, which could be better devoted to  problems  that already highly visible in their classrooms.

In particular, protective behaviour involves encouraging students to complain of bullying or abuse but does not provide adequate ways of dealing with these problems. A lot of time will be spent dealing with intractable problems that are already known or the inevitable large number of false positives. Talking about bullying or abuse in a way that does not elicit effective response, exposes children to further bullying or abuse in retaliation.

There is no comparison/control group, and so little likelihood that the trial can conclude anything but no differences among the three interventions, but with the ambiguity that we can’t tell whether they are equally effective or ineffective.

Maybe there is a further cynicism among a small interconnected elite in a small country – let’s not to take a critical stance toward such wasteful and ineffective programs, lest we risk benefiting from future such initiatives by being identified as too critical of funded programs. Labeled as “too critical” reduces the likelihood of getting funded, but also a participate in the evaluation of future proposals because of a critical “bias.”

Along with my British colleagues, I am often called upon to evaluate grants for the German funding agencies, which are concerned about loyalties and conflicts of interest among German investigators interfering with dispassionate review of German proposals to improve physical health and mental health service delivery. Perhaps the British should consider similarly relying more on outside expertise, but I think there are cultural barriers to that happening.

I blog at a number of different sites including Quick Thoughts, PLOS blog Mind the Brain, and occasionally Science-Based Medicine. To keep up on my writing and speaking engagements and to get advance notice of e-books and web-based courses, please sign up at CoyneoftheRealm.com

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