Behaviour change interventions to reduce risky substance use and improve mental health in children in care: the SOLID three-arm feasibility RCT

Introduction

Drug and alcohol use is a major public health problem that places a significant economic strain on the NHS and society. 2 Substance use accounts for 11% of the total burden of disease, calculated as disability-adjusted life-years lost, in high-income countries. 3 It was estimated in 2013 that alcohol-related harm costs the UK £21B annually,4 with an additional £15.4B estimated to result from drug addiction. 5 The Modern Crime Prevention Strategy 2016 states that alcohol is a key driver of crime. 6 The north-east has the record highest rate of alcohol-related deaths in England. 7

Risky substance use in adolescence predicts adult alcohol and drug use and significantly increases the risk of adult mental health disorders, crime and poverty. 8–10 There have been some positive trends over recent years with regard to young people’s substance use and related risky behaviours. For example, fewer young people (aged 16–24 years) in England report drinking alcohol regularly,11,12 and more abstain from using alcohol than in previous years. 4,13 Although there has been an overall fall in drug use in teenagers over the last decade, the UK is still in the top five for lifetime use of cannabis and other illicit drugs in 15- to 16-year-olds and the top 10 for binge drinking (heavy sessional or risky single-occasion drinking) in the last 30 days across 36 European countries. 14 In a 2016 longitudinal survey of English secondary school pupils aged 11–15 years, 19% had tried smoking and 44% had tried alcohol. 15 In addition, 24% had tried drugs, compared with 15% in 2014, which the authors believe is accounted for by new questions on novel psychoactive substances (NPSs) and nitrous oxide. 15 The most recent figures from the National Drug Treatment Monitoring System (NDTMS) on young people accessing specialist services show that the number of adolescents accessing such services continues to decline year on year. 16 However, the number of younger people (those aged < 14 years) accessing services has increased by 10% since 2014–15. The most common drug used problematically by those in treatment was cannabis (88% of services users reported a problem with this drug), followed by alcohol at 49%. Eleven per cent of those in treatment reported problematic ecstasy use, 9% used cocaine, 3% used amphetamines and 4% displayed NPS use. 16 Encouragingly, the most recent NDTMS statistics on young people’s substance use suggest a decrease of 45% in problematic NPS use since 2016,16 perhaps because these ‘legal highs’ became illegal in May 2016.

The following sections highlight the specific health, substance use, education, employment and offending status of children in care, henceforth used to make reference to looked-after children and care leavers.

Children in care and health

In the UK context, looked-after children are children up to the age of 18 years who are under the legal guardianship of local authorities. 17 Such young people are described as being in ‘out-of-home’ care in both the USA and Australia. 18,19 Care leavers are young adults who were previously under the legal care of local authorities and are still entitled to support, depending on their circumstances. Care leavers are typically aged 18 to 21 years, but can range in age from 16 to 25 years depending on their circumstances, such as being in education. 17

On 31 March 2018 there were 75,420 children in care in England, which represents 64 children per 10,000 of those aged < 18 years. 20 The number of children ‘looked after’ in England has risen steadily over the past 9 years. The main reasons for children and young people entering the care system are abuse or neglect (61%), family dysfunction (15%), family acute stress (8%) and absent parenting (7%). 20

Children in care may live in a range of placement types, such as children’s residential homes or secure units with foster carers or relatives, or be adopted or unaccompanied asylum seekers, or can remain with birth parents while under supervision from social workers. 21 Recent evidence suggests that levels of placement stability for children in care are low. In 2016–17, the mean placement duration was 314 days (10.5 months) and the median was 140 days (just under 5 months). 20 Twenty-four per cent of placements lasted < 1 month and only 22% of placements lasted > 1 year. 20 The impact of this, as Unrau and Seita explore with care-experienced adults, can have a lasting emotional impact and affect an individual’s ability to trust and build relationships. 22

Children in care have multiple risk factors for substance use, poor mental health, school failure and early parenthood. 23 These factors include parental poverty, absence of support networks, parental substance misuse, poor maternal mental health, early family disruption and, in the majority of cases, abuse and/or neglect. 24,25

Young people who have experience of the care system are more likely than their peers to have experienced adverse childhood experiences. 26,27 A Social Care Institute for Excellence report, Improving Mental Health Support for our Children and Young People, highlights the combined effects of young people’s experiences prior to care and those during care as having an impact on their mental health. 28 Such experiences are associated with a number of poor long- and short-term health outcomes,29 including problematic substance use, mental health problems,30 obesity and cancer. 31 For example, more than 50% of children in care rate their well-being as low, compared with only 10% of their same-age peers. 32 Similarly, 50% of those in care meet the diagnostic criteria for a psychiatric disorder, compared with 10% of non-care children who have mental health issues. 32 All children in care in England aged 4–16 years are required to complete an annual Strengths and Difficulties Questionnaire (SDQ) with their foster carer or main residential care worker. In 2017, 49% had a score within the normal range (score of 0–13), 12% had a borderline score (score of 14–16) and 38% had a score giving cause for concern (score of 17–40). 20 Those in foster care placements had the lowest scores, 51% scored within the normal range, 13% were borderline and 36% gave cause for concern. 33 By contrast, within the rest of the population of children in care, 39% were in the normal range, 13% were borderline and 47% gave cause for concern. 34 The mental health needs of children in care are evident in the Children’s Commissioner 2015 report. 35 Children in care significantly over-represented peers in relation to accessing specialist Community Adolescent Mental Health Services (CAMHS). Although < 0.1% of children in England are in care, they represented 4% of children referred to CAMHS. 35

Longitudinal data suggest that young people who have been in care have higher levels of depression in adulthood. In the British Cohort Study (BSC70), at age 30 years, 24.2% of care leavers reported depression, compared with 12.4% of those who had not been in care. 36,37 In addition, care leavers were four times more likely than their peers to self-harm in later life. 38 Children in care had a nearly fivefold increased odds of at least one mental health diagnosis, including anxiety, depression or behavioural disorders [odds ratio 4.92, 95% confidence interval (CI) 4.13 to 5.85], than their non-looked-after peers, further increasing their risk of substance misuse and poor life chances. 39

Evidence suggests that children in care have a higher rate of teenage pregnancy than their peers. 40 Over a 14-month period in 2012–13 in Wales, children in care aged 14–17 years had a conception rate of 5.8% compared with 0.8% among peers not in the care system.

Substance use

As outlined in Introduction, risky substance use in adolescence is a predictor of adult-related alcohol and drug use, mental health disorders, crime and poverty. 8–10 Children in care aged 11–19 years have a fourfold increased risk of drug and alcohol use compared with children not in care. 41 Twenty-five per cent of children in care aged 11–19 years drink alcohol at least once a month, compared with 9% of young people not looked after. A national survey of care leavers showed that 32% smoked cannabis41 daily and data from 2012 showed that 11.3% of children in care aged 16–19 years had a diagnosed substance use problem. 42,43

In the year to end of March 2017, 4.1% of children in care were identified as having a substance misuse problem (not including tobacco), with older teenagers being more likely to be identified as such (11% of 16- to 17-year-olds vs. 5% of 13- to 15-year-olds). 20 Those in foster care appear to be the least at risk: 2.1% were identified as having a substance misuse issue, of whom 46% received an intervention and 42% refused an intervention. However, within the rest of the population of children in care (non-foster care placements), 10% were identified as having a substance misuse problem, 62% of whom received an intervention and 39% refused an intervention. 33 In March 2018, there were 15,583 young people accessing specialist substance misuse services, of whom 7% (1093 young people) stated that they were living ‘in care’. In addition, of the 11,052 new presentations in 2017–18, in self-reports via the NDTMS, 1204 (11%) young people identified themselves as a looked-after child, 957 (9%) identified themselves as a child in need and 829 (8%) reported that they had a child protection plan in place. 44 International evidence suggests that those living in institutional or residential care homes are at particular risk of legal and illegal substance misuse, compared with non-care peers and those living in other placement types. 19,45–47

Children in care are over-represented among drug users in later life and tend to start using substances earlier, more regularly and at higher levels than their peers. 48 Relatedly, 12% of young people accessing substance misuse services are children in care,49 and this group are disproportionately represented in the criminal justice system.

Recent policies stress that children in care are a high-risk group who are vulnerable to substance misuse and linked mental health problems, as identified in Ethics approval. The 2017 Drug Strategy,49 the National Institute for Health and Care Excellence (NICE) (2017) guidelines Drug Misuse Prevention: Target Interventions50 and the NICE (2010) guidelines Alcohol Use Disorders: Prevention51 identify children in care as a ‘high-priority group’ who are at increased risk from substance-related harm. Despite this, there is limited research and an absence of cost-effectiveness data, and, at the time of writing (2019), no national guidelines on the most effective interventions to decrease risky drug and alcohol use in this group. This lack of data was highlighted by the Chief Medical Officer’s annual report for 2012,23 which stated that one of the key research areas was to assess the most effective interventions to reduce multiple risk-taking behaviour, including drug and alcohol use, in this group. 23

Literature shows that risk-taking behaviour clusters in adolescence and behaviours, such as smoking, alcohol consumption and unprotected sexual intercourse, co-occur. 52,53 In addition, young people who engage in any one risk-taking behaviour are likely to engage in others. 54,55 The involvement in multiple risk-taking behaviours can be linked to contextual factors. The majority of young people presenting to specialist drug services have multiple and overlapping vulnerabilities in addition to substance use, such as being looked after, mental health problems, not in education, employment or training (NEET), experience of child sexual abuse, offending or domestic abuse. 16 Forty per cent of 19- to 21-year-old care leavers in England are NEET compared with 13% of all 19- to 21-year-olds more broadly. 34

Education

Fifty-seven per cent of children in care aged 11 years have a special educational need, a rate 40% higher than among their peers who are not in care. 20 A child will be defined as having special educational needs if they have a learning problems or disability that mean that they need special education support. 56 The disparity in educational achievement between young people in care and those who are not continues as they progress through the education system. At age 16 years, the average attainment score for children in care is 19.3, compared with a score of 44.5 for children not in care. 20 Children in care have lower educational attainment and participation post secondary level,57 and those who enter care later (i.e. between age 10 and 15 years) do less well in secondary education than those who enter care at a younger age. 58

A study of 181 children in care aged 7–15 years in an English local authority found that they performed less well than the general child population in regard to assessed mental health, emotional literacy, cognitive ability and literacy attainment. 59 However, there were some positive exceptions of children performing well (16%, n = 30) and this was positively correlated with having face-to-face parental contact at least once per month and being in mainstream education. However, there was no significant relationship with the age on entering care, the primary reason for entering care, the length of time in care, or placement type.

A study of longitudinal data of Danish children born in 1995 shows that those in ‘out of home’ care settings change school more often than other young people, and that such change is associated with adverse educational outcomes. 60 Longitudinal data from the UK, Finland and Germany show that, in all three countries, care leavers are more likely to have no qualifications and less likely to have a higher-level qualification than their same-age peers who have never been in care. Males, in particular, are more likely to have no qualifications. 36

Literature shows that young people who truant or are excluded from school have an increased risk of alcohol and/or drug use. 61 It is also reported that young people who have truanted from school are 1.85 times as likely to have consumed drugs within the past 12 months and are over twice as likely to have consumed alcohol within the past week. 62

Employment

Care leavers have a higher risk of unemployment than those who have not been in care. 63 Forty per cent of 19- to 21-year-olds are NEET, compared with 13% of all 19- to 21-year-olds. 20 Such disadvantage and poorer outcomes last into adulthood, showing ‘a continuing legacy of adversity’ for those who have been in care, particularly in relation to education and employment. 36 Across the UK, Finland and Germany, care leavers are over-represented in economically inactive categories. In the 1970 British Cohort Study, of those born in 1970, at age 30 years, 65.8% of those who had been in care had attended full- or part-time education compared with 82.1% of those who had never been in care. By age 30 years, 7.1% of care leavers were unemployed, compared with 3.1% of those who had never been in care. A total of 16.3% of care leavers were not working to take care of family/home, compared with 9.9% of those who had not been in care. In the UK, at age 30 years, care leavers were more likely to have claimed Jobseekers Allowance (4.3% vs. 1.6%), claimed income support (7.7% vs. 1.7%) and were much more likely to have been homeless or of no fixed address before the age of 25 (22.5% vs. 6.5%). 36 Care leavers have three times the risk of being homeless than those who have never been in care. According to the more recent Longitudinal Study of Young People in England (now referred to as Next Steps), a birth cohort study of those born in 1989–90, care leavers at age 20 years are showing similar trends to those in the 1970 cohort at age 30 years. Those who have been in care are over-represented among the unemployed (17.9% vs. 6.2% of 20-year-olds who have not been in care). 64

In line with the disrupted school attendance reported above, young people with poor attendance are more likely to leave school at 16 years of age, with few or no qualifications, and therefore are seven times more likely to be recorded as NEET. 62

Offending

In the year up to 31 March 2017, 4% of children in care aged between 14 and 17 years had received a conviction, final warning or reprimand. Children in care are five times more likely to offend than all children. 20 Of those in foster care and aged between 10 and 17 years, 1.2% received a conviction, final warning or reprimand, compared with 15% of children in all other placements. 33 Research from the criminal justice system in Scotland showed that 34% of youth offenders had been in care. Of these offenders, 75% reported drug use (vs. 57% of those not previously in care). 65

Summary of the needs of children in care and potential solutions

As highlighted in sections Children in care and health to Offending, children in care are at risk of experiencing a myriad of negative outcomes, which will affect their emotional, physical and economic prospects into adult life, resulting in a significant cost to society and increased risk of intergenerational poverty. Effective interventions for children in care could have a beneficial effect on the long-term mental and physical health of these vulnerable young people, importantly reduce health inequality and, due to their increased risk of early parenthood, potentially impact intergenerational health. In response to the needs of children in care, the SOLID trial was developed to test the feasibility and acceptability of two behaviour change interventions in an attempt to address the substantial gap in evidence relating to effective interventions for children in care residing in varying forms of placement.

Research aim

The SOLID pilot feasibility trial aimed to assess the feasibility and acceptability of a definitive three-arm multicentre RCT (two behaviour change interventions and care as usual) to reduce risky substance use (illicit drugs and alcohol), and improve mental health in looked-after children and care leavers (children in care aged 12–20 years).

Research objectives

The primary objectives within the SOLID pilot RCT were as follows.

Phase 1: formative study –

• To adapt two behaviour change interventions for children in care to help reduce risky substance use (MET and SBNT). This phase was carried out with children in care, their carers (residential key workers and foster carers), drug and alcohol workers, and social workers with responsibility for children in care, to ensure acceptability and feasibility of the intervention packages.

Phase 2: pilot feasibility randomised controlled trial –

• To conduct a three-arm pilot RCT [comparing MET, SBNT and a control (usual care)] to determine if rates of eligibility, recruitment and retention of children in care, and acceptability of the interventions, are sufficient to recommend a definitive multicentre RCT.

The secondary research objectives were as follows.

Phase 1: formative study –

• To refine the intervention packages for integration into care pathways for children in care.

• To conduct a survey of the leads for young people’s drug and alcohol treatment services across England to identify ‘standard practice’ within and across agencies.

Phase 2: pilot feasibility randomised controlled trial –

• To establish response rates, variability of scores, data quality and acceptability of the proposed outcome measures for the future definitive trial (i.e. self-reported alcohol and drug use, health-related quality of life, mental health and well-being, sexual behaviour and placement stability 12 months post recruitment), to inform a sample size calculation for a definitive multicentre RCT.

• To assess acceptability, engagement and participation with the MET- and SBNT-based interventions by children in care, their carers and front-line drug and alcohol workers.

• To carry out a process evaluation to include fidelity of intervention delivery and qualitative assessment of the barriers to successful implementation, and to assess if key components from the MET and SBNT interventions can be combined to develop a new optimised intervention.

• To develop cost assessment tools, assess intervention delivery costs and carry out a value of information analysis to inform a definitive study.

• To apply prespecified STOP/GO criteria and determine if a definitive multicentre RCT is feasible, and, if so, to develop a full trial protocol.

• To consider findings from the study as a whole in order to develop a core intervention delivery package, potentially of a single optimised intervention, linked to a theory of change model to use in the definitive trial.

Rationale for choosing SBNT and MET interventions

Two evidence-based interventions, MET69 and SBNT,70 were chosen to be adapted as they have been shown to be effective in decreasing substance use in a range of participants including adolescents. 71

Motivational enhancement therapy is a concentrated version of motivational interviewing. This client-centred, counselling approach adds a problem feedback component to standard treatment. 72 The problem feedback component enables the practitioner to reflect on the material elicited about the impact of drug and alcohol use on the young person’s mental health, physical health, relationships, behaviour and offending, and encourages the young person to discuss this further, for example:

We discussed the fact that your foster carer was worried about your drinking. You told me that you found that you were more irritable the day after you had drunk alcohol. Can you tell me more about this?

Within the MET approach, there is a basic assumption that the motivation and responsibility for change lie within the client, and it is the therapist’s role to create an environment to enable the client to change. A systematic review by Carney and Myers73 concluded that motivational interviewing and MET have shown therapeutic promise for adolescents with problem substance use. 73–75

Social behaviour and network therapy is a counselling approach which utilises a combination of behavioural and cognitive strategies to help clients build social networks that are supportive of positive behaviour change in relation to problem substance use and goal attainment. 76 NICE recommends family interventions when working with young people presenting with complex needs, such as substance misuse and mental ill health. 77 SBNT offers an intervention with the potential to galvanise a support network for children in care that can draw support beyond the immediate family. This is important, as most forms of help focus mainly on the individual with the drug and/or alcohol problem and pay little or no attention to the social context. In addition, given the potential for family fragmentation and broken relationships, it is unlikely that the more traditional family interventions would be feasible for the population of children in care. Therefore, the challenge that Copello76 tried to address when developing the SBNT approach was to find a way of working and helping people that takes the social context into account and uses a whole social or family system to help and support change and reduce problems, while also developing an approach that is simple enough to be used in routine practice. The principle of incorporating a support network into the intervention was believed to be suitable to use within this study, as it was hoped that the six sessions could be used as a platform to create a support network, or at least start a dialogue that could consider potentially supportive individuals, and promote cohesion that could ideally continue to be developed beyond the period when the young person is in contact with services.

Although both MET and SBNT have been shown to be effective at reducing substance use in the general population of children and young people, less is known about their effect with those who are likely to have more fragmented family relationships and are currently looked after by the local authority. For the SBNT approach, the nature of social networks and how they differ for children within the care system was paramount to understanding how to effectively engage and work with this group of young people.

Developing a theory of change model

In accordance with guidance from the Medical Research Council (MRC) on developing and evaluating complex interventions,78 we commenced the adaptation of the interventions by building a theory of change model relating to our target population. We developed a behaviour determinants intervention (BDI) model for each intervention (RL, RM, EK and AC). 79 These models highlighted the key behaviours targeted by the interventions, the determinants for change and how the team visualised the proposed change pathways for the interventions. The models are illustrated in Figures 2 and 3. We also considered the absence of appropriate family support and supervisions, and the life experiences which led to an individual’s placement into care, as the central vulnerabilities of children in care. We predicted that an intervention seeking to decrease substance misuse by this group would need to address the behaviour determinants identified in the BDI models (see Figures 2 and 3).

FIGURE 2.

Behaviour determinants intervention theory of change model: MET.

FIGURE 3.

Behaviour determinants intervention theory of change model: SBNT.

When delivering the MET intervention, the therapist can elicit self-motivational statements from children in care by employing strategies to build and strengthen their motivation. By using this technique it was hoped that children in care could resolve the inherent ambivalence about their substance-misusing behaviour. 69 When developing the MET BDI model (see Figure 2), alongside the goal of strengthening motivation, we thought that it would also be helpful to provide personalised feedback to assist the young person to consider risks and tip the decisional balance.

When developing the SBNT BDI model (see Figure 3), we thought that the approach should promote the recognition of an informal network of supports that extended beyond traditional caregivers. We were aware that networks of support available to children in care would differ from those available to children and young people residing within more traditional biological families. However, evidence exists that social network support is key to helping people deal with problem behaviours, including substance misuse. Therefore, within SBNT, the therapist could usefully employ cognitive and behavioural strategies to help children in care to build social networks of positive behaviour change in relation to their goal attainment. 76

Formative qualitative research methods

In-depth one-to-one interviews, dyad interviews and focus groups were used to explore the assumptions inherent within our logic models (see Figures 2 and 3), the principles behind the MET and SBNT approaches and their relevance to children in care, and the broader therapeutic approaches, including the key behavioural and motivational domains that the interventions should address when working with the population of children in care.

All data were collected using semistructured topic guides. Guides were developed and adapted throughout the study in response to early research findings to ensure deeper understanding of emerging themes. Interviews and focus groups were audio-recorded and transcribed verbatim. Data were collected until data saturation was reached within each participant group and no new themes were emerging. Transcripts were anonymised and identifiable participant details removed. A participant key was developed and stored separately. Pseudonyms were allocated to each transcript and have been used within all reports and publications to maintain participants’ anonymity.

Interviews with children in care and carers (foster and residential) were chosen as the method of data collection. Interviews were chosen, as the semistructured nature of the topic guides meant that sensitive issues could be explored and personal experiences shared. Interviews also recognised individuals as experts in their own experiences, in respect of the topics of drug and alcohol use, any barriers and facilitators experienced when engaging with services (e.g. substance misuse services, mental health and services, such as Barnardo’s) and any potential recommendations for service improvements. The topic guides used for the interviews with children in care were developed with the SOLID PPI group, as discussed previously in Chapter 2. All study documentation relating to the formative research is shown in Report Supplementary Material 3.

Focus groups and dyad interviews were chosen as the primary method of data collection with social workers and drug and alcohol practitioners and participants were interviewed with colleagues within the same profession (i.e. social workers were interviewed together and drug and alcohol practitioners were interviewed together). The group interaction encouraged the exploration of a range of responses in a relatively short space of time. Furthermore, they proved to be an effective way to explore issues and quickly establish a range of experiences, views and knowledge. The professional focus groups and interviews enabled us to discuss the original components and principles behind the MET and SBNT interventions, alongside the proposed adaptations and whether or not they were perceived to be relevant to the context of children in care. They also enabled us to explore the broader therapeutic approaches required to work with children in care, the feasibility of delivering the interventions to this population and to consider potential barriers to delivering the interventions at scale.

Recruitment and sampling strategy

Social workers within the looked-after children and 16+ teams (teams working with children in care aged ≥ 16 years and supporting young people who are transitioning out of the care system) approached eligible children in care from their caseload. Eligible participants were defined as children in care aged 12–20 years, known by a social worker to have experience of substance use (previous or current personal use or exposure to substance use), who were able to provide informed consent and who resided in the study area. Social workers acted as gatekeepers, and shared a brief participant information leaflet with the young person. If the young person in care was willing to take part, the social worker completed a written assent or consent form with the young person and returned it to the study team. Children in care (n = 19) expressed an interest in taking part in the study. Once the form was received the study team was able to formally approach the young person in care. All 19 interested children in care were contacted by the research team to discuss the research and to arrange an appropriate time to visit and conduct an interview. Written informed assent or consent (depending on age of the child in care) was taken by the researcher before starting the interview, as described in Consent.

A purposive sample was recruited to ensure diversity with regard to age, exposure to drug and alcohol use, and placement type. The final sample was representative of the population of children in care, in so far as there was an equal mix of male and female participants and a range of placement types across the different local authority areas, as identified in Table 2.

Separate one-to-one interviews (n = 13) were carried out with carers across the research sites to ensure diversity of sample in terms of age, ethnicity and carer type (i.e. foster carer/family member/residential worker). An additional focus group with four carers was also conducted as part of an already established carer support group.

Social workers (n = 8) were purposively approached to take part in a focus group and four took part. This was complemented with two further dyad interviews with four social work staff. Sampling took place to ensure diversity in terms of the local authority site in which they worked, level of experience (i.e. social worker, team manager) and sex. The social workers within the looked-after children and care leavers teams were interviewed because of their key knowledge of the context of children in care, as well as of many of the ethical issues that informed the intervention development.

A focus group also took place with specialist young people’s drug and alcohol practitioners (n = 5). Practitioners were purposively approached to ensure diversity in terms of local authority site they worked in, job title (substance misuse practitioner, service manager) and sex. The drug and alcohol practitioners had key knowledge of interventions that currently work well with young people and they used their professional knowledge and expertise to inform the adaptation of the MET and SBNT interventions.

In addition to the focus group with drug and alcohol practitioners described above, one-to-one interviews were also carried out with three drug and alcohol workers who had delivered youth social behaviour and network therapy as part of a previous trial. 70 These interviews aimed to build on previous knowledge and experience of delivering youth social behaviour and network therapy to young people within a substance misuse setting and contributed towards adapting the treatment manual for the population of children in care.

We initially proposed to carry out individual one-to-one interviews with children in care and carers, and focus groups with professional participants. For pragmatic reasons we conducted a combination of individual interviews, dyad interviews and focus groups, depending on participants’ availability and preferred method of involvement. On reflection, the research team felt that the combination of interview and focus group data collection had a positive impact on the quality of the data generated. As planned, the interviews enabled us to collect an individual’s thoughts, attitudes and personal beliefs about being involved in and interacting with the child welfare system, and the focus groups provided an opportunity to consider how the interactional data between participants resulted in similarities and differences in experiences being highlighted.

Table 2 shows the qualitative methods that participants engaged in and the demographics of the participants recruited in the first round of qualitative work.

Consent

The children in care aged < 16 years were seen with an accompanying adult (parent, carer, social worker, children’s home lead) prior to the interview taking place and they were asked to provide informed assent. If the accompanying adult did not have parental responsibility (PR), the research team contacted the adult with PR to obtain informed consent. If the parent was not contactable or, in the view of the designated social worker, it was a risk to the young person for the parent to be contacted, the social worker or local authority guardian with PR was contacted to sign the consent form. Informed young person assent and consent, dependent on age and carer consent, were obtained prior to the young person taking part in any element of the study. Information on the study was shared with parents and carers as appropriate.

For those children in care aged ≥ 16 years and for all other participants within the formative phase of the research, informed consent was taken directly from the individual concerned by the researcher. Prior to informed consent being taken, a participant information leaflet was shared with each participant, and the research team talked through the leaflet and provided an opportunity for any questions to be asked. The research team also explained that participants could withdraw at any point.

After informed consent had been given to the research team, interviews and focus groups were carried out by qualitative researchers with experience of working with young people. The data collection took place at a location convenient for the participant. For young people this was in their home or at an alternative convenient private location, which ensured the safety of both the young person and researcher. For professionals, data collection took place in a private location within their usual working environment. When interviewed the young person was given a choice of whether or not they wanted to be accompanied by a trusted adult who would act as an observer; however, only two young people requested this.

Children in care participants were remunerated for their time with a £10 ‘love2shop’ voucher.

Qualitative analysis

Transcripts were analysed thematically;80 it was an iterative process, using the constant comparative method,81 in order to identify key themes and concepts. In practice, this entailed a line-by-line coding process and then analysis within a given transcript and across the data set as a whole. Analysis with qualitative software (NVivo) aided the organisation of thematic codes. The data were compared across the participant groups (i.e. children in care, professionals and carers), with similarities and differences being highlighted. In the first instance, data were analysed by two researchers in order to ensure intercoder consistency and agreement. The main themes and findings were presented to the wider multidisciplinary team that included expertise in a variety of backgrounds, including community child health, public health, social care, social science, drug and alcohol use, and clinical psychology. These qualitative data were used to refine the SBNT and MET approaches to ensure that they were responsive to the needs and views of substance-using children in care.

Data analysis focused on understanding internal and external drivers of behaviour and also on views about interventions promoting well-being and self-care in early life. Components of the logic models (behaviours, determinants and intervention components) were explored with participants to further refine the theory of change pathway and clarify intervention delivery issues.

Finalisation workshops: modification of interventions

A series of intervention finalisation workshops took place, during which findings from the preliminary thematic analysis of the qualitative interviews and focus groups were presented. The purpose of the workshops was to co-produce the final intervention manuals. Within the initial phase of the workshop, the research team presented the main themes that had emerged from the interview and focus group data, and participants were asked to consider the MET and SBNT interventions and discuss what the final manual should ‘look like’.

Five workshops were conducted: one with professionals (n = 14), all of whom had been interviewed earlier; and four with young people (n = 13), none of whom had been previously interviewed. All participants involved in the young people’s workshops either were currently in or historically had experience of receiving specialist drug and alcohol treatment. The workshops were inclusive of both children in care (n = 5) and non-looked-after children (n = 8). We took the decision to include young people not involved with the care system, as this element of the study needed to understand current treatment provision. Owing to social workers not systematically recording this information and gatekeeping to ‘protect’ young people, we found it difficult to identify young people in care currently on their case load with experience (current or previous) of accessing treatment. We decided to approach the drug and alcohol services involved in the study to recruit young people into the workshops. We wanted to ensure that we had maximum variation of young people, regarding age, sex and location of participants, who had experience of accessing drug treatment agencies, to discuss the developed interventions. We held a workshop in each active study site to enable participants to be involved in the study without having to travel long distances to take part. The workshops were all held within the well-established young people’s drug and alcohol services involved in the study, so participants were in a familiar environment.

The workshops provided an opportunity for the research team to present the preliminary findings to key participants. Verbatim anonymised quotes were used to identify areas of potential importance and to facilitate discussion between researchers and participants. Four researchers and participants then worked collaboratively to co-produce the final manuals. Co-production occurred through group discussions and using flip charts and paper to design worksheets and complimentary materials to be used within sessions.

The themes discussed within the workshops are shown in Table 3.

Areas of potential intervention adaptation were discussed within and across interviews, focus groups and workshops, and the findings from the qualitative data collection have resulted in a number of adaptations being made to the manualised interventions.

Following the workshops, the final adaptation of both manuals took place. Ongoing communication took place between the on-the-ground researchers involved in developing the manuals and the original intervention authors [Professor Alex Copello (SBNT) and Dr Gillian Tober (who has adapted both MET and SBNT for other clinical trials)], to ensure that the core components of each approach were retained throughout the adaptation process.

Theme 1: therapeutic relationships

A successful therapeutic relationship was highlighted as important by both professionals and children in care when working towards reducing substance use. The qualities of trust and genuine care were identified as the two main constructs that underpin a successful therapeutic relationship. The ability of children in care (and often inability) to trust and confide in professionals was a recurrent theme. Professionals acknowledged that children in care often experience disorganised and difficult attachment and recognised that their experiences leading up to their placement in care may have had an impact on their ability to trust other people. Therefore, although trust is one of the necessary conditions for any therapeutic relationship to be successful, it is particularly important for children in care, who may have experienced relationship breakdown and abandonment, being let down and having their essential needs unmet.

Professionals displayed a clear understanding of these complex attachment issues and discussed the need to ‘earn’ trust when engaging with children in care:

You need to put in the groundwork initially. I think with teenagers you need to gain their trust, you need to work for it. Because if they have been hurt, which they will have been, they will try to push you away. They won’t want to trust you.

Carly, social worker, focus group

Owing to the often inherent ‘lack of trust’ in professionals, practitioners recognised that they were expected to demonstrate their trustworthiness when engaging with children in care. Typically this involved practitioners being consistent and reliable. Equally, children in care described seeking qualities such as empathy, reliability and partiality, all of which are qualities that may have been missing in their early attachments. One foster carer described displaying his reliability in terms of being available ‘24/7’, stating that he is permanently ‘on call’ if a young person needs him:

. . . it is not a job because there is no job that makes you work 24 hours a day, 7 days a week and 365 days of the year, but this one does.

James, foster carer, focus group

From the perspective of children in care, the relationship between themselves and their allocated key worker within an organisation was a pivotal factor that determined whether or not they engaged with services. When establishing and facilitating a trustworthy relationship, young people explained the importance that they placed on professionals allowing them to ‘work gradually’, only sharing ‘personal information’ and making disclosures when they felt ready. Furthermore, the idea of professionals making self-disclosures was repeatedly reported: children in care felt it was important for professionals to ‘trade’ personal information, such as a hobby they enjoyed, details of a pet they owned, or an example of how they had resolved a problem successfully in their own lives. This process of sharing information was perceived to be beneficial to developing a trusting relationship, as sharing information was not completely one-sided. Children in care reported that such disclosure enhanced their sense of connection to the practitioner, as well as their own safety to disclose information:

When you work with someone you have to build a bond up first, before you can open up to them . . . It’s, well the way I’ve done [it] is just ask questions about them, and then if they tell you, then you know well if they’ve told me this then I can tell them that.

Sophie, 17, young person interview

Children in care described having multiple professionals involved in their ‘care package’ and a quality that young people desired was ‘genuine care’, inclusive of professionals going ‘above and beyond’ what is expected and providing unconditional care, although they did not always feel that they received this. Professionals, especially those within the social services teams, take on the corporate parenting role. This role dictates that safeguarding and risk management take precedence over the provision of emotional support. Therefore, much of the care a child usually receives from family members within a personal environment is provided by a professional who is employed to provide such care. To demonstrate that they care, many social workers describe being available outside their contracted working hours and going ‘above and beyond’ their role:

Myself and his YOT [youth offending team] worker had agreed between us that we would have our phones on 24/7. So that if he wanted to get in touch and check in we knew he was OK. So we did, we took turns and he did check in and he did arrange to meet up which was really good.

Steph, social worker, focus group

Children in care showed an acute awareness that social workers had a corporate parenting role to fulfil and that carers provided a role that they were ‘paid’ to do. This led to children in care emphasising the importance of practitioners who made them feel like they ‘genuinely cared about their welfare’. Interestingly, foster carers reinforced that they attempted to provide the same level of care and support to both their biological children and the children placed in their care, despite the paid position they were in:

Any child that comes to live with me, I know they are not mine, however I will work with them, I will play with them, I will live with them and I will do everything to my best ability in every area, in every arena because I want what is best for them.

Liz, foster carer, interview

Genuine care also involved professionals showing empathy to the young person and being available to provide ‘unconditional’ support. There was a belief, sometimes verbalised explicitly, at other times more implicitly, that genuine care stemmed from personal investment rather than a contractual obligation:

Like Josie talks to me, not like I’m just someone she has to work with, she talks to me like she cares.

Carla, 17, young person interview

Children in care felt that they were cared for if they were shown unconditional positive regard, regardless of their behaviour. This was a recurrent theme for professionals, who reported children in care regularly disclosing information to them regarding historical experiences that they had been witness to or subjected to. Foster carers described having to respond in a sensitive and non-judgemental way:

We had a young man who had been abused by a family member. He was feeling guilty himself about it and thought that we would feel disgusted that things like that had been done. It is letting him see that we are not disgusted. Straight away, ‘I have heard all of this before, you are not the only one. It is not your fault’.

Carol, foster carer, focus group

The ability of professionals to be non-judgemental was important to children in care, and some participants voiced concerns that practitioners would not be able to ‘cope’ if they chose to share some of the experiences that led to them being placed into care. One young person in care explained that he elected not to engage with services and open up for fear that professionals would then ‘leave him’:

. . . my family is **** up, really **** up. And if I sat there and told someone they’d probably run a mile, they probably would. So that’s why I’ve never really opened up to anyone, cause if I did they probably would run away, do you know what I mean?

Ewan, 17, young person interview

The above quotations identified the practical issues and challenges that needed to be addressed to facilitate a therapeutic relationship with children in care; therefore, it was important to acknowledge the importance of overcoming insecure attachments and incorporating methods of developing a trusting relationship.

Theme 2: engagement and challenges of working with children in care

Throughout the formative data collection, there was consensus that, if used in isolation, the more traditional one-to-one talking therapies were often unproductive for children in care. From a professional perspective, this approach was thought to be overly formal and could result in children in care disengaging with support services. Children in care also verbalised that they found it harder to engage with overly structured and formalised sessions:

It was like in a room . . . and like there’s a table there and it had like little seats round, and like, he was just on about things. Do you know, he didn’t make it very good, like, he didn’t make it very fun and enjoyable kind of thing. It was just like, boring. He was just writing things down that I was saying basically and it just upset me. He just kept on going over it and over it and over it, he was like ‘so how did that feel? Bla bla bla.’ I didn’t really feel comfortable.

Isabelle, 13, young person interview

There was a clear need for practitioners to be equipped with a number of skills and strategies to engage with young people. Practitioners needed to be responsive to the individual presenting to them and described using techniques such as ‘node-link mapping’, as used in the International Treatment Effectiveness Project,82 and mood cards, while staying true to the intervention they were trying to deliver:

There are not many young people who you’ll get to the point where you’re doing that one to one counselling really. It is few and far between. You’re being creative . . .

Adam, drug and alcohol worker, focus group

Many of the participants in care expressed their desire to attend sessions that enabled them to be actively involved in the work being completed, with practitioners implementing strategies that facilitated young people connecting with the work and the professional themselves, and maintaining concentration:

Writing it down or doing it like arts and crafts way because I don’t like just talking and having conversations cause I just get a bit bored and lose track, then I’ll start fiddling about.

Abbie, 18, young person interview

Alongside the necessity for an interactive approach, was the need for practitioners to be aware of the complexities of living in the care system for the young person. This awareness would help to facilitate a holistic approach to be taken to the work being conducted and could also help to identify goals that are not solely ‘substance use’ related. Children in care stated that they valued discussions that recognised the difficulties occurring in their lives. Professionals also identified the importance of taking a bespoke approach to treatment:

I think what’s coming out here is that with the kids we work with, the drug and alcohol issue is over there, if you like, and a whole raft of other issues are here. As workers we’re dealing with all of these here and that tends to sort the drug and alcohol issues out quite naturally.

Laura, drug and alcohol worker, focus group

Professionals highlighted challenges that arose owing to the transient nature of the population of children in care. It was identified that, when young people experience frequent placement changes, it can result in young people experiencing fragmented support in terms of changes to key workers, carers and professionals supporting them. It can also result in young people being eager to find friends even if these relationships are potentially destructive:

So they might, you know, have contact with their brothers or sisters, you know, it is just they get moved around, and when they are moved around they are vulnerable, they are desperate to have friends or they are desperate to have somebody to call their own . . . people get attracted to them who are, I would say, not the type of kids I would want my kids to knock around with.

Liz, foster carer, interview

Social support was identified as a potential challenge regarding the SBNT approach. Children in care and practitioners recognised that a positive support network was a central part of SBNT and accepted that social interaction is necessary in the resolution of most substance misuse problems; however, it was felt that support was not always available:

It is quite sad sometimes when they haven’t got anybody in the family, not even an uncle or a cousin or somebody who they can put down as a support really.

Steph, social worker, focus group

The challenges of finding appropriate network members was explored. In many interviews, the participant in care struggled to identify someone that they felt they could turn to, and feelings of not having support and the need to be self-sufficient were verbalised:

My boyfriend and his friends, and there’s a few of my friends. Actually they’ve got their own lives as well, they’ve got their own houses and their partners and they’re all settling down as well, so . . . there’s not really many people there. When you think about it though, how many of them can you turn to if you’ve got a problem? Cause there’s not a lot.

Abbie, 18, young person interview

As was expected within the children in care population, when individuals were able to identify individuals who provided positive support, it was often people outside the traditional family support network. This had potential for sources of support to be transient (e.g. teachers who would change with each school year). Professionals were often identified as sources of support, which could be challenging for the delivery of SBNT, as individuals may not be able to provide ongoing or out-of-hours support in the same way as more traditional family members would. Nonetheless, children in care recognised the support that was provided to them:

There’s two main people I’ve got in my life which provides me with support. One’s my boss, he’s a farm manager, I work with him most days. Another person is the manager of [name of school], he owns the company and he helps quite a lot by, when I moved out of here [residential children’s home] the first time, he’s the one that made me come back, and let me get my head back.

Philip, 17, young person interview

Screening tools used

Drug and alcohol treatment services were asked to provide information regarding the screening tools they used to assess the level of alcohol and/or drugs a child in care was consuming. The services reported using between one and three different screening tools. However, although some services reported solely on the screening tools used, other services completed the screening within the context of completing a more holistic initial assessment of need.

Ninety-four (84%) services reported using only one screening tool and for the most part, these were ad hoc, locally developed tools rather than validated tools. Twenty-nine (26%) services reported using two different tools and five (4%) services reported using three screening tools. Services reported using the different tools simultaneously during an initial meeting and over a prolonged period of time to establish levels of use and need. There was no standardisation regarding which tools were used and consistency varied even within agencies, as professionals reported using a tool that they felt best met the needs of the individual. Fifty-two (46%) services reported developing a tool ‘to meet their local need’, which, as identified above, could include an amalgamation of validated tools, such as the Alcohol Use Disorders Identification Test (AUDIT), Alcohol Use Disorders Identification Test for consumption (AUDIT-C) and Drug Use Screening Tool (DUST), and could also incorporate items from an assessment of need. The screening tools identified as being used can be seen in Figure 4.

FIGURE 4.

Screening tools used.

Interventions offered

Participants were asked to describe the delivery of the interventions offered to children in care, including the number of sessions, duration of sessions and frequency. When discussing the delivery of interventions, 67 (55%) services stated that they offered a completely ‘bespoke’ service, with each individual being offered a package of care tailored to their individual needs. This package of care was not restricted to a minimum or maximum number of sessions and could incorporate a mixture of tier 2 and 3 services to meet the child in care’s identified needs. Thirty-five (31%) services reported that they were commissioned specifically to conduct structured work delivered within 12 sessions. Twenty-one (19%) services identified that they offered a variety of structured work, such as harm minimisation and drug education. A maximum of 12 sessions was offered, although this could be flexible and could lead onto more bespoke work if necessary. Despite working in a structured way, services often reported having the flexibility to recommence work at a later time with a young person if a further referral was received or if the child in care’s circumstances had changed.

Delivery of services

A final area of interest was to explore the qualifications and/or professional training that drug and alcohol practitioners had achieved or participated in. The qualifications reported as present within services currently and/or regarding previous employees can be seen in Figure 5.

FIGURE 5.

What qualifications/training do practitioners have? D and A, drugs and alcohol; H and S, health and social.

The qualifications held by drug and alcohol workers were varied. Often workers had multiple different skill sets and expertise. Multiple responses were possible to these questions and multiple responses were present from each of the responding services. Youth work was the qualification reported most frequently (n = 93), with health and social care (n = 57), counselling (n = 48) and social work (n = 50) being other qualifications often transferable to the drug and alcohol work. There was no standardisation of training of drug and alcohol practitioners, and individuals utilised different skill sets when moving into this line of work.

Quality monitoring

Owing to the variable and adaptable service offers available to children in care, services were asked to describe what mechanisms were put in place to oversee the quality and content of sessions being delivered. Figure 6 shows the procedures in place to monitor the work being completed.

FIGURE 6.

How is quality and content of sessions monitored? YPOR, young people’s outcome record.

The quality of sessions was monitored using a number of different mechanisms, multiple responses were possible to these questions and multiple responses were present from the majority of the responding services. Line management was the most reported method and occurred at either monthly or 6-weekly intervals. Line management was used to incorporate both case management and professional development issues. Although 18 (15%) services reported that line management happens at ‘other’ frequencies and this spanned a range from managers having an open door policy within which practitioners accessed them as often as necessary, to formal line management only being scheduled every 8 weeks. Clinical supervision with an external supervisor or clinical psychologist was reported by 93 (76%) services, this provided an opportunity for practitioners to discuss individual ‘cases’, reflect on their practice and receive clinical guidance of how to work with children in care. Outcomes of care provision to young people were recorded within an individual’s case file.

Other mechanisms were audits completed by the local authority (n = 81, 66%); in-house case file management conducted by the service manager (n = 62, 51%); feedback received from the young people when they have completed a piece of work (n = 38, 31%); peer review, which often occurred in team meetings or within peer supervision (n = 24, 20%); and via the NDTMS or a young people’s outcome record (n = 14, 11%). Services referred to the young people’s outcome record more as a reporting process, rather than it reflecting the quality or contact of sessions.

When considering the number of methods used to measure quality and content of sessions, services reported using between one and six different mechanisms. Three services (2.5%) reported using one method, 17 (14%) reported using two methods, 32 (26%) reported using three methods, 49 (40%) reported using four methods, 20 (16%) reported using five methods and one service reported using six different methods to measure content and quality of the work delivered within their service.

Participant screening and identification

As part of the SOLID trial, social workers were asked to screen all young people on their caseloads aged 12–20 years, with a standardised instrument. Training sessions were conducted with social workers from each of the recruitment sites. These sessions introduced the CRAFFT screening tool, which is a nine-item tool that has been used extensively with young people and is sensitive and specific to identify problem substance use. 91 The researcher emphasised the importance of completing the CRAFFT screening tools with young people on their caseloads and explained how these data could be beneficial not only for recruitment into the study, but also for each local authority to develop a clearer understanding of the extent and nature of substance use within their local area. All young people aged 12–20 years, unless they were already in active treatment with drug and alcohol services, or were unable to access drug and alcohol services (e.g. due to currently residing out of the study area or an imminent move out of area), were eligible for screening.

Once training had been completed, each social worker carrying a caseload of children in care was provided with a screening log (see Appendix 1) and the appropriate number of CRAFFT forms, so that they could complete one form with each young person with whom they were currently working.

Prior to the social worker conducting the screening, a brief initial contact leaflet was provided to the child in care and discussed with them by their social worker, this provided details of the study. Following this discussion, the CRAFFT screening tool was completed. Page 1 of the form requested that the young person provide their contact details and asked if they consented to being contacted by a member of the research team to receive more information about the full study. Young people could elect not to provide their contact details and consent; in these cases, they could continue to complete the CRAFFT form anonymously.

Each screening tool had a pre-paid envelope attached for the completed forms to be returned to the research team. All of the screening data were entered and processed at Newcastle University, in accordance with the study ethics approval. Summary statistics on the data collected from the CRAFFT forms returned by the children in care within their locality were fed back to each local authority. These reports provided a breakdown of the number of children in care screened within that local authority area, along with the sex, age, placement type, self-reported drug and alcohol use, and self-reported risk taking behaviour of these young people.

If a child in care provided contact details, screened positive for substance use and agreed to be contacted, they were telephoned by a member of the research team, who introduced themselves, explained the purpose of the call, and checked that the young person could recall filling in the form and that they were happy to proceed. The researcher then arranged a date and time to meet the young person to take formal informed consent and complete the baseline questionnaire.

Trial inclusion and exclusion criteria

Consent to participate

Information on the study was shared with parents and carers and young people. Informed consent was taken directly from children in care aged ≥ 16 years. For participants aged < 16 years, assent was taken from the young person and consent was also obtained from an adult with PR. Those aged 12–15 years were seen by the researcher with an accompanying adult (such as a parent, carer, social worker or children’s home lead), who was asked to provide informed consent on behalf of the young person. If the accompanying adult did not have PR, the research team contacted the adult with PR (in most cases the allocated social worker) to obtain informed consent. If the parent was not contactable, or it was deemed by the designated social worker that it would pose a risk to the young person for their parent to be contacted, the social worker or local authority guardian with PR was contacted to sign the consent form. All of the RCT documents are shown in Report Supplementary Material 6.

Baseline data collection

After informed written consent was obtained, the researcher collected baseline information from the child in care using a self-completed questionnaire, administered via a tablet computer to provide greater privacy for the respondent. The researcher was available to support young people in completing the questionnaire, if necessary, and to answer questions of clarification, if needed. The baseline questionnaire recorded demographics; placement type; drug and alcohol usage via the AUDIT92 and Alcohol, Smoking and Substance Involvement Screening Test – Youth (ASSIST-Y);92 mental health and well-being via the Strengths and Difficulties Questionnaire (SDQ)93,94 and Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS);95 and health-related quality of life via the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). 96

The drug and alcohol practitioners

In each of the participating local authority areas, the specialist young people’s drug and alcohol treatment was provided by voluntary sector organisations with charitable status. In each study area, a drug and alcohol service agreed to take part in the study by allocating a worker to deliver each of the three treatment arms. Separate experienced young people’s drug and alcohol practitioners were available to deliver the two active interventions (MET and SBNT) or usual care (control). The practitioners had varying professional backgrounds, including youth work, social work, counselling and unqualified workers; all were experienced in the delivery of drug and alcohol psychosocial interventions for young people. Drug and alcohol practitioners received training on the specific intervention they were to deliver throughout the trial as documented in Chapter 3, SBNT and MET training.

Practitioner intervention logs

When delivering sessions, each practitioner was provided with a practitioner intervention log; this provided a system of recording details for each study participant. Within each log, practitioners were requested to record their own name and the demographics of the participant, inclusive of the unique identifier for the young person, age, sex, placement type and geographic location. Details were also recorded regarding the interventions themselves, such as dates on which sessions took place; the type of casework that had been completed, inclusive of delivery of the intervention (service user contact and non-service user contact, which included any preparation work for sessions and/or completion of paperwork, such as referral to other services); the amount of time spent on each activity; the mileage and travel time attributed to each session; and the number of people present at the session. Finally, a summary of the interventions was requested, monitoring the number of sessions offered and attended, the reason for non-completion of sessions if known and any referrals into mainstream drug and alcohol services. Once a young person had completed a maximum of six sessions, depending on identified need, the practitioner returned the completed log to the research team.

The practitioner logs had two main purposes. First, they helped the research team to calculate the cost of delivering the interventions, as discussed in further detail in Chapter 7, Practitioner logs. Second, the logs contributed to the assessment of the acceptability and fidelity of delivering the interventions, in terms of the number of sessions delivered and number of people present within sessions.

The 12-month follow-up method

Participants were contacted again 12 months post recruitment to complete a follow-up questionnaire. A recruitment window of 8 weeks (i.e. 4 weeks either side of the 12-month anniversary) was put in place to maximise follow-up.

The method of follow-up contact the research team initially used was the preferred method of contact identified by the young person at baseline. However, if telephone contact numbers were no longer available, the research team contacted the child in care’s allocated social worker to request up-to-date contact details to enable a follow-up questionnaire to be completed.

Once contact had been made and the young person consented to take part in the follow-up, the research team arranged to visit the young person in their home or an alternative suitable location at a time and date convenient to them. If the researcher was not able to organise a convenient time to meet the young person for a face-to-face follow-up, a telephone follow-up was offered.

The questionnaire was administered by the researcher. At baseline, most data were self-completed on a tablet (unless completed over the telephone, in which case the researcher read out the questions and recorded the answers on the tablet on behalf of the young person); however, the researcher was also available to provide clarification on questions if necessary. The timeline follow-back (TLFB) substance use and self-reported occasions of ‘drunkenness’ in the last 30 days101 was completed at follow-up and this was researcher administered.

As at baseline data collection, children in care provided information on drug and alcohol usage via the AUDIT92 and ASSIST-Y,92 mental health and well-being via the SDQ93,94 and WEMWBS,95 and health-related quality of life via the EQ-5D-5L96 at follow-up. To minimise respondent fatigue, as recommended during peer review, questions relating to use of health and social services,96 placement stability and potentially sensitive questions on sexual behaviour [Adolescent Sexual Activity Index (ASAI)]14,102 and antisocial/criminal behaviour103 were asked only at follow-up. Details of the additional data collection tools are provided below.

Romantic and intimate behaviour/antisocial and criminal behaviour

The ASAI, as previously utilised in the Avon Longitudinal Study of Parents and Children, which was a UK longitudinal birth cohort study,102 was used in the SOLID trial to assess romantic and sexual activities. The ASAI is a standardised tool for measuring interpersonal heterosexual behaviours among youths. 104 Questions relating to enjoyment of sexual experience from the ASAI were replaced by two questions from the European School Survey Project on Alcohol and Other Drugs (ESPAD) multicountry survey of alcohol and drug use, assessing regret in engagement in sexual contacts and engagement in unprotected sexual intercourse, which are particularly relevant in relation to sexual encounters preceded by substance misuse. 14 The advantage of using the ASAI is that it is graded, with more intimate sexual contact not asked about if lesser contact, such as kissing and cuddling, has not yet been experienced. This instrument had been discussed with the study PPI group, who acknowledged the graded nature of administration and supported its use.

In addition, questions previously used in the Edinburgh Study of Youth Transitions and Crime105 were included to capture data on antisocial behaviour. This questionnaire contains 15 questions. For each of 15 questions, the tablet version used in the SOLID trial asks ‘How often in the last year have you done any of the following?’ The questionnaire seeks to evaluate co-occurrence of antisocial behaviour and alcohol use.

The romantic and intimate behaviour and antisocial and criminal behaviour questionnaires were completed only at the 12-month follow-up visit. Therefore, it is not possible to calculate and present the change from baseline for these questionnaires.

Four measures were derived from the questionnaire (see Appendix 3, Table 30, for details). Romantic and intimate behaviour was the standard questionnaire score calculated as per the skipping rules, but romantic and intimate behaviour (minor), romantic and intimate behaviour (advanced) and romantic and intimate behaviour (regret) were not standard scoring schemes from the questionnaire. The skip logic for the SOLID trial-specific outcomes derived from the questionnaire data is shown in Appendix 3 (see Table 31).

Alcohol timeline follow-back

The TLFB is a drinking assessment method that obtains estimates of daily drinking. A calendar was used to provide retrospective estimates of daily drinking over a 30-day period. The TLFB was used, as it provides a wide range of information about an individual’s drinking (e.g. pattern, variability and magnitude of drinking). The TLFB in the SOLID trial sought to identify the ‘number of occasions where five or more standard drink units are consumed on a single drinking day’.

Qualitative interview

At the point of completing the 12-month follow-up questionnaire, the young person was also asked if they would be willing to participate in a qualitative interview as part of the process evaluation (discussed in Chapter 6) for the SOLID trial. For those willing to be interviewed, the research team carried out the 12-month follow-up and process evaluation interview at the same time, to help reduce the burden placed on participants. If the young person was willing to take part in an interview, consent was obtained using the procedure outlined in Chapter 3, Consent.

Once the young person had completed the 12-month follow-up (and interview when appropriate), they were given a £10 ‘love2shop’ voucher to thank them for their time and for supporting the study. Following this, the researcher confirmed that their involvement in the study had now finished and that they would not be contacted by the research team again regarding this study.

Statistical analysis and sample size

As this study was a feasibility trial and had relatively small numbers of participants, the main outcomes are feasibility outcomes. Accordingly, we principally reported descriptive statistics in order to inform the design of a future definitive study. No formal comparisons are drawn, as the sample size was not powered to detect differences. 67 All statistical analyses were carried out on an intention-to-treat basis, retaining participants in their randomised treatment groups.

The majority of the outcome data are presented below in simple descriptive tables giving percentages, means and standard deviations (SDs), medians and interquartile ranges or a five-number summary [minimum, maximum, median and upper and lower quartiles (as appropriate)], separately for each arm of the study. This information could be used to inform the design, choice of primary outcome, necessary sample size and approach to the analysis, of the anticipated definitive trial.

The pilot feasibility trial aimed to obtain data from a minimum of 35 respondents in each trial arm at 12 months’ follow-up to estimate the critical parameters to the necessary degree of precision for a continuous primary outcome [number of occasions drinking, ≥ 5 standard drink units in a single occasion and frequency of use of the most problematic classified substance in preceding 30 days, both derived from the timeline follow-back – 30 days (TLFB-30)]. Assuming a pessimistic 30% loss to follow-up, the sample size to be recruited was inflated to 50 young people in each of the three arms. Therefore, we aimed to recruit and randomise 150 children in care.

Statistical software

Statistical analysis was carried out by the trial statistician, a member of Institute of Health and Society biostatistics team, downloading snapshots of the data from the trial database (administered by Vera Solutions, London, UK) into a comma-separated values (CSV) file. Randomisation details were exported by Newcastle Clinical Trials Unit from the Macro database into a CSV file. These two sources of data were merged and imported into the statistical software package Stata^® 14 (StataCorp LP, College Station, TX, USA) for analysis.

Screening data

Screening was conducted slightly differently across research sites in response to the capacity and standard procedures of each site team. The social workers across the Durham 16+ team (teams working with children in care aged ≥ 16 years and supporting young people who are transitioning out of the care system) and in the Middlesbrough sites screened children in care during their routine appointments. In Redcar, two PAs within the social work team led the screening. Across the Gateshead, Newcastle, Stockton and Durham ‘looked-after’ teams, a researcher spent time within the social work offices to support social workers in completing the screening. The research team kept in regular contact with a key point of contact within each service (in most cases this was the team leaders).

There were 1782 children in care registered with the local authorities, across the study sites, at the time of this study. A total of 332 (19%) were deemed ineligible by social work managers for the reasons shown in Table 6. Thus, the total number of children in care aged 12–20 years potentially eligible to complete the CRAFFT was 1450, 81% of all young people across the six study sites.

Social workers were tasked by their team leads with screening as many of the 1450 children in care across the study sites as possible. The time period over which sites completed the CRAFFT was variable, ranging from 19 weeks and 1 day in Stockton to 47 weeks and 3 days in Newcastle, as shown in Table 7.

The local authority sites experienced multiple competing demands while taking part in the SOLID trial, with other commitments influencing the progress made regarding screening. Two local authorities were preparing for and having an Office for Standards in Education, Children’s Services and Skills (Ofsted) inspection. Therefore, within that time frame, only essential work was completed and only a small number of participants were recruited. One site had commitments to another research project and three sites experienced significant periods of time without a senior manager in post.

Different techniques were introduced across the local authority sites in an attempt to support screening of children in care within the planned recruitment period. Bespoke support mechanisms were put in place by the research team following discussions with the TMG, social work team leaders, managers and on-the-ground social workers. Two teams introduced student social workers or PAs to support the recruitment process (Newcastle and Redcar). Members of the research team spent time embedded within four local authority sites to support the recruitment of participants (Gateshead, Newcastle, Stockton and Durham ‘looked-after’ teams). An alternative technique that proved to be efficient for one team (Durham 16+ team) was the use of ‘stop the clock’ sessions over a 3-month period (May–July 2017) for social workers to have a dedicated time allocated to contact every young person on their caseload.

Of the 1450 potentially eligible young people, 536 (37%) did not complete the screening, either due to them declining to complete the CRAFFT (n = 131, 9%), or the social workers not completing the screening tool with all the young people on their caseload (n = 405, 28%). Social workers did not consistently report the reason for non-completion, so it cannot be reported.

The flow of children from initial screening through to study completion is presented in Figure 8.

FIGURE 8.

The SOLID trial Consolidated Standards of Reporting Trials (CONSORT) flow diagram. Reproduced with permission from Alderson et al. 67 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced with permission from Alderson et al. 67 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Social workers within the six study sites collectively screened 860 (59%) of children in care, aged 12–20 years, for drug and alcohol use, using the CRAFFT tool. 91,106,107 The numbers of children in care in each site, the number of potentially eligible young people (minus those identified in Table 6) and the number screened by each local authority site are shown in Table 8.

Of the 860 children in care screened for drug and alcohol use, 369 reported drug and/or alcohol use in the last 12 months as shown in Figure 9.

FIGURE 9.

Self-reported drug and/or alcohol use.

Out of the 860 young people screened, 2 (0.2%) 12-year-olds, 12 (1.4%) 13-year-olds, 18 (2.1%) 14-year-olds, 19 (2.2%) 15-year-olds, 57 (6.6%) 16-year-olds, 72 (8.4%) 17-year-olds, 69 (8.0%) 18-year-olds, 67 (7.8%) 19-year-olds and 52 (6.0%) 20-year-olds reported using one or more substances. Alongside reporting substance use, young people were asked to complete part b of the CRAFFT form to assess the number with ‘risky’ substance use. Just under one-third of young people screened (n = 278) reported one or more risk taking behaviour (Figure 10).

FIGURE 10.

Self-reported risk-taking behaviour.

Demographic characteristics

Baseline demographics, clinical characteristics and trial stratification factors are summarised across treatment groups descriptively in Table 11.

Note that participant 36 (female, aged 19 years) was randomised, but her baseline data did not transfer electronically to the trial database due to a technical fault. This participant’s data could not be included in the baseline analysis, leaving 111 participants providing baseline data. Follow-up data at 12 months post randomisation was collected for participant 36. (Some demographics for participant 36 were therefore not available, so these are coded as missing.)

Sex was fairly evenly distributed across the MET and SBNT groups, although females comprised 67% of those randomised to usual care. Ethnic group was well balanced, although there were very few non-white participants in each arm, reflecting the ethnic mix of the local authorities.

Recruitment errors

Baseline data are presented in Baseline questionnaire summaries. Further analyses looking at variables by sex, age and residential type are presented in Appendix 4 (see Tables 33–50).

Baseline questionnaire summaries

Table 12 shows the distribution of scores at baseline for the AUDIT, AUDIT-C, ASSIST-Y, SDQ and WEMWBS; the data for the EQ-5D-5L are discussed further in Chapter 6. Further analyses looking at variables by sex, age and residential type are presented in Appendix 4 (see Tables 33–50).

Owing to the questionnaires being completed on a tablet computer, there was no option to skip any questions. Participants could choose to exit the baseline data collection without completing all the questionnaires; however, this did not happen. All 112 children carefully completed the baseline data collection questionnaires; however, as discussed in Demographic characteristics, a data transfer error meant that data were missing for one child.

The 12-month follow-up data

In total, 60 children in care out of a potential 112 (54%) attended the 12-month follow-up visit, 19 (17%) declined follow-up, 11 (10%) did not attend follow-up meetings that were arranged, 18 (16%) were lost to follow-up due to the research team being unable to contact them and four (4%) could not be followed up for other specific reasons (follow-up deemed to be inappropriate by the allocated social worker for two and two could not be contacted as they were detained in a secure unit). When attempting to contact young people at follow-up, for 58 (52%) young people, their contact number had changed and for 54 (48%) young people their address had changed. Details of follow-up status are given in Table 15.

Of the 60 children in care followed up, 5 out of the 15 young people who participated in the intervention completed the questionnaire, the other 10 were lost to follow-up for a range of reasons [declined (n = 2), an appointment was made but the young person did not attend (n = 4), unable to contact them (n = 1), inappropriate circumstance (n = 1) and closed to social services (n = 2)].

In many instances, young people were lost to follow-up due to the multiple competing demands that they had going on in their lives, the frequent changing of mobile numbers and the placement instability, which meant that the contact details originally given were no longer current. Forty-two children in care (38%) were followed up within an 8-week window of 12 months, as indicated in Table 16.

The distribution of data for the proposed primary outcomes – episodes of heavy episodic drinking (≥ 5 units in 1 day) in the preceding 30- and 7-day periods as shown in Tables 17 and 18 – outcomes for a definitive trial were obtained from the TLFB-30 administered during the 12-month follow-up interview.

These questionnaires were assessed for completeness. For the questionnaire summaries, 60 young people had follow-up data, as shown in Table 19.

An (adult) AUDIT score of ≥ 8 indicates hazardous alcohol consumption and a score of ≥ 13 for females and ≥ 15 for males indicates alcohol dependency. An AUDIT-C score of ≥ 4 in males and ≥ 3 in females indicates hazardous alcohol consumption.

Data on romantic relationships and antisocial behaviour are presented in Tables 20 and 21, respectively.

Missing data

As the RCT demographic and questionnaire data were collected using electronic tablet devices during baseline and follow-up visits, the only missing data are baseline data for one participant whose data were collected but not transferred owing to a technical fault and 12 months’ follow-up data for the 52 participants who did not attend.

There were no partially completed questionnaires because the electronic tablets necessitated that all questions be answered before moving on. Only one participant did not complete the TLFB at the 12-month follow-up visit, but did complete all other questionnaires at that visit. As there were so few missing data when they were collected using electronic tablet devices, there was no gain in using shorter tools, such as AUDIT, ASSIST-Y, TLFB – 7 days and CRAFFT.

Non-completion of 12 months’ follow-up

Participants had the right to withdraw from the trial at any time without having to give a reason. No children in care formally or explicitly withdrew from the trial, but 52 did not attend the 12-month follow-up.

Safety data

There were no reported adverse events or serious adverse events occurring from the time of randomisation in the pilot RCT until follow-up was completed (12 months post enrolment).

Qualitative interviews

In-depth one-to-one interviews and focus groups were selected as the primary method of qualitative data collection. The aim of all sets of interview was to explore the acceptability of using the adapted MET and SBNT interventions and to elicit participants’ views on the study processes employed throughout the delivery of the project.

Drug and alcohol practitioners

Each drug and alcohol practitioner who had been involved in the study (n = 14) was asked to participate in an interview for the process evaluation. Only one practitioner declined, citing previous involvement in a focus group in the development phase as the reason (see Chapter 2). Service managers were also approached to undertake an interview and interviews were completed with three out of six service managers. One service had recently been retendered and the manager felt unable to comment on the study. In a second study area, the practitioner who had been delivering the MET intervention was ‘acting up’ into the manager’s role. Last, in the third service, interviews were scheduled to take place on two occasions, but unfortunately were later cancelled owing to unforeseen circumstances.

Children in care

The interviews with children in care (n = 37) were completed at the same time as the 12-month follow-up data collection (as described above in Chapter 5, The 12-month follow-up data).

Carers

Interviews and focus groups with carers (n = 30) included a mixture of residential workers (n = 23) and foster carers (n = 7). To reach our target audience, the research team organised interviews and focus groups with workers employed within residential homes in three local authority sites where the participating children in care resided at, as well as with foster carers who had experience of caring for children in care within the 12–20 years age range of the study and experience of managing substance misuse issues.

Social workers

Interviews with members of the social work teams (n = 27) took place at two separate time points. In both instances, participants within the study sites who had been involved with the initial CRAFFT screening were approached by a member of the research team and asked to take part in an interview. Interviews took place at the social worker’s place of work at a time and date convenient to them.

The first interviews and focus groups took place from July to October 2017, with 14 participants of varied experience and knowledge. Participants included front-line social workers, senior social workers and team leaders, a strategic manager, a social work student and PAs. PAs work closely with social workers to advise, assist and support young people in local authority care.

Researchers

Research associates (n = 3) carrying out the day-to-day work of the project were also interviewed by a researcher who had no prior involvement in this study.

Table 23 shows the qualitative methods that participants engaged in and the sex of participants recruited into the process evaluation.

Was the screening process acceptable?

The CRAFFT screening tool was not wholly appropriate in its current format, areas of discussion arose regarding concerns about the screening tool. The CRAFFT form asked young people to identify their substance use within the last 12 months. Professionals, both social workers and drug and alcohol practitioners, thought that this time frame was too long and that a shorter time frame would produce more accurate results, and suggested modifying the CRAFFT form to capture data within a shorter time frame. Suggestions varied between the 28-day time frame used for the NDTMS up to a maximum of 3 months:

I would say 28 days because that way staff members can actually quantify it alongside the work that they’re doing anyway because that’s what we deal with on a day to day basis, that’s what we use as a guide . . . So I think the drug use needs to be more prevalent and more relevant within a shorter time frame upon referral.

Christopher, drug and alcohol practitioner

In addition, the current method of scoring was not felt to be appropriate for distinguishing between use of a substance on a single occasion and problematic use:

The scoring of it, it fails to recognise when someone, by just saying, ‘Do you drink? Have you had a drink?’ It doesn’t distinguish different and potential levels of potential problems. So, it basically pulls in everybody so it produces a lot of negatives or potentially ends up producing a lot of work for no result. Many people then don’t need further information.

Sam, drug and alcohol manager

Was it feasible to retain children in care within the intervention?

Are the interventions acceptable to drug and alcohol practitioners?

One of the main aims of the process evaluation was to assess whether or not the principles and concepts of the interventions were acceptable to practitioners. The feasibility of intervention delivery also took into consideration the responses to the MET and SBNT training and supervision of the practitioners. One of the trainers stated:

By and large, these people came along with positive attitudes to training . . . as a trainer I want to motivate these people to practice in a particular way, because it’s good for them. It’s good for their practice and it’s good for their CVs [curricula vitae], and it’s good professional experience for them. I think, in the main, they were very open to it.

Paula, clinical trainer/supervisor

However, the consistency with which practitioners engaged with the clinical supervision was variable:

It was very mixed. There were a few highlights of people really doing hands-on work, and that was good. Then that went to another level where people aren’t doing it. But there were a handful of therapists that really ran with the idea and did really decent work.

Dale, clinical trainer/supervisor

Commitment to clinical supervision was difficult to gauge, as some drug and alcohol practitioners elected not to attend due to not delivering interventions to children in care as part of the study trial. They therefore deemed the clinical supervision sessions to be unnecessary.

How could future interventions be delivered differently?

Children in care emphasised the importance of flexibility when providing interventions, with traditional ‘talking therapy’ considered overly rigid and therefore hard to engage with. Multiple young people reinforced this belief:

I don’t like talking, it’s very easy to write it down on a piece of paper, than it is to say it, do you know what I mean?

Annabelle, young person, 15 years

I don’t know, it’s just hard to talk to people about saying, ‘Look, this is the problem now’, it’s hard to say isn’t it?

Angelina, young person, 20 years

Instead, children in care and practitioners reported that methods which sought to engage participants in creative methods of working may be useful. It was equally acknowledged that writing and other creative methods of engagement might not suit everyone:

I think it’s each to their own, isn’t it? Some people would rather just sit down, talk one-to-one, get it done and that, and some people would rather show themselves in a different way.

Dylan, young person, 19 years

In addition, alongside considering the content of the sessions, professionals thought that the low uptake of young people attending interventions could be attributed to the fact that it meant ‘another’ professional being involved in the care package for children in care. Discussion took place regarding amendments to the intervention delivery if the study was replicated. The main suggestion was that interventions should be delivered by a professional already involved in the young person’s care. However, the implication for this is that social workers, foster carers or residential care home workers may be expected to be involved in the delivery of interventions as key professionals involved in supporting children in care:

These children who have been taken into care have seen so many different people. They’ve had social workers and they’ve had foster carers, so they’ve been in court and they’ve been in trouble and all those kinds of things. You’re adding another person into the mix. What you probably want to think about is, ‘Who are all the people who are already in the mix by virtue of the legal requirements, which of those can we train to do this work?’

Paula, clinical trainer/supervisor

This prompted the research team to speak to professionals involved in children’s care and to explore whether or not they felt that delivering MET and SBNT sessions with a drug and alcohol focus was part of their remit, and whether or not they felt in a position to deliver the interventions.

Normalisation process theory analysis

Alongside the thematic analysis undertaken to identify the overarching themes (identified above) within the data across all participant groups, we applied normalisation process theory113 analysis to the data collected from drug and alcohol practitioners regarding the interventions. The findings identify how practitioners responded to the four core components of coherence, cognitive participation, collective action and reflexive monitoring.

Audio-recording methods

The drug and alcohol practitioners delivering the SBNT and MET intervention were requested to audio-record every session that they delivered, with consent from the participant. Following each audio-recorded session, the practitioners were requested to clearly label the session as outlined in the treatment protocol (session X, date 01.01.2019, young person’s initials) and upload it on to a secure server so that it was accessible to the research team and the clinical supervisors. The purpose of the audio-recordings was to assess the quality of the intervention delivery (treatment fidelity).

The research team (HA and RB) applied the validated UKATT Process Rating Scale (PRS), which was developed in the UKATT. 114 The UKATT PRS is applicable to MET and SBNT and consists of 26 items, rated as follows:

1. maintaining structure

2. agenda setting

3. explanation of philosophy of treatment/treatment session

4. review intersession change

5. consistency of problem focus

6. end of session summary

7. homework

8. drinking feedback/negative consequences

9. alternative activities to drinking

10. eliciting client concern about drinking

11. social support for change

12. eliciting self-efficacy for change

13. involvement of others in behaviour change

14. commitment to drinking goal

15. identifying sources of support for change

16. ambivalence

17. creating conflict

18. eliciting commitment to change drinking

19. eliciting optimism for change

20. therapist as task orientated

21. therapist as active agent for change

22. reflective listening

23. collaboration

24. interpersonal focus

25. exploration of feeling

26. empathy.

Each item was rated on the extent to which the practitioners carried out each specific item and the quality of the therapist’s behaviour, using the following scales:

To what extent did the therapist perform the behaviour within each item?

How well did the therapist perform the behaviour within each item?

The research team assessed the extent to which the intervention delivery was true to the therapeutic principles on which it was based.

Audio-recording findings

In total, 26 sessions were delivered (MET n = 17, SBNT n = 9) and of these, practitioners only completed nine recordings in total (MET n = 3, SBNT n = 6). The small number of recorded interventions significantly limited our ability to assess the internal validity. Out of the 14 practitioners involved in the trial, only two practitioners submitted more than one recording for the same young person, two did not submit more than one recording for the same young person and 10 practitioners did not submit any recordings at all. (One practitioner did successfully manage to deliver all six sessions of MET; however, the young person declined to be audio-recorded.) Owing to the small number of findings, no conclusions can be drawn from these data. Further details are provided in Appendix 5 following the UKATT PRS.

Data

The target population and characteristics of the sample are described in Chapter 5. All cost data for the delivery of the intervention were obtained from the practitioner logs. An example of a log sheet is presented in Appendix 1. All cost data presented are in 2017 Great British pounds.

The participant questionnaire collected data on service usage, and health was measured by the EQ-5D-5L. 115 The EQ-5D-5L was chosen for this study as the sample is aged between 12 and 20 years. Thus, given this age range and recommendations from the EuroQol-5 Dimensions (EQ-5D) user guide,116 the EQ-5D-5L adult version is more appropriate for this sample. For ages 12–15 years, both the youth and adult versions can be used, and for age ≥ 16 years the adult version is recommended. The EQ-5D-5L questionnaire was administered online and respondents had to provide an answer to a question before being allowed to move on to the next question. Thus, there are no missing responses for individuals who agreed to fill in the questionnaire.

Practitioner logs

Practitioners were asked to record every session for every client to enable us to calculate how cost-effective the interventions are to deliver. We asked practitioners to record (for each session) the date the session took place, the session number (1–6), if any travelling was required to deliver the intervention (practitioners were requested to record mileage and travel time in minutes) and the number of people present at the session (not including themselves).

Practitioners were asked to record the type of casework being undertaken. Activities would include any form of patient contact (e.g. telephone calls) and non-patient contact (including preparation work and completion of forms for referrals, etc.). We also requested that, for each session, practitioners recorded all activities associated with the preparation and delivery of the session, and the duration of each activity.

Once sessions had been completed, the practitioner log captured how many sessions had been offered, how many had been attended, the reason provided for non-completion of treatment, if known, and whether or not a referral into mainstream services was made.

There were 15 practitioners, and 76 young people were randomised to the intervention. Sixty of the young people contacted by practitioners declined to engage or participate with the intervention (the number of contact attempts and the reason for the young person deciding not to participate was recorded and is reported in Chapter 5). With the exception of one participant, practitioners did not fill out the second page of the log sheet, which captured the time spent contacting the young person and establishing that they did not want to attend the additional service offer of the SBNT/MET interventions.

Service usage

A total of 60 young people out of 112 who were eligible to participate in the follow-up agreed to take part in the health service usage survey. To better understand service usage of young people, all young people who agreed to participate in the follow-up were asked to complete a questionnaire on service usage on the tablet computer during the 12-month follow-up period. The method by which the electronic questionnaire was delivered meant that, in order to go on to the next question, each young person needed to provide a response to the previous question, thus ensuring completeness of data. The response rate was 54% (n = 60 young people). Five of the young people who participated in the intervention completed the follow-up questionnaire.

Feasibility of a definitive within trial economic evaluation

The within-trial feasibility study looked at the response rates and data provided in the practitioner logs and participant questionnaires to inform the development of survey material for a definitive trial.

Costs

We present the time spent on each activity, the hourly wage of the practitioner undertaking the activity and the cost per element of each activity. Mean, SD and range of travel time of practitioners to deliver the intervention, intervention delivery time and number of participants are presented. Costs for the first two sessions are presented, as only one young person participated in more than two sessions.

Benefits

Owing to a lack of engagement with the intervention, to avoid identification of the small number of participants who engaged with the intervention, the control and intervention groups are combined. Means and medians are presented for health service usage at 12 months’ follow-up (health service usage information was not collected at baseline). Proportions are presented for the five dimensions of the EQ-5D-5L across baseline and follow-up, with means, SDs and ranges presented for mean EQ-5D score at baseline and at follow-up.

Value of information analysis

It was originally proposed that the economic evaluation component for the feasibility study should involve a value of information analysis. 117 This analysis would have incorporated the data from the literature and data from the feasibility study. The data needed for the value of information analysis include cost data for the intervention and outcome data measured by quality-adjusted life-years. These data could come from the study and be supplemented with data from the literature. The purpose of this analysis would have been to help clarify the economic case for a definitive study and, by using a variant of value of information analysis, utilise expected value of sampling of information to inform decisions on the optimal sample size for a definitive trial. 67 Unfortunately, no useable data were available from the feasibility study and insufficient data were available from the literature to conduct the economic evaluation modelling exercise that underpins a value of information analysis.

Exploratory return on investment analysis was conducted to identify the range of values for benefits and total costs consistent with a return of investment of a minimum level; this is available on request to the authors.

Costs

Summary statistics from the log files of the practitioners for the 16 young people who did engage with the intervention are reported in Table 24. Practitioners successfully returned a complete practitioner log for children in care who attended any sessions.

Health service usage

The mean and median for health service usage over a 12-month period are presented in Table 25.

In free-text boxes, other health service usage reported by respondents was with midwives (n = 2) and CAMHS (n = 6). In this free-text box we do not know how many appointments they had with these health professionals.

EuroQol-5 Dimensions, five-level version (health-related quality of life)

Table 26 reports the proportions reporting each category in the baseline and follow-up questionnaire. These results are purely descriptive.

At the 12-month follow-up, 60 (54%) of the young people who completed the baseline questionnaire completed the follow-up questionnaire. Five of the young people who participated in the intervention completed the questionnaire. As with the service usage questionnaire, the mode of data collection ensured that the young person could not move on to the next question without completing the previous question. Thus, there are no missing responses in the EQ-5D-5L questionnaires competed.

In Table 27, we use the EQ-5D-5L values to calculate the mean EQ-5D utility scores at baseline and follow-up.

Within-trial economic evaluation

This pilot study showed that overall the tools used to collect the cost information and participant data on service usage and health-related quality of life seemed feasible. Practitioners and participants engaged with these materials. However, we have some suggestions to make to further refine these tools to inform future research in the area.

Cost data

If the intervention was to be used in a definitive trial, an additional log sheet should be provided to practitioners to get a better understanding of non-engagement with the intervention. This log sheet should contain information outlining the means of contacting the young person, how many times they were contacted and the length of time they spoke with the young person, as this would be useful to get a better idea of the true cost of the intervention. Data also need to be collected on administrative support, room costs and building maintenance for when the interventions were delivered, if this is relevant.

Health service use

The information from the free-text boxes in the questionnaires suggests that, in a definitive trial, CAMHS should potentially be included in a health service usage questionnaire. As a very small percentage of respondents had GP home appointments, this could potentially be removed from a questionnaire that would be part of a definitive trial.

EuroQol-5 Dimensions

From looking at the proportion of responses to each of the dimensions of the EQ-5D, a large proportion of respondents reported suffering from anxiety and depression. However, it is possible that the health attributes in the EQ-5D may be too narrow for this client group. In a definitive trial, it may be worthwhile including a condition-specific tool that measures quality of life related to mental health. 118 In addition, the EQ-5D has ceiling effects that another utility tool, such as the Short Form questionnaire-6 Dimensions, does not (although that tool has floor effects), which may make it a more appropriate outcome measure for a definitive trial. 67

Proportion of eligible participants consenting to pilot feasibility trial

The number of children in care screened was 860, of whom 211 were eligible.

Percentage of eligible participants consenting to feasibility trial: 112/211 × 100 = 53%.

Proportion recruited: 112/211 = 0.53 (amber).

Although the study did not recruit the target figure, lessons from this study could be used to maximise recruitment in a future study. The CRAFFT screening was completed by 860 (59%) of the 1450 children in care (aged 12–20 years) across the region, and 112 (53%) of the 211 eligible children in care were recruited and randomised into the study.

Proportion of children in care attending at least 60% of sessions as planned in combined intervention arms

Proportion of consented participants retained for measurement of key outcome data at 12 months

Sixty out of the 112 (54%) randomised provided follow-up data at 12 months (amber).

In total, 54% of recruited children were followed up to 12 months. Follow-up was particularly difficult due to frequent moves in this population and their changing contact details. However, the SOLID trial has shown that once participants were located and seen by the researcher, they were prepared to complete questionnaire data at both baseline and at follow-up. None of the participants asked to end the data collection process early and only one individual elected to not complete the TLFB at the 12-month follow-up.

Were interventions delivered with fidelity?

In total, only 26 intervention sessions were delivered to 15 young people out of the 76 children in care randomised to the two intervention arms. It was not possible to evaluate the fidelity of intervention delivery due to the low number of audio-recordings available, only nine audio-recordings were received.

Were interventions perceived acceptable by children in care and workers?

It was not possible to assess the acceptability of the MET and SBNT interventions due to the low number of participants who received the intervention sessions. Owing to the involvement of 24 children in care participants in the formative phase of the study, we believe the content should be acceptable. However, we can conclude that significant changes would need to be made to the location of these interventions within current service pathways, in order to increase participant engagement.

Does the value of information analysis show future research is worthwhile?

It was originally proposed that a value of information analysis would be conducted. Unfortunately, no useable data were available from the feasibility study and insufficient data were available from the literature to conduct the economic evaluation modelling exercise that underpins a value of information analysis. Therefore, an exploratory return on investment was conducted in order to identify the range of values for benefit and total cost consistent with a return on investment. The preliminary return on investment analysis suggests that a medium to large health effect would need to be demonstrated before the intervention would be considered cost-effective.

It is our judgement that criteria for progression to a definitive trial have not been met in this study.

As discussed in Chapter 5, major challenges were found in both screening and recruitment of children in care into the study. Screening of children by the six local authority social work teams took over a year to complete, with significant time and resource investment by the researcher and social work teams. The increased amount of time needed resulted from the impact of staff turnover, long-term sickness, restructuring of local authority sites and Ofsted inspections. Social workers acted as gatekeepers when deciding which children in care to screen, influenced, for example, by their preconceived beliefs of whether or not the young person used substances or were potentially too young to participate. Contact details for children within the care system were not always updated on the centralised systems, therefore obtaining the relevant contact details to make contact for the study follow-up was often problematic. These difficulties were fed back to team managers, leading to escalation to senior management level. It is hoped that future studies will benefit from this initial work to ensure that system data are accurate and up to date.

An embedded researcher or senior local authority member of staff seconded in a research role could provide an increasingly stable point of contact within the complex local authority setting, to facilitate more successful screening and recruitment. 67 The availability of a visible individual to be present throughout the research period would act as a facilitator within what is, primarily, a less research-mature environment.

The process evaluation highlighted that, no matter how effective an intervention is perceived to be by practitioners during development, if participants do not engage with it, the potential benefits cannot be achieved. It is essential that the service considers different methods to increase engagement. The participant interviews identified valuable insights into the facilitators of and barriers to engaging with interventions, and highlighted the role of self-perception regarding ‘problematic’ substance use. The children in care recruited in to this study did not feel that they have a problem, often due to the normative view of their drug and alcohol use. Participants did not feel that their use warranted an intervention from a specialist drug and alcohol practitioner, therefore a referral to a specialist service does not feel salient. This suggests that a different delivery agent is required if intervention delivery is to be successful.

The delivery of future interventions

The typical screen, refer and treat model used in the SOLID trial was problematic. Children in care were recruited into this study based on a screening outcome, suggesting risk due to substance use behaviour. The study was designed in this way to mirror the current system and was based on public health principles related to prevention to address avoidable future problems. However, it could be argued that being in the care system was itself a risk factor for increased drug and alcohol use. Moreover, the interventions were delivered by specialist drug and alcohol workers in a referral context. Any future trial needs to think about how we deliver harm reduction and preventative care for children in the social care system. This may well require additional resource. Accepting the view that being in care can generate increased risk for children and young people, a broader ‘care pathway’ approach may be needed in keeping with the principles of the thrive model currently used by the CAMHS for children and young people. 119 The thrive model promotes five categories: thriving, getting advice and signposting, getting help, getting more help and getting risk support. Thus, substance use counselling would fit with ‘getting risk support’, but would be part of a process that understands wider determinants of risk and risk behaviour. By delivering the adapted intervention according to the thrive categories, it would allow a person-centred and needs-led approach to be delivered to children in care regarding their substance use. 67 In the SOLID trial, we tried to use the existing drug and alcohol referral system to deliver novel interventions. This working between different sectors of the care system did not work. A new way of working, in which drug and alcohol workers become embedded to social care services and residential units, could be a better way of delivering these interventions. This fits with principles of place-based approaches,120 which argue that providers of services (in this case social workers and drug and alcohol practitioners) work together to improve health and care for the population they serve. Within the process evaluation, social workers stated that they would not be able to deliver these interventions unless they were given specific training and ring fenced time.

Evaluation design and support

Prior to beginning the SOLID pilot trial, we had secured senior ‘buy-in’ across six local authorities. We had a team of experienced researchers, including an academic social worker as a co-applicant, and we saw real excitement and enthusiasm from social work staff about research work being conducted in social care. However, social services departments are often less research mature than clinical contexts that have benefited from specific resources through the Clinical Research Networks (CRNs) to support research delivery over many years. Local authorities have experienced reduced funding due to economic austerity and many social work settings are understaffed and overstretched in terms of workload. Consequently, without additional, dedicated research support, potentially from an embedded researcher/social worker, then applied research in social care and, particularly, with children in care will prove difficult. This researcher would add much needed academic leadership within departments. They could be jointly funded and managed across academia and the local authority, which would give them clearance to engage clients and could significantly change the research culture within the units. Within the lifetime of the SOLID trial, the NIHR CRN has implemented changes to the eligibility criteria for studies. The NIHR CRN has now extended support into research taking place in non-NHS settings, such as health and social care and public health, these changes could facilitate the necessary change as it has within NHS research trials. 121 In addition, future studies within the social care context would benefit from performing an organisational readiness study with social work teams and drug and alcohol services, to be involved in research and deliver interventions prior to implementation of a RCT or evaluation study. Pragmatic evaluation design coupled with additional research resource for children’s services are needed to evaluate these novel models of care at scale.

Screening and risk perception

Mass screening of children in care as part of ‘standard practice’ within the social work teams was not feasible. The findings of the SOLID trial have shown that attention needs to be paid to the identification, screening and intervention delivery for this high-risk group of young people. The screening results highlight that for this population, older teenagers are more likely to be reporting alcohol and/or drug use. Within this study, drug and/or alcohol use was most prevalent in young people aged between 16 and 19 years, with reported use peaking at 17 years of age [72 (8.4%) of respondents reporting use within the last 12 months]. However, the existing current models and pathways of care have been shown to be ineffective, resulting in a significant amount of need being unmet by services. Screening would need to be completed using an alternative method in a future study. The current screen and refer model used in the SOLID trial has been shown to be problematic. The completed screening tools could have detected problematic drug and/or alcohol use and provided an opportunity to offer an immediate therapeutic intervention. Having an embedded researcher with capacity to promptly engage a young person may have provided scope to tentatively explore the impact of their drug and/or alcohol use on their mental health, physical health, relationships and behaviour. This opportunistic interventions could be used to sensitively introduce a problem feedback component regarding their substance use and may have initiated a stronger recognition of risk by the young person. An embedded researcher within social care departments would have the potential to increase the uptake of screening with children in care, improve the engagement of social workers in very stretched services and provide an increasingly tailored response depending on the information provided at the screening stage. An embedded researcher could be an individual who is ‘either university based or employed with the purpose of implementing a collaborative, jointly owned research agenda in a host organisation’. 122 This model is often found within a health-care setting, such as medicine and nursing; however, is less established within social care settings. Cheetham et al. 122 provide an example of how having a researcher embedded within the local authority environment can increase the situated understanding of the cultures and norms of an organisation, and also recognise the realities of conducting public health interventions. 122 An embedded researcher would have the capacity to take into consideration the context of the environment and stakeholders’ interests. 123 In addition, the perceptions of ‘problem substance use’ differed between the children in care and practitioners working within the service systems currently in place. If the requirement is for children in care to be engaged with a substance misuse intervention and that intervention can be delivered opportunistically and quickly around the needs of children in care, then a place-based approach to intervention delivery needs to be taken. 120 In addition, the child in care needs to perceive their substance use as an area they want to address. In our sample, many young people were more concerned about other problems in their lives and that substance use was a symptom not a cause of problems. Consequently, work on any substance use needs to be set into a wider context of adverse childhood experiences30 and difficulties experienced in care. 89

Interventions

The MET and SBNT interventions modalities were chosen as they have both shown to be effective in decreasing substance use in participants, including adolescents. 69–71 There is strong evidence for the use of brief interventions. A Cochrane review by Kaner et al. 124 reported that at 1 year follow-up the amount of alcohol people drank each week had reduced and that longer counselling provided little additional benefit over brief interventions. However, we were unable to test the effectiveness of delivering brief interventions to this population of young people due to low attendance at the available sessions. Future studies would need to consider the best way to engage children in care in interventions that promote a harm reduction and prevention component, alongside offering a therapeutic approach.

Screening tool

The CRAFFT screening tool should be adapted to enable young people reporting substance use within the last 30 days, as opposed to 12 months as it is currently, to ensure that the information provided is current and relevant. The age range of young people being recruited into the study should be modified to 12–17 years. The rationale for suggesting this age range, is that data demonstrates that substance use is starting to emerge in children as young as 12 years. Among the young people screened, 66 forms (8%) were completed by children in care aged 12 years, with two (0.2%) children in care reporting substance use (alcohol, cannabis and NPS). By comparison, 93 forms (11%) were completed by children in care aged 13 years, with 12 (1.4%) positive for substance use, and 90 forms (10.5) completed by children in care aged 14 years, with 18 (2%) children in care reporting substance use. This suggests that if early intervention and preventative work is the aim of the study, 12 years is the correct age to commence screening, as it correlates with initiating substance use. This of course requires individuals to be approached sensitively due to their vulnerability, and issues of capacity and competency to engage with interventions would command further exploration.

Screening children in care aged ≥ 18 years also posed a dilemma. Young people within this age category are legally old enough to drink and by default did not identify their reported alcohol use as a problem as ‘alcohol is legal’. In addition, children in care were increasingly starting to transition into independent living accommodation, to enter the college environment in which exposure to alcohol in a social context was increasingly likely. Altering the inclusion age to children in care aged < 18 years would ensure that individuals were still ‘open’ to social services and would provide the necessary mechanism to follow up children in care. In addition, such young people are under the legal age to drink; therefore, any alcohol use could be deemed as risky and could warrant an intervention being delivered.

Scoring AUDIT

For all 10 questions, scores range from 0 to 4. For questions 1–8, the first option in the question scores 0 and the last option scores 4. For questions 9 and 10, which have only three options, the scores are allocated as 0 for the first option, 2 for the second option and 4 for the last option.

Interpretation of AUDIT score

A score of ≥ 8 is associated with harmful or hazardous drinking.

A score of ≥ 13 in women and ≥ 15 in men is likely to indicate alcohol dependency.

Missing items

Complete questionnaires will be analysed. Complete questionnaires should contain responses to all 10 questions, but there are two options to skip questions (when the questionnaires will be still considered to be complete): if participant answers ‘never’ to question 1 then skip to questions 9 and 10; and if questions 2 and 3 both score 0, again can skip to questions 9 and 10.

Note, that the AUDIT can be split into three domains. The questions measure different domains of alcohol consumption problems. The breakdown is as follows:

1. questions 1–3: measure frequency in alcohol consumption

2. questions 4–6: measure alcohol dependence

3. questions 7–10: measure alcohol-related problems.

The frequency in alcohol consumption is also known as the AUDIT-C and scores between 0 and 12. An AUDIT-C score of ≥ 4 for men and ≥ 3 for women indicates hazardous drinking or active alcohol use disorders.

Scoring ASSIST-Y

For each substance listed, sum the scores for questions 2–6.

Note that tobacco is not coded for question 5 so should be sum of questions 2–4 and 6 for tobacco.

Interpretation of ASSIST-Y score

Missing items

For any of the five subscales in Table 29, if at least three of the five items are completed then the scores can be scaled up pro rata (e.g. a score of 4 based on three items is scaled up to 6.67, rounded to 7 for all five items).

A total difficulties score is generated by summing all scales, except the prosocial scale. Scores range from 0 to 40.

Considered ‘missing’ if one of the four subscores is missing.

In addition, externalising score ranges from 0 to 20 and is sum of conduct problem and hyperactivity scales. Internalising score ranges from 0 to 20 and is sum of emotional problem and peer problem scales.

Note that the four separate scales add more value in high-risk samples, so are more appropriate for the looked after child.

The SDQ scores can be used as continuous scales, sometimes categories can be used for particular score ranges.

The full breakdown is 80% of population are ‘close to average’, 10% slightly lowered, 5% low and 5% very low.

Interpretation of well-being scores (for self-assessment, from the NHS)

• 0–32: very low score.

• 32–40: below average score.

• 40–59: average score.

• 59-70: above average score.

Missing items

A harsh approach to missing items is to drop any score that does not have all 14 items completed. This is acceptable when just a few of the responders have missing items, but often that is not the case. A softer approach can be appropriate, but none of the possible methods to deal with missing items have been assessed for the WEMWBS.

Suggested methods of dealing with missing data are (bold is approach expected in the SOLID trial):

• calculate mean of answered items and use that as the value for missing responses.

The suggested limit for missing items is three, so responders missing more than three items should be omitted.

For the SOLID trial we assessed the missing items. We will consider the randomness of missing items (to ensure that certain items are not been systematically omitted).

For all questions also ask

If ‘yes’, ask how much did you enjoy it? Not at all (1), a bit (2), quite a lot (3) or very much (4).

Then ask did they have a condom? No (0), yes (1).

For question 7 onwards also ask

Did they regret? Not at all (1), a bit (2), quite a lot (3) or very much (4).

Descriptive statistics can be presented separately for males and females.

As there is not a scoring manual for this questionnaire, the chief investigator suggested that we split the activities in the questions into minor and advanced. Note that question 1 is not asked in the SOLID trial. The first five questions (questions 2–6) fall into the minor category, and the remaining four questions are the more advanced (questions 7–10). Note that question 1 was not asked in the SOLID trial, so minor category will be the sum of questions 2–6.

The stopping rules will also need to be considered in the analysis of this questionnaire.

Scored 1 for having done the activity, and 0 for not.

Summary statistics for both categories will be presented. The chief investigator also wanted to summarise the ‘regret’ subquestion asked after each item. (So the study will not be looking at the ‘enjoyed’ and ‘had a condom’ subquestions for this feasibility study.) The regret question is scored as 1 (not at all), 2 (a bit), 3 (quite a lot) or 4 (very much).

For the self-reported romantic and intimate behaviour, measured using items taken from the CASI questionnaire used in the Avon Longitudinal Study of Parents and Children and supplemented with questions relating to regret in sexual encounters and unprotected sex used in the ESPAD, four measures were derived from the questionnaire (number 1 was the score calculated as per the skipping rules, but numbers 2–4 were not standard scoring schemes from the questionnaire – the SOLID trial-specific outcomes derived from the questionnaire data).

1. Romantic and intimate behaviour. This summarises the whole questionnaire with a score for each participant. This includes the subquestions relating to ‘enjoy’, ‘regret’ and whether or not they had a condom with them during the particular specified activities.

2. Romantic and intimate behaviour (minor). This is simply a score derived from adding up the scores to questions 2, 3, 4, 4a, 5 and 6 of questionnaire (1 for yes, 0 for no, so scores range from 0 to 6).

3. Romantic and intimate behaviour (advanced). This is simply a score derived from adding up the scores to questions 7, 8, 9, 9a, 9b, 9c and 10 of the questionnaire (1 for yes, 0 for no, so scores range from 0 to 7).

4. Romantic and intimate behaviour (regret). For each of questions from question 7 onwards the participants were asked if they regretted the action. They can score the regret as 1 (not at all), 2 (a bit), 3 (quite a lot) or 4 (very much). The regret score is calculated as the sum of these regret parts of questions. Note that due to stopping rules the minimum regret score can be 0 if the participant did not take part in any of the activities for which the regret question was asked. Scores of 1–6 imply that the participant answered one to six questions, but had no regrets about any of them (score range is 0–28).

The skip logic for the questionnaire is shown in Table 31.

• Skip logic 1: if participant answers ‘no’ to questions 3, 4 and 5 then stop, otherwise continue.

• Skip logic 2: if participant answers ‘no’ to question 6 then stop, otherwise continue.

• Skip logic 3: if participant answers ‘no’ to question 8, and also question 7 then stop, if question 8 is ‘no’ but question 7 was ‘yes’ then move to question 9 (continue).

• Skip logic 4 to skip logic 7: from question 9 onwards, if answer is ‘no’ then stop, otherwise continue.

• Skip logic 8: if answer to question 10 is ‘yes’ then end.

The score for each question are calculated as:

• Questions 1–6: score is 0 if answer ‘no’ or if ‘yes’ enjoy (1 = not at all, 2 = a bit, 3 = quite a lot, 4 = very much). Score ranges from 0 to 4.

• Questions 7 and 8: score as for questions 1–6 + regret (1 = not at all, 2 = a bit, 3 = quite a lot, 4 = very much). Score ranges from 0 to 8.

• Questions 9 and 10: as for questions 7 and 8 + condom (no = 0, yes = 1). Score ranges from 0 to 9.

Hospital services

1. In the past 12 months how many times have you visited an accident and emergency department as a patient?

2. In the past 12 months how many nights have you spent in hospital as a patient?

3. In the past 12 months how many times have you been admitted to hospital but not been kept in overnight?

4. In the past 12 months how many appointments have you had as an outpatient at the hospital?

General practice services

1. In the past 12 months how many times have you visited a doctor at your general practice?

2. In the past 12 months how many times has a doctor visited you at home?

3. In the past 12 months how many times have you visited the nurse at your general practice?

4. In the past 12 months how many times has a nurse visited you at home?

5. In the past 12 months how many times have you received a prescription?

Social and care services

1. In the past 12 months how many times have you been visited by a social worker at home?

2. In the past 12 months how many times have you visited a social worker at their office?

3. In the past 12 months how many times have you been visited at home by a care worker or advisor?

4. In the past 12 months how many times have you visited a care worker or advisor at their office?

Criminal justice resources

1. In the past 12 months how many times have you been arrested, cautioned or received an on-the-spot fine?

2. In the past 12 months how many days have you appeared at a magistrate’s court?

3. In the past 12 months how many times have you appeared at a crown court?

4. In the past 12 months how many days have you spent in prison?

Descriptive statistics only were provided for this questionnaire.