Eleven themes were generated relating to factors influencing the experience and use of the DAWBA within the trial. Five of these acted as facilitators and six as barriers.

Figure 1 provides a summary of these facilitators and barriers identified through the analysis. It draws a distinction between those specifically tied to the process of implementing the DAWBA within the STADIA trial, those that were pre-existing contextual factors acting as broader facilitators and barriers influencing the delivery of the intervention, and those that related to the mechanisms that were expected to underpin the intended outcomes but were not sufficiently activated [30]. These core functions of the process evaluation (implementation, context and mechanisms) are represented in the blue boxes alongside the major components of the delivery of the intervention during the STADIA trial and the expected outcomes in the white boxes. Whilst not part of the process evaluation, these simplified elements of the trial logic model are vital for framing the process evaluation results [31] Fig. 2.

Fig. 2

Summary of Process Evaluation Results (blue boxes), framed within STADIA Trial logic model (white boxes)

Table 2 maps the themes relating to barriers and facilitators to the use of the DAWBA identified in the analysis onto the structure of the CFIR domains and constructs [24]. These are described in more detail with illustrative quotes below.

Table 2 Participant demographicsFacilitatorsWillingness to engage in the STADIA trial

A number of internal motivators acted as incentives for young people and parents/carers to take part in the trial and demonstrated that it was feasible to recruit to the trial during the internal pilot. This contextual factor highlighted the role of ‘Innovation recipients’ (CFIR individual domain) being engaged with research and open to innovations to improve services.

Some reflected that engaging in this study gave them a sense of shared endeavour and identity that had some positive personal benefits for them. It made them feel less alone and was perceived as acknowledgement while waiting for an assessment, also providing additional information during that wait. A few also believed that participating in the study might increase the likelihood of their referral being accepted.

“If I participate it is just the feeling that I feel less alone, with all this because sometimes it is very challenging and very tough” – Parent/carer (Control)

Others were motivated to improve services through research and reflected on their negative prior experiences with CAMHS, including referral rejection and long waiting times. This inspired them to assist in seeking service improvements.

“Research, yes I think it is quite good, because hopefully these Trusts will take that on board and try and make sure that people have better outcomes” – Parent/carer (Control)

Some participants reflected on a sense of altruism, to contribute to the greater good and make things better for others.

“that's the benefit, is that feeling that you are helping with something, that's a positive for me” Parent/carer (Intervention)

Acceptability of DAWBA by young people and parents

The use of the DAWBA was met with predominantly positive perceptions by young people and parents/carers. They used the DAWBA report to help understand their symptoms or as a form of ‘evidence’ in seeking help from external services (e.g. schools, primary healthcare, private mental health services). This aspect of ‘Innovation Design’ (CFIR Innovation domain) promoted the active use of the DAWBA report by young people and parents.

Many participants were positive about the accessibility and presentation of the DAWBA report, which used colour coding and a graphical depiction to communicate the young person's emotional difficulties compared with population norms. The online access to completing the DAWBA was generally a facilitator, especially for young people.

“The visualisation is good, it's really easy to understand the different levels that are there and then a really nice summary. I think that the format of the report is actually really, really well thought out as well.” – Parent/carer (Intervention)

Parents and carers found the DAWBA report beneficial in providing clarity and points of reflection about the severity of their child’s symptoms. Putting their child’s symptoms in a population context offered reassurance to parents, particularly for those  children and young people whose DAWBA ratings showed them to be in the average range.

it made you realise that there are people with bigger issues that what you think you may have...so it puts it into context what behaviour you are seeing may not be as severe – Parent/carer (Intervention)

This reassurance was also reported by parents whose children had scored highly on the DAWBA, as they felt validated in seeking help. Parents also hoped that the added information would be useful in when seeking support from others.

I have since been able to go to the GP and say look we have had the report through now, can we now actually look at getting [child] a diagnosis, [child] does have really severe anxiety, [child] does get depressive episodes and I don't think this just pretending it will go away is very helpful; … for us to have a report that shows these things and has validated [child]'s experiences and ours ... it has been received quite well, like a report gets listened more than we do.” – Parent/carer (Intervention)

The report was also seen to have benefits for the child, both in terms of having something concrete for themselves, which acknowledged their experiences, and as an opportunity to open conversations between parents and the child.

“[child] loved the report so, we got the report through, the first person I showed it to was [child] and then because I got it through on my phone I have been able to send it through to their phone and said to [child] look it is up to you who you share this with, this is your information, remember stuff you share with people cannot be taken back. I quite often find [child] sitting there having a read through of it” – Parent/carer (Intervention)

DAWBA provides additional information for clinicians

Although few DAWBA reports were encountered by interviewed staff, they were considered as having the potential to provide additional information in clinical sessions. Clinicians could see benefits of ‘Innovation Design’ (CFIR Innovation domain) and their appraisal of the DAWBA was often in direct comparison to other tools used such as the Revised Child Anxiety and Depression Scale (RCADS) and Strengths and Difficulties Questionnaire (SDQ), generally viewing the DAWBA as “more thorough” with “more areas covered” and “more visual”.

"I think the DAWBA is very thorough, ... the amount of detail that it goes into is helpful, I'm not a big fan of RCADS and SDQ ..." Clinician

In Single Point of Access (SPA) teams, who make initial decisions about referral acceptance into CAMHS, there was better awareness of the DAWBA report and perceptions that it could help with referral decisions.

“as part of our decision making about whether they come into CAMHS or not, we would review [the DAWBA report] and just have a look and see from that person's rating ..... so that's how we would use it to help us make decisions or maybe understand, okay yes you still have anxiety but that still means you don't need CAMHS but there might be another service that's more appropriate” - Clinician

In subsequent clinical consultations, following referral acceptance, the DAWBA report was thought to be a useful starting point for conversation between clinicians, young people and their parents/carers, and to give further detail and expression regarding their experiences.

“In terms of the emotion in the first appointment ... people are frantic to be reassured that you're not going to then just pass them on for another few weeks for another assessment and it felt that [the DAWBA report] had taken some of that out, it was something to focus on at the time” – Clinician

Some clinicians described how it helped them prioritise which problems to focus on in an initial assessment.

“the DAWBA helps me to think is it coming through more mood or anxiety or sleep problems or conduct problems, and then I'll focus the assessment” - Clinician

Young people and parents perceived the report as providing additional information about the child that could be used by a range of healthcare professionals and education providers. They also saw the benefits of the report to clinicians if they were offered an assessment.

“I think in terms of going for an assessment that it's going to be very helpful because it kind of has given a starting point to talk about and what doesn't need to be talked about. I think it will be very helpful and will cut short a lot of questions” – Young Person (Intervention)

Dedicated research/administrative resources

Researchers working in each site invested the most time and labour in the study and assisted in the operationalisation of the DAWBA into clinical team practice. Having this embedded and dedicated team member was a key ‘Available Resource’ (CFIR Inner Setting domain). The critical tasks carried out to implement the DAWBA included supporting participant completion of the DAWBA, generating the DAWBA reports, sending them out, sharing and adding them to clinical records and highlighting its presence to clinicians. The clinicians commented that, without this support, incorporating the DAWBA into practice would need additional administrative resources.

“a time element to the organisation, the administration, you know, all the elements of how it's sort of input into the system, how it's sort of, you know, managed, would need to have time” Clinician

Leadership of change

Clinicians identified the importance of invested and enthusiastic leaders of change in facilitating the use of the DAWBA in services. PIs at each site were instrumental in this ‘Implementation Lead’ role (CFIR Individual Role domain) and pivotal in raising awareness of the DAWBA through emails and regular presentations to inform clinicians about the study. They and site researchers also engaged in ongoing active communication to increase clinician awareness and active searching for the DAWBA.

“[The site PI] is a big advocate for [the DAWBA] and [the researchers] were very, very clear and always very keen to kind of talk and problem solve and support you with any questions you had around.” Clinician

BarriersCOVID-19 pandemic and changes to online and hybrid services

For the majority of interview participants, the COVID-19 pandemic was at the forefront of their experiences during the STADIA trial and therefore had a strong impact on how the DAWBA was used and on CAMHS generally. This broader contextual factor represented a ‘critical incident’ (CFIR Outer Setting domain) that had a dramatic effect on how CAMHS were delivered as well as on children and young people, parents and carers and CAMHS staff. New ways of working and of accessing mental health support meant changing from predominantly face-to-face appointments to online/virtual, and then changing again to a hybrid model, representing a significant change in practice, resources and service demand.

“My main experience of coming across [the DAWBA], and this is part of the difficulty I think, because it came in during the pandemic, was everything became very disjointed, so in terms of being able to work around teams, you got your referrals, [but] didn't have that informal conversation that we're talking more about with your colleagues.” – Clinician

The rapid changes in practice and procedure meant that the DAWBA was not at the forefront of clinician concerns. Communication was more disjointed than usual, making reminders about looking for the DAWBA reports in electronic records more difficult. This may have contributed to limited DAWBA reports being seen by the clinicians interviewed for this study.

Experience of waiting times for CAMHS prior to first consultation/assessment

Long waiting times existed prior to COVID, but the pandemic exacerbated these and there was also a subsequent increase in referrals. This resulted in a considerable wait between referral and first consultation/assessment (if the referral was accepted). This contextual factor related to ‘work infrastructure’ (CFIR Inner Setting domain) and provided a backdrop to clinical interactions that were fraught with pressure, frustration and distress.

For many young people and parents/carers, the receipt of a DAWBA report during these extended waits provided some form of interaction and acknowledgement during the referral process. Receiving the report helped participants feel that they were getting something back, offering comfort in difficult times.

“because I've not heard anything yet from the referral, it is quite nice to sort of have a bit of acknowledgement.” – Parent/carer (Intervention).

However, clinicians felt under more pressure due to the waiting times and increases in clinical severity resulting from extended waits. They described how these demands on services led to a tendency to focus on existing practice and tried-and-tested approaches rather than being open to innovations and new methods.

“if you've high waiting lists and high levels of people complaining of how long they're waiting for the service and people getting worse because they've been waiting that long for this service then the priorities will shift to how do we offer treatments ... so if you're in survival mode as a service then innovation becomes a secondary thing because we might not be here next to implement this new innovation if we don't survive this current storm that we're in” - Clinician

Limited capacity to find and use DAWBA in clinical teams

Clinicians were concerned about the additional workload and time needed to be aware of and engage with the DAWBA report: to find it in a patient’s electronic clinical records, read it, and use it within the clinical assessment.

“[you] need to have time, and I think time is something that none of us have much of, so it would be how and who and where that time is going to come from.” Clinician

The context of high pressure on clinicians meant that, in practical terms, clinicians felt that they had limited capacity to incorporate additional information to existing processes. A specific challenge was related to the time needed to find the DAWBA report within a patient’s electronic clinical records, which, in the context of high demands and time pressures, was seen as a considerable barrier to using it. Clinicians reported electronic clinical records as generally “very cumbersome” and making it “really challenging” to find things, which made introducing new tools or documents more difficult.

“[The electronic clinical records] would be a big barrier to using the DAWBA .... it's just all the pressures of work that would get in the way of finding the time to do it” Clinician

Combined with the time needed to get clinicians to change their routine practices, which was difficult when they felt under pressure, this meant that adapting usual practice to find and use the additional information within the DAWBA report was met with considerable indifference.

“where would you find the time to retrain, get people to start thinking a different way; and then you think of the priorities that you currently have” Clinician

Challenges with ongoing communication to staff about the DAWBA

Given the context of long waiting lists, pressure on staff time, and the tendency to revert to usual practice, staff reported needing more frequent communication and convincing information about the DAWBA to keep it at the forefront of their minds and encourage its use. Without regular reminders to check for the DAWBA report in electronic clinical records or ask patients about it, a barrier to use arose from the lack of competence and knowledge reflecting the ‘Capability’ (CFIR Individual Characteristics domain) of clinical teams. The form of communication was highlighted as being important and, despite concerns about time pressures, clinicians still preferred direct, in-person meetings about the DAWBA and the trial. These were perceived to be more effective than emails, even though they were more challenging to arrange. Most clinicians were unaware of emails or newsletters sent from the STADIA team due to the volume of emails clinicians receive and the tendency for these to go unnoticed. It was felt that in-person meetings and presentations by persuasive and trusted people were a better form of information.

“I think if it's to do with people, you know, I think that's always the clincher, if it just comes in an email form or it's in some kind of newsletter, nobody's going to see it or notice it, so yes, how creative people can be and meeting with individuals, meeting with teams” Clinician

There was also some confusion about the validity of the DAWBA tool and whether it was an established measure or one that was being tested. Some participants identified a need for more engagement with clinicians and information on the DAWBA at the start of the trial, specifically raising awareness to a wider range of clinicians who could come across it. This would include what the DAWBA report looked like and where it could be accessed (although, throughout the trial, this was done regularly through site PIs and researchers).

“[We needed to] introduce and give more information about the DAWBA because I think they'd never heard of it and they didn't know enough about that it was standardized tool and that it had good reliability and validity, it was just something that I think they worried about” Researcher

Attitudes to diagnosis

There was some reluctance to use the DAWBA stemming from individuals’ general attitudes to diagnosis. This clearly acted as a barrier to using the DAWBA which was related to individuals’ commitment or ‘Motivation’ (CFIR Individual Characteristics domain). Many clinicians described a preference for a formulation approach over diagnosis as this was considered more holistic, less stigmatising and avoided labelling in a population where presentation of symptoms may change with age.

“100% [prefer formulation], as putting kids into nice, neat diagnostic boxes just feels unrealistic, or for anybody.” Clinician

The DAWBA, with its diagnosis-based language and focus, is clearly aimed at facilitating the diagnostic process, bringing into question the suitability of the tool in services that prefer formulation. There was also a sense of reluctance to engage with diagnosis and diagnostic tools from staff who were not from medical backgrounds with the general belief that only medical doctors made diagnoses.

“some are quite anti-diagnosis if you like. There is a very mixed consensus isn't there, around how we use diagnosis, whether we should, how useful the language is, etc and of course the DAWBA report itself is based off the DSM isn't it and the ICD 10 I think?” Researcher

However, there a variety of views on the role of a diagnosis were expressed. Young people and parents/carers generally expressed desire for a diagnosis in order to access support from other services.

“If they diagnose you, they actually have to help you.” Young Person

Other professionals were concerned that a diagnosis was essential for some interventions (e.g. educational, medication) and a reluctance to diagnose may impact young people who need support. Commissioners also articulated the importance of data on diagnosis for funding of services.

“diagnosis can sometimes open a door for accessing other services and funding as well as being containing, reassuring, so yeah it can definitely be really helpful.” Clinician

DAWBA not seen or used widely at consultation/assessment stage

It became evident that DAWBA reports were not necessarily being used in the way expected or articulated in the logic model. The main hypothesised mechanisms through which the DAWBA would affect outcomes was by clinicians accessing and using the DAWBA reports at two stages: (1) triage—as part of the decision to accept or reject a referral; (2) assessment—for accepted referrals, during initial assessment consultations to help inform diagnostic decisions. However, few clinicians interviewed had seen or used a DAWBA report, particularly in stage 2. This could be partly due to proportion of referrals that were rejected but also challenges finding the report in the electronic clinical records. One clinician identified the need for a DAWBA report to be flagged so it was more obvious to clinicians.

“I guess one thing that would be helpful is if when you saw the client and a DAWBA had been completed there was an alert that comes up on [the electronic clinical record] just saying this client has a DAWBA ... and then a link to where to go and check it so that you're not having to trawl through notes to see that, so that would be helpful because I didn't see that until after that choice appointment.” Clinician

For those that had seen a DAWBA report in the electronic clinical records, there was a reluctance to use it if a long period had passed between DAWBA completion and the actual clinical consultation. This seems to reflect a lack of ‘Opportunity’ (CFIR: Individual Characteristics Domain) for clinicians to use the DAWBA reports in the way intended during assessment consultations. Furthermore, some DAWBA reports had discrepancies with the clinical formulation or diagnosis. Sometimes this was discussed with the patient but some clinicians chose to ignore the DAWBA when this occurred.

“the clinical interview did not marry up very well with what the DAWBA kind of revealed so I guess it made me more aware that certain areas may need further exploration... With children and adolescents in particular, things change over time and are transient so maybe when the DAWBA was completed that was entirely accurate but actually things may have progressed in a different way” - Clinician

However, many did see a potential benefit of using the DAWBA to inform the referral process, as a pre-referral screening tool. This could bring benefits to both child or young person and the service by informing which referrals were most appropriate for CAMHS intervention and which better signposted elsewhere. Commissioners and clinicians were also positive about the potential of the DAWBA for engagement during long waiting times, informing referral acceptance or redirection to other services, or in initial assessments. This ‘Adaptation’ (CFIR: Implementation Process) happened during the implementation of the DAWBA into sites.

"I'd be keen to think about how that may be complemented in [the single point of access] service." Manager

This would potentially reduce clinical burden by taking place before assessment (as situated in the trial). Others felt that to be most beneficial clinically, the DAWBA should be completed closer to assessment so the information was more up to date.

“it's quite a detailed assessment of that young person and from a referral screening perspective, those that had participated in [completing] the DAWBA, it was really really useful in terms of offering them their initial assessment because you have so much more additional information that was actually coming from the young person and the family as opposed to what a GP might write, or a school might write in a referral, which is only their perception, so it's really helpful, […] It's been used as a way of thinking about the referral we've had in and making a more informed process of decision about what's going to be right support for that young person. And then I guess if they come into the CAMHS treatment pathway then it informs that clinician who's picking them up about where they were at, so although it may be a long waiting list there's still an element you can then match, you can then sort of gauge how they've progressed and what's you know got better, what's not. You've got a baseline really to look at.” – Manager