Distress Brief Intervention - under 18s elements: evaluation

Findings

Development of the under 18s elements of DBI

This section draws together data from the scoping phase and stakeholder interviews to explore:

• whether the under 18s elements of DBI have been implemented as planned.
• what the facilitators and barriers to implementation are.
• how the service fits alongside existing services and support for young people.
• whether the training has met the needs of those who received it.

Planning and implementation

Collaborative Development of the DBI Extension

The DBI central team worked with a team at the University of Glasgow to develop the approach for both the extension of the adult DBI programme to 16- and 17-year-olds and the test of change. This partnership was seen as adding value to the programme in that all developments were rooted in the evidence base regarding best practice in providing interventions to young people in distress.

Evidence-Based Design and Stakeholder Engagement

The DBI Central team worked with the University of Glasgow and a DBI national clinical advisor for children and young people to guide the development of the extension of the adult programme to 16- and 17-year-olds. The team at the University of Glasgow considered the applicability of DBI to this age group through desk-based research and made recommendations to the DBI programme board. This was followed by a period of engagement with stakeholders, where the University of Glasgow conducted semi-structured interviews and focus groups with leaders and practitioners from third sector and statutory (e.g. agencies and services who work with young people in this age group, as well as existing DBI service partners) to understand any practical considerations which should be taken into account. In addition, the team at the University of Glasgow was able to engage with a number of young people, leading them to carry out 6 semi-structured interviews with young people aged 17-20 years with lived experience of distress, including 2 interviews where the young person had experience of the existing DBI Level 2 service, and a focus group with members of a youth forum (n=6 participants; 14-16 years).

Designing the Test of Change

For the test of change, the University of Glasgow reviewed the DBI model from the view of its use with children and young people. The team at the University of Glasgow engaged with numerous organisations which work with children and young people to benefit from expert input on issues such as consent and parental involvement. These included young people’s groups, social work, those involved in children's welfare, Princes Trust, Barnardos and See Me. Semi-structured interviews were also carried out with members of CAMHS teams, school-based counsellors and school-based wellbeing support services (e.g., Quarriers). A young people’s advisory group, comprising clinical and academic experts in children and young people’s mental health, members of the DBI Central Team and leaders from education, as well as DBI delivery partners was also established to support the development, implementation and ongoing delivery of the test of change.

Challenges and Adaptations During COVID-19

Engagement with young people to inform the development of the test of change was made challenging by the ongoing COVID-19 pandemic. However, to support development and adaptation, the University of Glasgow carried out 5 semi-structured interviews with members of youth-focused organisations (e.g., TRIUMPH Youth Advisory Group members, See Me Youth Champions). Supported by the See Me Children and Young People, University of Glasgow also collected 82 survey responses from pupils attending North and South Lanarkshire schools to better understand pupil experiences and views of distress and help-seeking.

Early Insights from Young People

After the initial implementation of the test of change, two young people also took part in interviews as part of an early insights review. While acknowledging that the number of young people included was limited, an unpublished ‘early insights review’ which was shared with CYP Advisory group, DBI Programme Board and Scottish Government noted the depth of insights provided. The young people reported that they highly valued the immediacy of the support provided by DBI, felt it was suitable and met their needs, and helped them to develop better ways to cope with their distress. While the team did also engage with one parenting organisation, direct engagement with parents has been recognised as a gap in the development of the under 18s elements of DBI.

Geographic Scope of the Test of Change

As at August 2025, the test of change is currently live in Lanarkshire, Aberdeen, West Dunbartonshire and Inverness, as well as in a DBI equivalent service, Compassionate Distress Response Service (CDRS) in Glasgow City and East Dunbartonshire. With the exception of West Dunbartonshire and the CDRS, the test of change is being piloted in the sites which were originally involved as pilot sites in the development of the adult DBI service, meaning that the test of change has been introduced into sites where DBI is well-established. West Dunbartonshire, and the CDRS in Glasgow City and East Dunbartonshire are DBI “associate” sites, meaning that they were not involved in the original DBI pilot and were established at a later date.

The Role of the Compassionate Distress Response Service (CDRS)

For the CDRS, the test of change is not related to education and is an extension of their pre-existing service (for 16- to 25-year-olds in East Dunbartonshire; and 16 and over in Glasgow City) which now allows them to support 14- and 15-year-olds in distress. As this service uses pre-existing model and structures, young people accessing this service have a different experience to young people who access the service in other areas. The CDRS pathway for 14- and 15-year-olds does not currently include schools, and young people may receive support for a longer period and be referred on to group work or peer support. While the delivery of DBI to 14 to 25 year olds through the CDRS follows the core principles of DBI of a 24-hour response and connected, compassionate care, the implementation deviates significantly from the approach taken by other areas, in that support is provided for up to one month and young people can access other types of support available from the CDRS such as group work.

Inclusion of CDRS in Evaluation

It should be noted that the CDRS service is not considered as an official part of the test of change. The CDRS was not originally planned to be part of the under 18s evaluation. However through engagement with all areas involved in the under 18s elements of DBI, it was agreed to increase the scope to include the CDRS cases, partly to support the goal of achieving the required sample sizes, but also because, through engagement, the CDRS model (which is slightly different to DBI but fully aligned with the principles of DBI) was considered a valuable element to include to fully assess the implementation of DBI for under 18s across Scotland.

Implementation Approach and Flexibility

Stakeholders noted that DBI was introduced through the test of change incrementally and using an improvement science approach^[2], and therefore changes and improvements to the way in which DBI was implemented were to be expected. In addition, the Level 2 staff members were empowered to be flexible in providing the intervention to young people, meaning that a level of discretion is built into the delivery. When designing the test of change pilot, the age limit was set at 14 to 17 years, or S3 to S6. As some young people in S3 are aged 13, a change was required in the age limit to allow 13 year olds in S3 to access the service which was available to their peers.

Facilitators and barriers to implementation

A number of key factors supported the development and implementation of the under 18s elements of DBI. Both the extension to 16- and 17-year-olds through existing referral pathways and the test of change were underpinned by strong policy drivers at a national level within Scotland. Stakeholders discussed an overall policy objective to de-medicalise distress and to introduce alternatives to support provided through medical settings. The Scottish Government’s Programme for Government 2018-2019 included a commitment to expand the Distress Brief Intervention programme pilots during 2019 to include people under 18.

The rationale for developing the test of change to trial the extension of DBI to those aged 14 and over was underpinned by recommendations from the Children and Young People’s Mental Health Taskforce, as well as Audit Scotland’s report on children and young people’s mental health, which indicated a 22% increase in referrals to CAMHS and a 24% increase in rejected referrals between 2013/14 and 2017/18. The Scottish Government’s Mental Health and Wellbeing Delivery Plan 2023-2025 included a commitment to assess the suitability of DBI for 14 and 15 year olds.

Although not the aim of the DBI programme, stakeholders recognised a need to alleviate pressure on overstretched and over-subscribed CAMHS services and to reduce waiting lists as a driver for the extension of DBI to under 18s. Managing waiting lists and communicating with parents of young people in distress were described as taking up significant amounts of time for CAMHS. Stakeholders identified a gap in services for the increasing numbers of young people being referred to CAMHS who needed immediate support but did not meet the criteria for CAMHS.

So, it's been recognised that a more effective response to that would be firstly an early intervention approach, secondly that it would be community based and accessible - as much as possible, ideally in hours. (Strategic stakeholder)

Both the strong governance of DBI, and the reputation of DBI itself, were highlighted as key facilitators in the implementation of DBI. The Children and Young People’s Advisory Group, which works in parallel with the DBI Programme Board, was identified as an important factor in bringing together expertise in children and young people, and in developing relationships with CAMHS and education.

DBI’s reputation as an evidence-based, reliable and reputable service which had been tried and tested with adults helped to build trust and confidence in the test of change, particular among CAMHS staff. The incremental growth model used by DBI in developing and implementing the service was seen as a strength. So too was the close relationship with the University of Glasgow in increasing confidence that the extension of DBI to under 18s was developed with academic rigour, grounded in evidence.

So, the fact that there might be a service that's got accountability, a governance structure, a response - which the NHS recognise, consistency, reliability - is a massive asset because people are much more likely to refer to that and make a confident referral to it. (Strategic stakeholder)

Stakeholders also identified some challenges and areas for further development in the implementation of the test of change. Building and maintaining relationships with, and securing buy in from, schools has required significant effort from Level 2 services. In areas where this has been successful, leadership buy in and a key DBI contact within the school who could champion DBI were seen to be crucial. Determining the most appropriate and effective way for DBI to engage with parents and carers was identified as an area which could benefit from further exploration.

Fit of DBI alongside other services

This section explores how DBI complements existing support available in schools and CAMHS. DBI offers a unique, immediate, distress-focused intervention that fills a gap not addressed by other services. Overall, it was seen as enhancing rather than duplicating or replacing existing provision. Stakeholders acknowledged that DBI must operate as part of a wider network of services to meet the diverse needs of young people experiencing distress.

Schools commonly offered in-school support such as school counselling, Let's Introduce Anxiety Management (LIAM), pastoral support from guidance or pupil support teachers or emotional literacy support assistants (ELSA) and youth work referrals. Pupil support teachers spoke about the support that they were able to offer young people in distress within school, but also about the demands on their time due to heavy workloads and teaching commitments, which meant that they were not always able to dedicate the time to young people when it was required. DBI was described as fitting well alongside in-school support as DBI providers were able to offer the time to sit with the young person, listen to them and validate their feelings.

I don't have time to spend the time that a lot of what these pupils need is an adult validating their feelings and giving them attention. That's what's usually missing from their life, which is usually the main cause of their distress. I give that as much as I can, but having DBI there to do that as well in probably a more trained capacity is really helpful. (School-based Level 1 referrer)

School counselling was available within referring schools, but school staff frequently spoke about long waiting lists for appointments and, in some cases, pupils having to wait until the next term to receive support. DBI was seen as complementary to school counselling as it is immediately available and uses a more solution-focused approach. It was also suggested that DBI was more accessible to some young people, particularly boys and young men, who may not be willing to engage with school counselling.

Counselling waiting lists are usually in the region of six to eight weeks, unless I put it to urgent one. Even if it's urgent one, the highest priority, it'll still take two weeks, so DBI is gold dust to me. (School-based Level 1 referrer)

School staff also spoke about referring young people to CAMHS but similarly encountered “endless waiting lists”, with some staff voicing that they were reluctant to refer pupils to CAMHS due to the length of the wait for support. There was a perception that CAMHS was only suitable for those young people experiencing the most severe distress, or that CAMHS predominantly deals with Additional Support Needs (ASN) assessments and medication. DBI was described as having a lower threshold for support than CAMHS.

School staff who participated in interviews also identified other options available for supporting young people, such as recommendations to parents that they seek support from primary care. However, school staff found that the response from primary care was often unhelpful, in that GPs were unwilling to support unless a young person had self-harmed, and that pupils were passed back to the school or referred on to CAMHS.

That merry-go-round of asking a parent who's really upset, is looking for help for the young person, to go to the GP, for the GP to bounce it back to us to try and find a solution. It's really tough, and having DBI on that as a go-to for me is like a secret weapon sometimes. (School-based Level 1 referrer)

It was acknowledged by Level 1 referrers, DBI providers and strategic stakeholders that DBI could not fill all the gaps in the current support landscape for young people, and that there were some types of situations where DBI was more effective and others where it was less appropriate. DBI was seen as working well for cases in which a young person is able to recognise that they are in distress and ask for help, and when a young person’s feelings are more internalised as they are experiencing sadness, anxiety or worries.

In cases where a young person displayed more externalised behaviour, such as through violence and aggression, a more specialist response was deemed to be more appropriate. DBI was also seen as less effective for young people whose distress stemmed from trauma or wider concerns in their lives which were the responsibility of the adults who care for them, such as problems with housing or family dysfunction.

School staff and DBI staff members highlighted remaining gaps in the support landscape which were not currently met by DBI or any of the other services available. These included support for young people with long-standing problems such as trauma and family dysfunction which would require long term support, and support for young people under the age of 14, and particularly for the transition between primary and secondary school and lower secondary school. Level 2 staff members described gaps in follow-on support after DBI, such as independent counselling, mentoring and other third sector support and, where there was follow-on third sector support, it was described as ‘patchy’. Finally, for some young people in particularly challenging social circumstances, support with housing and everyday life skills such as budgeting were seen as gaps in provision.

School staff and Level 2 staff members highlighted what they saw as the elements of DBI which made it distinct and complementary to the other support available for young people, namely the promise of contact within 24 hours and DBI’s compassionate, solution-focused approach. Referrers valued the quick response and that DBI did not have a waiting list. This promise of immediate support was highlighted as something which could not be offered by other services. They reported that this was also valued by parents. The interview conducted with a parent echoed this, as they also reflected positively on the immediacy of support from DBI compared to waiting lists for other services. The quick response was also viewed by the parent as a form of early intervention that could address certain behaviours before they worsen, like poor school attendance. The 24-hour response was seen by referrers as validating the young person’s feelings and described by one referrer as an act of compassion.

Where I think DBI is absolutely priceless, is they will make contact with the young people in distress within 24 to 48 hours. Whereas if we are referring families to go and see GPs, if we're referring families to our youth counselling, or CAMHS, or request for assistance to social work, these are not quick fixes; they're just not. (School-based Level 1 referrer)

Referrers and Level 2 staff members also highlighted how DBI’s approach differs to that used by school counselling and CAMHS in that DBI is solution-focused, time limited and non-clinical. It was suggested that this may be more appealing to young people who were hesitant to speak about their emotions and that the relationship between a Level 2 staff member and a young person was more of a peer-to-peer relationship than between the young person and their guidance teacher, or the young person and their parent.

So I think that is very different than the support usually offered for young people, and I think there's a wider support when you think about stigma, help seeking, and these kinds of things. I think if it can be a very positive experience, a respectful experience, then the hope is that not only are you equipping young people to manage day-to-day and in the future, but they also feel okay about asking for help if they ever do need it and can understand the importance of doing that. (Level 2 staff member)

Going in there as an equal, I'm not coming in here as an adult to tell you what to do; I'm not coming in here to say that 'You're a young person. You need to listen to me.' It's, 'We are absolutely equals. I'm just here to provide the safe space, to metaphorically hold your hand through this difficult process, and let's find some things that work for you together. We're working on this together.' (Level 2 staff member)

DBI Level 2 staff members were perceived as being more flexible; for example, being able to meet at times that suited young people, able to offer more sessions than a guidance teacher, or more frequent sessions than a weekly session with a school counsellor.

I think another strength that DBI had over other supports available, is that it wasn't a rigid once-a-week contact that the young person would have. So, even though it was short term and maybe the phone calls themselves were nowhere near as long as a session that they would have with a counsellor, for example, I think the constancy, it was maybe more intensive. There was maybe more momentum that was being built up to actually develop those strategies to cope yourself. (Level 2 staff member)

From the Level 1 referrers and Level 2 staff members, it is clear that DBI is often being used to bridge the gap in support while young people are on waiting lists for other services. Participants shared instances of those aged 16 and 17 who were referred through the adult programme being supported by DBI while they were on the waiting list for adult mental health services, and those referred through the test of change receiving support from DBI while they waited for school counselling or CAMHS appointments.

School referrers spoke about putting in referrals to CAMHS and DBI simultaneously to secure immediate and longer-term support for young people. However, the impetus for multiple referrals was not only from schools, as Level 2 providers shared examples of asking for young people to be put on the waiting list for school counselling while they were receiving support from DBI, and CAMHS services referring to DBI to ask if the young person could be supported until their CAMHS appointment. In these cases, DBI provision is an additional, rather than alternative, service which supports the young person in the short term while they wait for further care. It was suggested that this may prevent young people’s distress from escalating further.

It's definitely filling the big yawning gap that's caused by waiting lists, even for counselling. (School-based Level 1 referrer)

So, we have this young person for four weeks, we're doing our check-in, we just are making sure they're okay, if they want to talk to us, they can talk to us about it. By the time we finish with them, they have their CAMHS appointment, so that then is back to the actual clinical intervention to kind of take on board. (Level 2 staff member)

It is not currently possible to track how often young people who are referred to DBI are also concurrently referred to, or are on waiting lists for, other services such as school counselling or CAMHS as this information is not collected within the DBI routine dataset.

DBI was also being used in some cases as an introduction to further intervention, and as an opportunity for young people to try out support with a view to them engaging with school counselling at a later date.

I know previously, in some of the schools - because some of the schools that we work in have got counsellors in there as well. So, if the referrals for DBI were running low, we would suggest maybe introducing that young person into DBI to give them an idea on how that support looks in the future. If they've never experienced anything like that before, it can be quite daunting for them. (Level 2 staff member)

Delivery of training and whether it has met the needs of Level 1 referrers and Level 2 staff members

This section discusses the training which has been developed for Level 1 referrers and Level 2 staff members for both the expansion of DBI to 16- and 17-year-olds and the test of change, and the extent to which this training has met the needs of those who received it.

Expansion to 16-17 year olds

In 2019, the University of Glasgow team developed a 10-page briefing for existing DBI Level 1 providers to support the extension of DBI to those aged 16 and over. The briefing was designed to complement and extend the existing adult training materials, ensuring the additional training commitment for already trained staff was limited.

During development, the briefing content was reviewed by delivery partners, stakeholders and pilot areas. The University of Glasgow observed delivery of the briefing across two DBI Level 1 training sessions attended by Emergency Department staff and Police Scotland staff. Later in 2019, the briefing material was incorporated into the standard training resources for DBI Level 1 referrers.

The University of Glasgow also developed and delivered two-day DBI Level 2 training sessions for each site. This additional training to support the extension to those aged 16 and over adopted a young persons’ lens on DBI and all who attended were required to have first attended the core DBI Level 2 training for the adult programme which also lasted two days. In 2020, a training delivery pack was created to support in-house training of this additional element. In 2024, the training packages were comprehensively revised and DBI Level 2 training resources were consolidated to form a single two-day DBI Level 2 training for delivery of DBI to those aged 16 and over.

Test of change: Level 1 training

Beginning January 2021, University of Glasgow began delivery of training to support the test of change. The DBI Level 1 Children and Young People Training^[3] was facilitated by University of Glasgow and delivered virtually to pupil support (i.e. guidance) teachers in schools in selected sites. Initially the facilitated training lasted 2.5hrs, but this was subsequently extended to 3hrs following feedback.

The training sessions cover young-person specific stressors and concerns that may contribute to distress, different common presentations of distress in young people and practical activities to support the identification of children who may benefit from a referral, providing a compassionate response, and the referral process. The tripartite pathway linking schools, DBI Level 2 and CAMHS is also introduced. The fact that the training was evidence based and developed by an organisation with an established reputation and longstanding relationship with DBI was seen as important in enhancing the credibility of both the training and the programme as a whole. The Level 1 training emphasises the need for flexibility in where and how young people may want to engage with DBI.

In general, Level 1 referrers from schools expressed very positive views about the training provided and indicated that it had met their needs and given them all the information that they needed to make a referral. Training for Level 1 school staff includes contributions from specialist clinicians working in CAMHS and from a DBI Level 2 service provider to, “put a face to the end of the referral form”. School staff appreciated CAMHS input as it provides reassurance about the rigour and legitimacy of the DBI programme and demonstrates that wider mental health contexts have been considered.

… I think also because CAMHS are part of the tripartite pathway that has been developed for the children and young people work, it’s important to have them there and be able to speak to that as well and what their role might be to provide some reassurance that this is a functioning pathway rather than a pathway on paper only. (Strategic stakeholder)

Level 1 referrers particularly appreciated “buzz sessions” delivered by Level 2 staff which offered a useful opportunity to refresh their knowledge. Level 2 staff also found these useful in building relationships with Level 1 referrers. One staff member had found it useful to see some of the materials used with young people by DBI Level 2 and reflected that this was not included in the training but that other Level 1 referrers may find it similarly useful.

…but there's formal training and then there's the buzz session and I'll be honest with you, the buzz session of the team being able to sit around with everybody in the team and just query things and even identify things like would it be possible for you to look into coming in and speaking to classes almost proactively about strategies or maybe year groups as well… (School-based Level 1 referrer)

A few participants described challenges they had experienced with Level 1 training, including high turnover of staff in schools meaning that regular top-up training was required. A staff member at one school described difficulty in accessing the training due to it being delivered online by the University of Glasgow on specific dates which their staff could not attend, though this was mitigated by a Level 2 staff member attending the school to deliver the training.

Future plans to further embed the Level 1 training included developing resources for the DBI National Training Network and to develop training that the local lead agency would use to train Pupil Support Teams in schools.

Test of change: Level 2 training

DBI Level 2 training to prepare staff to deliver the test of change was also developed and delivered by the University of Glasgow. This builds on existing training for delivering the programme to adults and young people aged 16-17. The team at the University of Glasgow developed an evidence-based approach to the training and engaged with Level 2 staff members to harness the experience that they had garnered through delivering DBI to adults. The COVID pandemic imposed some limitations on the extent of engagement with young people to inform the training but, as described, a number of interviews, focus groups and a survey of school pupils was carried out. Additionally, highly knowledgeable and experienced representatives from CAMHS and educational psychology on the Children and Young People’s Advisory Group provided important input and comment on the training.

Beginning in January 2021, University of Glasgow began delivery of the DBI Level 2 Children and Young People Training. The training was delivered for each of the participating DBI Level 2 teams and consisted of:

• three preparatory ‘CAMHS Essential’ e-modules accessed via Turas (a digital learning platform).
• participation in a virtually delivered 4hr facilitated training session co-developed and led by University of Glasgow and the DBI CYP Clinical Advisor.

This Level 2 training was additional to the core DBI training and includes information on child protection, legal elements of consent, safeguarding and information sharing processes as well as the wider context of how distress presents in young people and the experience of adolescence. Additional tools and support resources for children and young people and an information booklet designed to inform and support the parents of young people referred to DBI Level 2 service are included. Other material includes an enhanced set of standard operating procedures for contacting young people following a referral, where GPs and referring schools are notified daily of any unsuccessful attempts to contact a young person.

Feedback about the training from DBI Level 2 staff was generally very positive, and they described the training content as informative and insightful. Level 2 staff members also felt that the training they had received on delivering the test of change complemented their wider DBI training and highlighted both the similarities and differences between working with adults and young people. This element of the training was seen as particularly beneficial for those who had less direct experience of working with children and young people.

A lot of our team continue to be non-experienced of working with children and young people. All of us have mostly come from working with adults in regard to mental health and wellbeing. So yes, the training, I think, helps ease concerns or questions around about that age group because a lot of us weren't experienced in that. (Level 2 staff member)

However, it is important to note that the DBI training for delivering the under 18s test of change was one part of a wider training offer which is open to Level 2 staff members through their delivery organisations. Level 2 staff members mentioned having received in-house training on topics such as child protection, self-harm and eating disorders and accessed external training including ASIST Suicide Prevention Training. If DBI were to be rolled out more widely for under 18s, it would be crucial to ensure that training relevant to working with children and young people (such as child protection and other topics) is in place and completed by all Level 2 staff members and teams around the country prior to DBI being offered and any other gaps in training should be identified.

Level 2 staff members and strategic stakeholders described some challenges associated with the training for the test of change. These included staff turnover within Level 2 teams with the result that new staff members who required training had to wait for the next date on which the training was being conducted.

Where the difficulty comes in or the challenges come in is where new members are brought into that existing team, the staff turnover and we’re talking about kind of repeated training sessions for the same teams so that they can accommodate new members of staff coming in and leaving and things like that. So that becomes a challenge around capacity. (Strategic stakeholder)

Some opportunities to develop the content of the training were identified, including more focus on how to build trust and rapport with the young person. There was also the suggestion that the training could include guidance on how to engage with schools, build relationships with referrers and navigate the complex dynamics between schools, young people and parents.

I don't think the training really sets you up with how complex engaging with a young person is. (Level 2 staff member)

Stakeholders noted that the development of a training pack to enable Level 2 training in-house by DBI was underway which would support Level 2 teams to deliver training to new staff members.

In due course, our plan would be that the children and young people training would also sit within the responsibility of a DBI National Training Network which is under development and this is going to be a National Network of suitably qualified trainers around the country who can support and maintain training with consistency and adherence to the model and fidelity without so much input from the training team directly. (Strategic stakeholder)

Delivery of under 18s elements of DBI

In this section, we draw mainly on aggregate analysis of the data routinely collected by DBI Level 2 to explore the kinds of referrals which have been made, whether DBI met its targets for speed of response, appropriateness of referrals and differences in the way that DBI was delivered to under 18s compared with adults. This data includes under 18s referred through the established DBI referral pathways, the CDRS and the test of change involving schools and CAMHS. Data for adults (those aged over 18) are also referred to where this provides additional context for the under 18s data.

All data tables for this chapter can be found in the accompanying tables. Qualitative data from the interviews with stakeholders is included to provide explanation and context.

Type of referrals

A total of 2,219 under 18s referrals were made between 31st May 2019 to 30th September 2024, with the majority of service users reported as female (68.0%), followed by male (31.1%) and other (0.9%) (Data Table 3.1). Level 1 referrers and Level 2 staff members shared their perception of the reasons for this, including that girls and young women may have more overt presentations of distress and may be more proactive in seeking support than boys and young men. Level 1 referrers and Level 2 staff members also highlighted their perception that a relatively higher proportion of trans and non-binary young people were accessing DBI via the test of change compared with the adult programme.

I think boys, there is that - possibly even where I live, the West of Scotland - male attitude, where it's about, you don't talk about your problems. You can deal with them, and the phrase [chuckles] - I hate to say it - but 'man up', whereas it's not really appropriate. (School-based Level 1 referrer)

It's half the number of males to females that were referred, but there's also a non-binary person which I think is worth mentioning in terms of gender and stuff, that we do see a lot more non-binary, and I think higher levels of transgender people coming through the younger pathways. (Level 2 staff member)

Most referrals were made for 16 year olds (30.3%) and 17 year olds (41.7%). Of those aged under 16, referrals were highest for 15-year-olds (12.3%), followed by 14 year olds (11.9%) and aged 13 and under (3.8%) (Data Table 3.2).

Of those with recorded SIMD and ethnicity, the majority of under 18s referrals were White Scottish/British/Irish/Other (96.2%) (Data Table 3.3) and over one-third (34.8%) were from the 20% most deprived areas in Scotland (Data Table 3.4).

Education (34.2%) was the most common referral source overall. The next most common referral source for all under 18s referrals was primary care in hours (17.3%), followed by NHS 24 (16.5%), and A&E department (8.8%) (Data Table 3.5). The majority of referrals for children and young people under the age of 16 were from education pathways (88.9%). The main referral sources for 16 and 17 year olds were NHS 24 (22.8%) and in hours primary care (22.7%) (Data Table 3.6).

Reasons for accessing DBI

The DBI Level 2 data indicate that stress/anxiety (61.0%), depressed/low mood (58.0%) and suicidal thoughts (33.2%) were the most commonly reported presenting problems among under 18s referrals (Data Table 3.7). ‘Self-harm’ was reported by 24.0% of under 18s, which is higher than among adults referred to DBI (9.4%) (Data Table 3.8). This was broadly consistent with the most commonly reported presenting problems among adult referrals (Data Table 3.9)^[4].

The most commonly reported contributory factors in under 18s referrals were relationships (45.3%), emotional well-being (36.9%), life coping issues (35.7%) and factors which were described as ‘education-related’ (22.4%) (Data Tables 3.10 and 3.11). This is also consistent with the most commonly reported contributory factors among adult referrals (Data Table 3.12)^[5].

The referrals data are supported by evidence from the stakeholder interviews and focus groups, which highlighted stress and anxiety as common presenting problems among young people accessing DBI Level 1 and Level 2 support. Level 1 referrers frequently highlighted the instance of suicidal ideation and behaviour, and self-harm, among those they referred. Participants also mentioned presenting problems not captured by the DBI Level 2 data, such as concerns around disordered eating, social media, and issues relating to gender and sexuality.

…social media has got a lot to do with things as well and how things are perceived and how you look and while you can work with that it seems to be quite heightened at Christmas and when graduations and leavers balls and things like that are happening, it seems to be quite a lot of pressure for some people. (Level 2 staff member)

There was a perception that referrals made to DBI from CAMHS were more complex than those made by schools, and that frequently those referred had experience of suicidal thoughts and self-harm. It was also mentioned by CAMHS staff and Level 2 staff that CAMHS referrals to DBI tended to be made to support young people during the wait for further support from CAMHS, or while young people are waiting for a diagnosis of a neurodiverse or mental health condition.

So it’s often a range of those sorts of things, of them just feeling quite stuck in that moment and actually you see that they’re responding well to kind of just talking that through, where they could kind of make use of that idea of some emotional containment in that moment to help them kind of move forward through a bit of a crisis or a transition. (CAMHS Level 1 referrer)

Some differences in presenting problem and contributory factors were identified by gender. The DBI Level 2 data indicated that, in the under 18s referrals, ‘depressed/low mood’ was more common among males (62.7%) than females (55.7%), whereas ‘stress/anxiety’ was slightly more common among females (62.1%) than males (58.5%) (Data Tables 3.7 and 3.9). Self-harm was also higher among females (27.4%) than males (16.5%). Considering all under 18s referrals, 6.0% had self-reported alcohol or substance use at point of referral, with use higher in males (8.3%) than females (4.8%) (Data Table 3.13).

There was no clear consensus of views from Level 1 referrers and Level 2 staff members regarding whether they perceived there to be gender differences in the reasons for referrals among young people. Some felt that they saw self-harm more frequently among girls and young women, and substance use issues, anger, aggression, truanting and difficulties with emotional regulation more frequently observed in boys and young men. Others did not see differences in presenting problem by gender. The view was expressed that, while the outward presentation of distress may differ by gender, the underlying issues were similar across genders.

There are different behaviours, but actually I think the core issues that are being tackled are the same, regardless of gender actually, but the presentations that we see are quite different. (School-based Level 1 referrer)

The DBI Level 2 data did not suggest any clear trends in presenting problems or contributory factors by age (Data Table 3.11). However, in the case of self-reported alcohol or substance use at point of referral, a higher proportion of 16 year olds (7.6%) and 17 year olds (7.9%) were reported as under the influence than young people aged 15 and under (1.3%) (Data Table 3.14). Again, there were mixed views from Level 1 referrers and Level 2 staff members regarding whether the reasons for accessing DBI differed by age. For some, the issues with which young people presented were similar across age groups and were perceived to stem from a common difficulty in coping with their emotions.

So I think you could look at what's the different reasons, but I think in amongst what we see is maybe just that ability to feel like they can cope or know what to do, or know what they're thinking or feeling, connecting to their emotions, and things like that. We see a lot more with our younger age group. (Level 2 staff member)

Others felt that those aged 16 and over tended to require support with exam stress or “real world problems” such as housing and finances, and that their problems tended to be more entrenched compared with younger pupils. There was also the view that those aged 13-15 tended to present with more severe and immediate distress and problems within their peer group.

Distress is more intense among 14-15 year old stage (S3 and S4) as young people are developing physically, mentally, hormonally. By S5 and S6, young people are more composed, more able to verbalise a need for help. (School-based Level 1 referrer)

Targets for speed and response

Consistent with the DBI model that contact should be initiated within 24 hours of the referral, almost all (99.8%) of under 18s referrals through the test of change pathway had a Level 2 contact attempt within 24 hours (Data Table 3.15). Through the established DBI referral pathways, nearly all (99.9%) of 16 and 17 year old referrals had a Level 2 contact attempt within 24 hours (Data Table 3.16).

Considering all test of change referrals, nearly two-thirds (64.2%) were successfully contacted by Level 2 within 24 hours (Data Table 3.17). This is similar to 16 to 17 year old referrals made through the adult pathway, with 67.3% reported as having a successful contact within 24 hours (Data Table 3.18).

Appropriateness of referrals

Overall, only 2.7% of all under 18s referrals were classified as inappropriate and were not accepted by the DBI service (Data Table 3.19). Of all the under 18s test of change referrals from schools or CAMHS, 0.8% were reported as ‘inappropriate referrals’ and those tended to be for children and young people aged 13 and under in the school setting (Data Table 3.20). This is consistent with the findings from the interviews with Level 1 referrers from schools and Level 2 staff who outlined difficulties with referrals of children and young people who did not meet the age criteria for DBI. Further discussion of the ability of Level 1 referrers to provide an appropriate Level 1 intervention is in the Level 1 outcomes section.

Changes which have been required in the use of DBI with young people compared with adults

Overall, under 18s received longer interventions and more sessions than adults. Under 18s and adults most commonly received support sessions by telephone, although this was somewhat less for under 18s than for adults. Community settings, categorised within the routine data as face-to-face settings, were more commonly used with under 18s than for adults. This includes settings within schools as well as in the wider community, such as libraries and cafes. Patterns of signposting and initiated contact were similar in adults and under 18s.

Of all under 18s who engaged in Level 2 support with at least one supportive phone call, over half (55.3%) had a DBI Level 2 intervention that lasted between 0-14 days and less than a quarter (22.3%) had a Level 2 intervention which lasted 15-21 days (Data Tables 3.22 and 3.23). In comparison, 61.4% of adults who engaged in Level 2 support with at least one supportive phone call had a Level 2 intervention which lasted 0-14 days and 21.3% received support that lasted 15-21 days (Data Tables 3.24 and 3.25).

The average length of a Level 2 intervention for under 18s who had engaged in Level 2 support with at least one supportive phone call was 16.2 days (Data Table 3.26) whereas the average length for adults who had engaged in Level 2 support with at least one supportive phone call was 14.6 days (Data Table 3.27). This is consistent with the findings from qualitative interviews, as Level 2 staff had shared that they believed young people required support that lasted longer than 14 days and highlighted that greater time and effort was required to build a relationship with a young person compared with an adult. This is more fully described in the children and young people’s outcomes section.

According to the DBI routine data, under 18s who had engaged in at least one supportive phone call at Level 2 received more sessions on average (4.3) than adults who had engaged in at least one supportive phone call (3.9) (Data Tables 4.3 and 3.29 respectively).

DBI support sessions were most commonly delivered over the telephone for both under 18s and over 18s (Data Tables 3.30, 3.31 and 3.32). However, a higher proportion of adults (93.8%) had Level 2 sessions over the telephone compared with all under 18s (74.7%). The second most common setting for under 18s was community setting (16.1%).

Nearly three quarters of all under 18s (72.3%) and adults (74.8%) were reported in the DBI routine data as having used a Distress Management Plan (D-MaP) (Data Tables 3.33 and 3.34).

The DBI routine data included information on whether individuals who accessed DBI were signposted or initiated to other services. Initiated refers to when DBI Level 2 services supported the individual to make initial contact with other services (assisting by making initial contact with an appropriate post-DBI service, on behalf of the person to initiate contact). Signposted refers to the Level 2 staff member telling the individual about a service or providing them with contact details for the individual to contact themselves. Signposting and initiation to other services was broadly similar in under 18s and adults (Data Tables 3.35 to 3.50 inclusive).

Out of all under 18s, around two-thirds (64.3%) were recorded as signposted to non-statutory organisations and over one-third (37.8%) were signposted to statutory organisations.^[6] This is similar to the experiences of adults (64.6% signposted to non-statutory and 35.4% signposted to statutory). Of the under 18s who were recorded as signposted to non-statutory organisations, the most common signposting categories were self-help resources (28.6%), health and wellbeing support services (22.3%), and counselling or meditation services (17.8%). Signposting to self-help resources was more common in under 18s than adults.

For under 18s who were recorded as signposted to statutory organisations, the most common signposting categories were NHS 24 (47.3%), NHS primary care (35.4%) and education/training (5.6%).

Around one-quarter of all under 18s (25.1%) and adults (23.6%) were recorded as supported by DBI Level 2 services to make initial contact with non-statutory organisations^[7]. Of the under 18s who were supported by DBI Level 2 services to make initial contact with non-statutory organisations, the most common categories were self-help resources (50.5%), health and wellbeing support services (12.1%), and other helplines (8.1%).

A smaller percentage of under 18s (9.1%) and adults (12.7%) were supported by DBI Level 2 services to make initial contact with statutory organisations. Of the under 18s who were supported by DBI Level 2 services to make initial contact with statutory organisations, the most common categories were NHS primary care (29.9%), NHS acute care (emergency services in cases of concerns regarding physical health or self-harm) (15.0%), and social work (11.2%).

Outcomes of under 18s elements of DBI for children and young people, Level 1 referrers and Level 2 staff

This section describes the process by which intended outcomes were identified for those who deliver or receive support from the DBI and the development of the Theory of Change for the under 18s elements of DBI. This section subsequently presents data related to each of the intended outcomes and assesses the extent to which these have been achieved for young people, Level 1 referrers, and Level 2 staff members.

Theory of Change

The DBI under 18s Theory of Change (ToC) was developed during the scoping phase of this evaluation over two scoping workshops and one ToC development workshop. The ToC development workshop was held in April 2024 and attended by representatives of DBI Central team, DBI Level 2 staff members, education staff and educational psychologists. At this workshop, attendees discussed inputs, activities and outcomes including the addition of new short- and medium-term outcomes to accurately represent the impact they felt DBI may have for those involved.

The ToC below is split into outcomes which are relevant for:

• Those delivering DBI Level 1 to young people aged under 18 - school staff, CAMHS and referrers from the DBI adult pathway including police, Scottish Ambulance Service, Primary Care, Accident and Emergency, NHS 24 and Psychiatric Liaison Service.
• DBI practitioners delivering DBI Level 2 to young people aged under 18.
• Young people aged under 18 accessing DBI, either through the adult pathway, the CDRS or the test of change.

The outcomes used for the Theory of Change for the adults DBI programme (See Figure 4 in the supporting document) were used as a basis for discussion when developing the DBI under 18s Theory of Change (See Figure 2 in the supporting document). These existing outcomes were assessed for their relevance to the under 18s elements of DBI and modified where appropriate.

Children and young people

This section synthesises data from interviews with young people, DBI Level 1 referrers and Level 2 staff members, strategic stakeholders, DBI routine data and reflections from a parent of a young person who received support from DBI.

Data tables for this section can be found in the accompanying annex tables. Findings are presented underneath each of the ToC short term outcomes for young people, and under some of the medium-term outcomes for which this evaluation can provide evidence.

Theory of Change outcomes for young people

Short term outcomes

• Young people receive a DBI Level 1 intervention that is compassionate and appropriate to their needs
• Young people referred for a DBI Level 2 intervention are given an accessible offer of support, which they take up and engage with the Level 2 provider for up to 14 days including developing a distress management plan
• Young people develop tools and strategies to recognise and manage their distress with the support of their Level 2 staff member

Medium term outcomes

• Young people receiving a DBI Level 2 intervention who require other supports are signposted to services appropriate for their needs
• Young people are able to access appropriate ongoing support if needed
• Young people use the tools and strategies they've developed to manage their distress
• Young people are able to recognise and act on signs of escalating distress
• Young people are able to recognise when they need help, know where to get help and ask for help when they need it

Long term outcomes

• Young people who receive a DBI Level 2 feel less distressed and more able to manage future episodes of distress

Young people receive a DBI Level 1 intervention that is compassionate and appropriate to their needs

The routine data collected from young people at referral and throughout the Level 2 intervention indicates that young people broadly rated their Level 1 intervention as compassionate^[8], with an average rating of 8.6 (0: not at all to 10: completely, range 4 to 10) (Data Table 4.1). The young people gave an average rating of their perceived ability to manage their immediate distress as a result of the Level 1 service's input^[9] of 6.9, (0: not at all to 10: completely, range 0 to 10) (Data Table 4.2). Younger people aged 13 and 14 gave higher average responses than young people aged 15 to 17.

DBI aims to attempt contact with all of those referred within 24 hours, and this was achieved for almost all young people. Around two-thirds of young people were successfully contacted by DBI (Data Tables 3.17 and 3.18). Nearly all of the young people who took part in an interview reported they were successfully contacted by a DBI staff member within 48 hours of their referral being made, with others contacted within a week.

Although the target for DBI is that a contact attempt is made for all referrals within 24 hours, this contact attempt is not always successful. Young people may not be available, be in class or simply not answer the phone. Therefore, it can take up to 48 hours or longer for the young person to be successfully contacted. Most of the young people described their initial contact as positive, brief and focused on topics such as the problems the young person was facing, a description of what the DBI service is and how it would work.

So they’d sent me a text just kind of say, “Hi my name’s [DBI Practitioner] from DBI. Is there any point I can call you just to discuss kind of what we’re doing and get together and that?”. They did it so quickly as well, it was very kind of instant. Sometimes you need to wait like a week or something for things and stuff, I think they’d messaged me within a day, and it was so good. So of course I had my first phone call. It was, yeah, it was kind of just saying like, oh, this is what we’re doing, this is what we’re here to talk about. (Young person)

In the interview with the one parent who took part in the evaluation, they described experiencing administrative errors during referral which delayed the young person receiving their first support session. As this occurred during the holiday period, there was a perception that the delay did not have a detrimental effect on the young person though the parent did share that they would have liked to have been informed on the progress of the referral.

Young people referred for a DBI Level 2 intervention are given an accessible offer of support, which they take up and engage with the Level 2 provider for up to 14 days including developing a distress management plan

This outcome is addressed in three parts. First, we explore whether young people are given an accessible offer of support, then whether they take up and engage with the Level 2 provider for up to 14 days and, finally, whether they develop a distress management plan.

Young people are given an accessible offer of support

Overall, young people most commonly received support sessions by telephone. There was greater use of community (school) and other settings with young people referred through the test of change. The ‘other setting’ refers to sessions that have predominantly taken place via written correspondence, for example through texts between the young person and the Level 2 provider (Data Tables 3.30 and 3.31).

Level 1 referrers and Level 2 staff members spoke about the accessibility of DBI for young people and the ways that accessibility was provided to some extent through choice in mode of delivery and flexibility in the days and times that young people could meet with their Level 2 staff member. Young people also spoke about this in their interviews and this highlighted considerable variation in how DBI was delivered. In some areas, the norm appeared to be for a young person to be seen in school and provided with weekly appointments for an average of four weeks. However, in other areas, young people were not offered in person appointments, and the intervention was delivered solely by telephone calls over a period of two weeks or, on occasion, longer. In one area, one young person who received support via the CDRS pathways spoke of being invited to attend a group work programme that lasted several months.

Some young people spoke positively about their experience of being given a choice about where and how they received DBI. This appears to have supported their engagement.

I think the way they’ve done it is really nice, so they gave me an option whether to go on call or I think the other one was like over video call too… (Young person)

They were like we can either schedule for a phone call or face to face and of course I kind of prefer face to face more, so I just kind of said, “Oh, can we do face to face,” and they were like, “Sure, where do you want to meet? Do you want to meet in school, outside of school, whereabouts?” And I think it’s really nice because it kind of feels like you do have that control, you know? Kind of like you're making that decision for yourself, you're not being told, okay, I’ll meet you here then. (Young person)

The extent to which DBI was perceived to be flexible and accessible differed between Level 1 referrers and Level 2 staff members, and young people. Level 1 referrers from schools and CAMHS highlighted the ways in which they felt that DBI was made accessible to young people, such as the 24-hour response from referral to DBI Level 2, flexibility of scheduling support, the modes of support sessions and the availability of spaces for in-person support.

The 24-hour response to referral was reported by school staff as a facilitator to accessing support; school staff stated that young people and parents reacted positively to the speed of response. Level 1 referrers from schools and CAMHS reported that young people and parents felt reassured and validated that immediate support was available. This was echoed by several young people who reported finding the quick response time very helpful.

Level 1 referrers viewed the flexibility of scheduling Level 2 support positively. They described instances where Level 2 staff members coordinated with the young person to organise suitable times for support. Level 1 school staff highlighted the limitations of capacity among guidance staff within schools to allow time to support young people directly or to coordinate support sessions on behalf of Level 2 staff. Level 1 school staff therefore appreciated the ability of Level 2 staff members to schedule sessions independently from schools, as Level 2 staff would directly coordinate with young people to find a suitable time for support.

It's one-to-one and it's tailored to them, and I think the service are quite flexible with coming into school or doing it virtually. There's quite a lot of wiggle room with them to meet the needs of the young person. (School-based Level 1 referrer)

Next day - got a text message. Pretty much “Would you want to come down for a meeting?” and I came down to a meeting. (Young person)

Level 1 referrers and Level 2 staff members shared that the flexibility of modes of support enabled young people to access DBI. There was a perception that young people had a stronger preference for in-person support. This finding was echoed by young people, most of whom said that they would have preferred face to face support. Additionally, in an interview with a parent, support sessions within the school were viewed positively as a safe space to offer support.

Several of those who received telephone support described the limitations of this approach. Although there were a few young people who spoke about being given a choice as to where, when and how their support sessions took place, this varied by provider and, for many young people, this was decided for them and reflected the way in which the service providers delivered the service e.g., solely in school appointments; solely telephone appointments; a mixture of in-person and telephone appointments.

I feel like that’s one of the downsides to it, I prefer to see people in person, I hate doing stuff over the phone, I just don’t like it but that’s kind of… I don’t know if they do see people in person or whatever, I never had that option… (Young person)

...it’s not ideal. I mean, you know, when you're going through like a crisis and your kind of isolated anyway to kind of be told, yeah, we can kind of help you but it’s going to be over the phone, it’s like, oh, great. (Young person)

Level 1 and 2 staff acknowledged some challenges with providing an accessible offer of support. These included finding appropriate and confidential spaces within schools for young people and Level 2 staff to carry out support sessions and lack of provision during school holidays.

Young people engage with the Level 2 provider for up to 14 days

Overall, 82.1% of all under 18s referred took up an offer of support from DBI and engaged to some extent (Data Table 3.19). This figure includes those who engaged with support through to planned (58.6%) or unplanned closure (9.6%) or took up one supportive phone call (13.9%). Young women were slightly more likely to engage with DBI (83.5%) than young men (79.0%). The proportion of those who could not be contacted by DBI was 14.6% and was slightly higher in young men (16.6%) than in young women (13.5%). Out of all under 18s referrals made through the test of change pathway, 85.7% had engaged in at least one supportive phone call, with females (66.4%) more likely than males (58.3%) to engage with DBI Level 2 through to planned closure (Data Table 3.20). These figures are broadly similar to uptake of DBI referrals for adults (Data Table 3.21).

In the interviews, Level 1 referrers from schools reflected on the reasons for differences in uptake of DBI between girls and boys. Some thought that girls are more likely to seek help with their problems, compared with boys. However, others thought that DBI was well suited to the needs of boys as they were less likely to engage with school counselling and a shorter term and more solution-focused intervention was thought to be more appropriate for them.

School counselling, you often don't get so many of the boys wanting to do it because they can view it as a bit wishy-washy, and they're just not necessarily keen. (School-based Level 1 referrer)

The young people described variation in the frequency of their contact with DBI services. Often this appeared to be driven by the DBI service or Level 2 staff member, rather than the young person. Contact between appointments also varied, with some young people reporting no contact outwith their appointments. When there was contact between appointments, this appears to have been predominantly confined to the DBI Level 2 staff member emailing resources, such as links to coping / distraction techniques, their D-MaP or reminders of appointment times. Only one young person appeared to have been given the option to contact their DBI practitioner if required. Some of the young people reported that this would have been helpful.

DBI Level 1 referrers and Level 2 staff members discussed children and young people’s willingness to engage with support. From the referrer’s perspective, the speed of response to referral contributed to a young person’s willingness to engage with Level 2. They reported that the reassurance of receiving support quickly made young people more willing to engage.

So, I would say the biggest impact that DBI has on the young people is when they find out they're going to have someone who is going to contact them or speak to them in that period of time they are very willing to go with it. (School-based Level 1 referrer)

Other referrers shared that there were only a few cases of young people not engaging with Level 2 and that these were due to their level of distress being too high. They also discussed the reasons why young people may only engage with support for a shorter period of time than 14 days. For example, school staff suggested that young people may feel that they had received enough support from DBI to be able to manage their distress, or may disengage early due to upcoming school holidays, or may have plans that clash with their support. In addition, older students were perceived as being more likely to disengage from support earlier.

There was also a perception that DBI Level 2 staff were too quick to give up on contacting a young person when they do not appear to engage or who might not be comfortable speaking on the phone. School staff described how young people require more persistence and work to allow for them to engage with the support, and suggested additional modes of contact such as text, email and in-school contact. Once school-based Level 1 referrer described their experience of the Level 2 service closing the referral in cases where young people did not respond to contact from DBI Level 2:

That's a shame because a couple of times that's happened… that they've just completely shut it because the child hasn't engaged. It's like, you need to give them a chance. You can't just do it a couple of times. You really need to work on teenagers. It's not like adults, as we were saying. (School-based Level 1 referrer)

The setting in which DBI was provided was viewed as both a barrier and facilitator to engagement. There were Level 2 services which initially offered only phone or virtual support and reported improved engagement when face-to-face support was introduced. This aligned with the views of Level 2 staff members that young people tended to prefer face-to-face as a mode of support.

Level 2 staff members also thought that a young person’s personal circumstances may affect their ability or willingness to engage with support. For example, young people may not be able to engage over the phone because of challenges at home and not having a quiet, private space in which to access support over the phone.

Additionally, the one parent interviewed for this evaluation spoke positively of having support within school as there was a guarantee that the young person would attend school on the days they had committed to having a session with a Level 2 staff member. They also discussed how they felt the young person would not have engaged with support offered by a GP, as this would have been perceived as more serious and they would have been less likely to open up to someone.

Where young people had not engaged with support, Level 2 staff suspected that this was due to a lack of understanding of what support is offered through DBI. For example, one Level 2 staff member gave an example of a young person who had only engaged with DBI after being referred for a second time because they had a better understanding of what DBI was and the support on offer.

There were Level 2 services which had carried out additional work within schools to promote DBI, as well as ensuring practitioners had dedicated days within schools for consistency. Since implementing this work, they noticed an improvement in the level of engagement among young people with Level 2 support.

The data routinely collected by DBI shows that 55.3% of all young people under 18 who took up support received support of up to 14 days (Data Table 3.23). A further 22.3% of all under 18s received between 15 and 21 days of support from DBI, and 10.5% received support for between 22 and 28 days. Almost 12% of young people received support for 29 days or longer.

Young men were slightly more likely to complete DBI within 14 days (58.5%) than young women (53.9%). Young people aged 17 were also more likely to complete DBI within 14 days (60.8%) than those aged 14 to 16 (49.3% to 51.9%). Compared to adults, young people were more likely to receive support beyond 14 days (Data Tables 3.23 and 3.25).

Of all young people who took up Level 2 support, there was an average number of 4.3 sessions, with little variation by age or gender (Data Table 3.28). Around three-quarters (72.3%) of young people who took up support from Level 2 received 0-5 sessions and nearly one quarter (24.6%) received 6-10 sessions. A higher proportion of young people aged 13 to 15 years old (29.6%) had received 6-10 sessions than 16- and 17-year-olds (22.6%) (Data Table 4.5).

Almost all the young people interviewed reported that they would have preferred the DBI intervention to have lasted longer and that its 14-day limit left their contact feeling unfinished.

I would prefer it to be longer, but it was all right, it was good while it lasted but I think it should be a bit longer than just two weeks … of course most people require help for longer than just two weeks. (Young person)

Finishing DBI felt like a bit unfinished… I kind of thought I had a bit more time and that she would work through them more with me and go through those things, and we kind of didn’t. (Young person)

A longer duration could have enabled more time for the young people to share the extent of the challenges they were facing.

I think maybe a bit longer would have been better because it was like only four sessions, it was hard to fit a lot of stuff in. (Young person)

I felt like…like kind of unprepared, when she said it [ i.e. that the following session would be the last DBI session], I felt a bit worried but also because… We hadn’t really spoken about that much it felt kind of like, like a little bit of a waste. (Young person)

This sentiment was echoed by Level 2 providers and is more fully discussed in the Level 2 outcomes section. Level 2 providers found that 14 days was frequently insufficient to deliver DBI to young people and suggested that building rapport with young people took longer than with adults.

Young people develop tools and strategies to recognise and manage their distress with the support of their Level 2 staff member

Young people’s distress reduced during the time they were supported by DBI. When young people were asked about their level of distress at DBI Level 1, the data routinely collected showed an average rating of 7.5 (0: no distress to 10: extreme distress) (Data Table 4.6). The average distress rating at the start of Level 2 for all under 18s was 6.4 (Data Table 4.7), reducing to 3.7 at the end of Level 2 (Data Table 4.8).

Around one third of young people (30.6%) had a reported distress score reduction of 3-4 between Level 1 and the end of Level 2, with a higher proportion of females (33.1%) than males (25.2%) reporting this (Data Tables 4.9, 4.10 and 4.11). Over a quarter of young people (28.0%) had a distress score reduction of 5-6, with a higher proportion of males (34.2%) than females (25.3%) reporting this. The DBI routine data also showed 16.2% of young people had a distress score reduction of 1-2 and 12.4% had a reduction of 7-8. Approximately 10.3% of all young people had either no change or worsening distress reported in the routine data.

When asked about their ability to manage their immediate and future distress at Level 2, the average score for both was 8.3 (Data Tables 4.12 and 4.13). In the DBI routine data collected, young people were asked to rate their ability to meet their own goals at Level 2 on a scale of 0: not at all to 10: completely^[10]. Out of those recorded, the average score was 8.1 (Data Table 4.14).

Some young people shared tangible examples of how DBI had helped them manage their distress, describing the positive impact of the techniques and strategies they developed with their Level 2 staff member on their thoughts and emotions.

I can like express my feelings differently than the way I did. Like the coping mechanisms that we came up with were a lot, like really helped. They really did help. (Young person)

I’ve tried the breathing techniques, and it’s helped a lot because like if I’m ever having an argument with my pals over the phone or whatnot, I just know how to just like to calm down, take a breather… (Young person)

It’s helped me like understand a wee bit how I feel. Yeah, and like I’m… Like I manage to express my feelings a wee bit better when I talk. (Young person)

Level 1 referrers and Level 2 staff members discussed their perceptions of the impact of DBI on children and young people’s ability to recognise and manage their distress. Level 1 referrers in schools reported positive impacts on resilience, confidence, coping skills and help-seeking behaviour. They described instances where young people had been more confident to approach staff for support after receiving support from DBI and of using the coping strategies from DBI to manage their distress. There were some young people who they perceived as receiving support early enough that they did not need further intervention.

School staff shared perceived changes in young people’s presentation, such as improved school attendance and engagement, as well as positive changes in body language. Similarly to Level 1 referrers from schools, Level 2 staff members also perceived an immediate change in the young people they were supporting. They described young people appearing more confident and their perspective changing by the end of the support. Level 2 staff also reported that they received feedback from guidance staff and directly from young people that the support was helpful. Some Level 2 staff members stated that they did not receive a high number of re-referrals from schools, which they assumed was a positive sign of the impact of DBI on managing future distress.

If I'm honest, I think it makes a massive difference, sometimes just to have someone to listen to, because that's a lot of what we do; it's just providing them with a safe space to listen and not to be a mum, dad, carer that, 'You must do this or you must do that.' It's a safe space that they can speak to us and we will listen. I think it makes a huge difference. (Level 2 staff member)

...if you can get in at that age range, before bad habits are developed, and get healthy coping strategies, hopefully then in the future, they're not going to need to access services like this because they're going to know how to manage their feelings and how to manage situations. So yes, it's very positive. (Level 2 staff member)

In an interview with a parent, they described that their child had been engaging with their practitioner since starting to receive support from Level 2 and reported that their child seemed less anxious. However, they did acknowledge that the young person was still receiving support and that it was too early to determine the impact of DBI.

Both Level 1 referrers and Level 2 staff members described variation in the extent to which DBI had made a difference to young people’s distress. School staff perceived that this depended on the individual and the level of their distress, and that they had re-referred young people to DBI Level 2. There were Level 1 referrers from schools who shared that young people with mild distress, such as resulting from academic pressure, were more likely to benefit from a brief intervention than those who were experiencing more severe distress. Level 2 staff described how engagement with and understanding of the tools and resources used by DBI varied depending on the young person’s level of distress and circumstances.

Yes, depending on the person's level of distress and what's going on with them, some people go through, in their time of support, eight to ten tools. We get through loads. They really understand everything. You know when somebody says something to you, and you just click straightaway and go, 'That makes so much sense,' and A, B, and C all fall into place? You can see that happening with others. (Level 2 staff member)

It doesn't work for every young person, but there are some young people that you go round the houses, and you haven't found what works yet, but I have seen it work for quite a few, and even just having that time to offload, to strategize, to regroup, and to go forward again. I have seen a lot of young people respond very well to that. (School-based Level 1 referrer)

Not all Level 1 referrers were able to reflect on the impact of DBI on young people, due to a lack of feedback from young people or, in the case of CAMHS referrers, having no interaction with the young person after making the referral to Level 2.

A core component of the DBI intervention is the co-development of a D-MaP^[11] with the young people to help them develop a means to reduce future distress and a plan to help them cope with future distress when it occurs. Around three-quarters of young people were recorded as having completed a D-MaP, and around half of the young people interviewed knew what the D-MaP was and reported discussing this with their Level 2 DBI practitioner. Others spoke of having discussed coping strategies with their DBI practitioner, which could suggest they were creating a D-MaP. Some, however, reported that they discussed neither future coping strategies nor the D-MaP. There were mixed responses from young people to using a D-MaP and coping strategy elements of DBI. Some reported that they found the D-MaP helpful and one young person had shared it with their family. Others, however, found the focus on action planning and coping strategies to be obstructive, or even patronising.

I’ve had a look at it [D-MaP] so far, I’m going to actually get it printed off because I think it would be quite helpful for me in the future. I’ve not used the resources yet, but I think it would be helpful for me to kind of have handy. (Young person)

And it helps a lot, it was just putting down like all my details, things that helped me, things about me, stuff like that. (Young person)

……Or like they say things like, go a walk, and it’s like- Like I’ll say I had an overdose and all of that and they’ll say like, well a relaxing walk and that doesn’t normally help. (Young person)

Level 2 staff reported variation in how young people responded to the strategies used during DBI interventions. These strategies were often introduced through worksheets, but staff noted that engagement tended to improve when strategies were actively used with young people rather than simply shown to them.

Staff also shared that the strategies helped address multiple issues and often shifted young people’s perspectives on the causes of their distress. In some cases, they observed increased confidence among young people after using techniques aimed at building self-esteem.

Additionally, alternative approaches—such as mood tracking apps and creative tools to encourage self-reflection—were found to be effective in supporting young people who were more reluctant to speak during sessions.

So, we've picked this up and we've understood it as workers and as first responders is that they are not going to tell you they're feeling suicidal. They're not going to tell you that, so what we do is that it's how we convey that information. What we then try is that they need to draw, they need to doodle it, they need to just write one word or bullet points where they can just say, 'Right, see when you've got your next appointment, right? If you don't want to talk about it, don't talk about it. Just show your app. Or show that paper that you've written, or the booklet that we've sent out. Take that with you and give it to them.' (Level 2 staff member)

The parent interviewed for this evaluation discussed how they would try and encourage their child to use the tools and strategies from DBI. Although they found this to be difficult, they shared that the young person was familiar with some of the strategies and would occasionally use them.

Young people generally found the strategies the DBI staff members suggested helpful. Strategies appeared to help most when they were tailored to the individual, with generic strategies being found to be less helpful. While young people seemed to accept that paperwork was part of DBI, they did not like this element and generally had negative views about using worksheets.

…It’s like kind of the typical like try and, erm, just you know take a break every now and then at work and stuff, if you're feeling really stressed. Which I can understand but that whole problem with my work is that we don’t really get breaks necessarily. So, it’s not just like I can go for a quick break, pull my phone out for like 10 minutes and like read through this whole thing. (Young person)

I think the worksheets were good, but I think maybe more time to talk more instead of like doing the writing. Like, I don’t know, I just think maybe talking a bit more would have been a bit better for me. (Young person)

Young people are able to access appropriate ongoing support if needed

DBI Level 1 referrers and Level 2 staff members discussed the process of accessing ongoing support after a young person has finished a Level 2 intervention. It was common for Level 1 referrers in schools to share support options available through schools, such as counselling services, self-help resources and youth support programmes and interventions.

In addition to school staff receiving training to support young people with their mental health, they also reported signposting young people to external services and resources. This included CAMHS, social work and third sector organisations that offer mental health support. CAMHS referrers also discussed support options outside of DBI, such as specific types of support offered through CAMHS such as Family Therapy teams and eating disorder pathway, and GPs. They described how CAMHS would also signpost young people to community agencies and self-help information.

Level 2 staff described their how process of helping young people nearing the end of their support from DBI was substantively different to the one used in the adult service, due to the greater involvement of staff as well as other professionals.

Level 2 staff members described preparing young people for their support ending. This included building resilience through developing resources and strategies to support them to manage future periods of distress, promoting help-seeking behaviour and identifying appropriate services to signpost to if needed.

There was also a sense from Level 2 staff members that schools could provide an ongoing support structure for young people while they implemented the tools and techniques that they had developed, reducing the need for follow-on support.

I think when we think about next steps for people who are 18 and over, there generally might be another service or a resource or what have you. With our young people, I think it is much more about working in partnership with the school staff and maybe us giving a little bit of support to the young person to say what they maybe need from the school, and then helping actions to happen around that. So it's a little bit of a different feeling, I think, when it comes to maybe signposting or next steps. (Level 2 staff member)

Along with self-management, Level 2 staff members have also coordinated with schools to put young people on waiting lists for school counselling whilst receiving support from DBI. However, from the interviews with young people, it was clear that school counselling was not always their preference. There were also cases where Level 2 staff members were working alongside CAMHS staff or with parents if the young person had provided consent.

Level 1 referrers and Level 2 staff members highlighted challenges with ensuring young people accessed follow-on support. It was common to raise waiting lists as a barrier to accessing support from other services, including school counselling and CAMHS.

A key gap in support for young people are services that offer immediate and regular support. School staff described their reluctance to refer to CAMHS due to long waiting times for support. There was also a view that the prospect of long waiting times can negatively impact on parents’ trust or faith in the school’s ability to support their child.

In a very ideal world, we wouldn't have any waiting lists at all, but unfortunately, we do, and sometimes it can be a two or three-week wait before the youth counselling. (School-based Level 1 referrer)

…sometimes what you find is the parent - there's almost that kind of they can lose a bit of trust in you because they've come to disclose something, but you haven't managed to get them something in a quick enough timescale as well. (School-based Level 1 referrer)

There were perceived barriers for young people accessing follow-on support. Lack of funding for services offering support to children and young people was highlighted as a barrier. There were Level 1 referrers in schools who noted how they had lost support options over the last few years, thus increasing the workload of staff. Similarly, Level 2 staff acknowledged a lack of or limited funding as hindering young people being able to access appropriate support. There was a view that young people in the older age range were too late to be referred to CAMHS due to the waiting list.

Level 2 staff members highlighted differences in signposting options between schools and Level 2 providers, suggesting that Level 2 providers may be more aware of what support is available at a community level than guidance teachers. They described using a whole person approach, which involved connecting young people to other activities that could involve socialising and exercise.

Whilst there were Level 2 staff who described having an extensive list of services for signposting, there were perceived gaps in the type of support available to young people. This included free counselling services, housing support, third sector social and peer support, life skills, budgeting and mentoring programmes.

It's the one thing that comes up majority of the time is, 'Is there counselling?' It's not something that we can signpost to because we don't signpost to services that cost money. We're not going to signpost somebody to somewhere where they have to pay for something, because a lot of people are not in the position to be able to do that. Free counselling services are few and far between. (Level 2 staff member)

Overall, the young people described a lack of follow-on support following their DBI contact, echoing the lack of resources for this population highlighted by the DBI Level 2 staff members . Only one young person reported their Level 2 staff member making a referral on their behalf.

Around half of the young people interviewed said they had been signposted on to other agencies, with school counselling being most common. However, many young people reported they would not use school counselling, either as they previously found it unhelpful or they had a friend who had reported negatively on their experience.

Some of the young people felt they would benefit from longer term support but were yet to contact the services that had been suggested to them, as they would need to do this themselves. Others shared they had needed to re-visit their GP and felt it was back to the drawing board in terms of trying to find appropriate help.

Many young people remained on the waiting lists for specialist services such as CAMHS, but they had been referred to these prior to DBI, or referrals were made to school counselling or other mental health services at the same time they were referred to DBI. In most cases the young people had been given a list of standard resources including helplines or digital applications, that most reported being unlikely to use.

I think I’d use like the helplines but a lot of the time when I have- When I do get upset I think to myself like, what are you doing, this is so cringy and then I stop and then- So I feel like, and if I was to message like a chatroom I’d just like really cringe myself out. (Young person)

… of course, they’re very helpful for some people but it’s never really my first thought. I get really like- I think it’s weird to say it like sometimes when I thought about things I get like really bad social anxiety, so the thought of having to phone somebody that I’ve never met, call somebody that I have kind of no prior [contact with]. (Young person)

In contrast to most of the young people, one young person spoke of feeling exceptionally supported by their Level 2 staff member who took time to identify appropriate follow-on support and resources that would be helpful for them.

Me and the lady had talked a lot and I was saying I struggled with suicidal tendencies and she had- And I said my experiences with helplines weren’t great, and I listed some helplines that a lot of times I’d called and they never picked up or I was waiting for like an hour or so…Yeah, it was crazy, and she had given me some numbers which aren’t those obviously, the ones she had recommended, and I got a really good helpline out of it that I like to go to frequently. (Young person)

Additional outcomes

Unintended outcomes are those which were not identified as intended outcomes of DBI during the development of the Theory of Change for the under 18s elements of DBI. This includes positive as well as negative outcomes. An additional unintended outcome which was identified for some of the young people interviewed was that they felt listened to and validated by their Level 2 staff member.

Most young people reported their Level 2 staff member was easy to talk to and was understanding. Some young people reported that their Level 2 staff member had developed a very positive relationship with them, which helped their sense of validation.

We’d go from like a good topic and then somehow get carried away to other topics, and I just never shut up…Very understanding. She really listened, she paid attention to little things I said, big things I said, anything. (Young person)

…they were super understanding (Young person)

[they have] been absolutely amazing. It’s been helpful so much, honestly. I think like it’s so strange because I like, I technically class her as my friend. I don’t want to class her as a worker; I want to class her as more of a friend because it’s someone who I talk to more… (Young person)

For many of the young people interviewed, the best aspect of DBI was having someone to talk to and feeling listened to.

Just that I did finally have someone to even talk about like little things, it was just better to be able to say them out loud instead of keeping them to myself. (Young person)

The best thing about DBI is that I can freely speak to them without any judgement, and it’s very supportive. I can just end up telling them anything that’s going on, or if I feel like this has happened and what- It’s just generally very supportive. (Young person)

Similarly, Level 2 staff highlighted the value of young people having someone to speak to that is not a parent or school staff member. They discussed building rapport and trust with young people and providing a safe space to share sensitive information. Direct feedback from young people receiving support also demonstrated that they felt listened to and in control.

This positive relational approach supported the young person’s engagement with DBI, and their experience overall. However, not all young people experienced this additional outcome of DBI. Where the Level 2 staff member was not perceived as being compassionate or interested in the young person, young people reported feeling that their worker was ‘going through the motions’ or didn’t appear to know what to say to them. This was particularly the case in instances when young people disclosed suicidality or experience of sexual abuse.

…we get along. I get along with [Level 2 staff member], she’s quite nice but I do think that like…Like I’m not like an afterthought I think I am just someone she has to phone. (Young person)

I say they [Level 2 staff member] know what they’re doing, I actually don’t think they know what they’re doing and like that’s the problem. (Young person)

Level 1

In this section, we draw on data from interviews with Level 1 referrers in the test of change (teachers and CAMHS staff) to explore the experience of provision of DBI and the benefits and unintended consequences for Level 1 referrers. Findings are presented underneath each of the ToC outcomes for Level 1 referrers.

Theory of Change outcomes for Level 1 referrers

Short term outcomes

• Frontline staff have the skills, competencies and confidence to deliver a DBI Level 1 intervention
• Frontline staff can identify young people for whom a referral to DBI would be appropriate
• Frontline staff working in A&E, the police, ambulance services, primary care, social work, schools or CAMHS, or other first responders, deliver a DBI Level 1 intervention that is compassionate and appropriate to the needs of those they are referring

Medium term outcomes

• Frontline staff receive feedback from Level 2 on their referrals, which increases their confidence in DBI and in delivering a DBI Level 1 intervention

Frontline staff have the skills, competencies and confidence to deliver a DBI Level 1 intervention

As part of ensuring staff have the skills, competencies and confidence to deliver a DBI Level 1 intervention, referrers in schools underwent mandatory training on how to deliver a DBI Level 1 intervention. Further details of the training received by Level 1 referrers are given in the development section.

The training was effective in supporting Level 1 referrers in developing staff confidence. The buzz sessions and refresher sessions delivered by Level 2 staff in particular were reported as giving Level 1 referrers the opportunity to refresh their knowledge and question the Level 2 providers directly. Those who did not receive refresher training suggested that having these sessions could raise the profile of DBI among staff who make fewer referrals.

Another improvement to training suggested by referrers was to include examples of resources used in DBI Level 2 to support children and young people as this could improve their understanding of the intervention.

Level 1 referrers also discussed their confidence in making referrals. They described having a good understanding of the service and the circumstances in which referring to DBI would be appropriate. School staff in more senior roles, involving supervision of other staff making referrals, shared that they felt more confident in their staff’s ability to make appropriate DBI referrals. As a result of seeing an improvement in the referrals, they trusted their team to make direct referrals to the DBI Level 2 service.

Some school staff raised issues regarding staff turnover having an impact on the ability to make referrals. There were cases of staff who underwent the initial training and were no longer working within schools. Additionally, staff who missed the initial training also lacked confidence to make referrals. Other barriers included a lack of buy-in from school staff and guidance teachers lacking the capacity and time to refer young people.

Frontline staff can identify young people for whom a referral to DBI would be appropriate

Level 1 referrers generally reported feeling confident in their ability to make appropriate referrals to DBI Level 2. They cited their relationship with Level 2 providers and the individual Level 2 staff members working within them and feedback on referrals, as well as rarely having referrals declined, as contributing to this.

School staff reflected on some challenges with making appropriate referrals, particularly in relation to age, during the initial stages of the test of change. However, facilitators to making appropriate referrals included having buzz sessions with Level 2 services. Since addressing this lack of understanding of the age criteria, appropriate referrals had improved. Despite this, some Level 1 referrers described challenges when they identified a young person in distress who was ineligible to receive support from DBI due to not being old enough.

I think it's technically 14, because that is one of my concerns. I'm quite often presented with a young person who I would like to refer. In fact, the other day I actually started talking about DBI to somebody and realised that they weren't old enough. Which really concerns me, because one of the other things that's difficult in my job is that by the time I have a young person presenting with distress in my room, the cause of that distress has been ongoing. (School-based Level 1 referrer)

School staff also discussed the flexibility of the referral criteria as contributing to making appropriate referrals. Some referrers stated that they had not yet encountered a scenario in which DBI would not play a helpful role. Others shared using their own judgement on whether an intervention is needed for the young person.

I don't think there's ever - there is very rarely a scenario that I don't think DBI would be helpful. (School-based Level 1 referrer)

I do have to say that whilst that is on my mind from time to time that I could refer more, I'm also going through the thought process of how immediate that intervention, is it needed and warranted? There is a criteria of what I think, well, this young person is maybe not at as significant a risk of risk-taking behaviour as perhaps - I always make a judgement on that, and it hasn't gone wrong so far. (School-based Level 1 referrer)

Frontline staff working in A&E, the police, ambulance services, primary care, social work, schools or CAMHS, or other first responders, deliver a DBI Level 1 intervention that is compassionate and appropriate to the needs of those they are referring

In interviews, Level 1 referrers were asked about their approach to delivering a Level 1 intervention. They demonstrated compassion through adopting a non-judgemental approach and validating a young person’s feelings, ensuring they felt heard. There were school staff who highlighted that a compassionate response could look different depending on the needs of the young person. Being patient, allowing sufficient time and a safe space for the young person, and responding quickly so they have someone to turn to were also discussed as an integral part of their compassionate approach to delivering a Level 1 intervention. Both CAMHS and school staff highlighted the importance of building a trusting relationship as part of offering a compassionate response to young people.

I think it's just having that calm, unfazed, subjective demeanour and trying to just connect with them as a person and just let them speak, let them voice what's going on. Don't interrupt. Don't judge. Don't try to go in too early with a support or a comment. Just let them vent and then show that understanding with the body language and the soft use of language that - yes, just to let them know they're being heard and that somebody's going to try to help. (School-based Level 1 referrer)

Frontline staff receive feedback from Level 2 on their referrals, which increases their confidence in DBI and in delivering a DBI Level 1 intervention

Level 1 referrers from schools and CAMHS highlighted the value of receiving feedback on referrals from DBI Level 2 staff. School and CAMHS staff discussed the benefits of having a good relationship with the Level 2 provider. Communication from DBI Level 2 staff was reported as being prompt and helpful when addressing issues or questions regarding referrals. Additionally, there were school staff who described being well informed by Level 2 staff of any changes to the referral process or the service.

…the people that do work with DBI, they're very, very approachable, they're very honest. They do exactly what they say they're going to do. I think the referral process is discussed regularly at meetings. If there's any changes to the service, it's emailed, it's communicated. If there's any new people, or if anybody's leaving, it's not a surprise, it's not a shock. It's, 'This will be the new person'. (School-based Level 1 referrer)

DBI Level 2 staff were viewed as approachable, with both CAMHS and school staff knowing they can contact the service with any questions. School staff also shared having a reciprocal relationship regarding communication, with DBI Level 2 staff giving feedback on the referrals made and school staff reportedly feeling comfortable to reach out with any queries.

…I would say it's strong enough that they can come back and tell us if we had done something wrong in a referral or they needed more information or if something was missed out. Likewise, I would be comfortable enough just to ping an email over and ask them for a bit of guidance on something. (School-based Level 1 referrer)

While not all referrers reported receiving feedback from Level 2 about the appropriateness of their referrals, those who did said it improved their confidence and helped inform future decisions about referring young people to DBI.

So actually it’s really nice to get a bit of feedback of yeah that was an appropriate referral, that young person worked well or actually they only attended one session, then they felt they couldn’t commit to the other 2 follow ups because there was still a degree of overwhelm or something else happening that they kind of didn’t manage it. So it’s useful because I think it tunes you in as a referrer as well to when you’re with a young person thinking okay that might work well or that might not work well based on the sort of feedback that I’m kind of getting from the DBI Service. (CAMHS Level 1 referrer)

Impacts for DBI Level 1 referrers

Both school and CAMHS staff commonly highlighted the positive impact of having DBI as a referral option. They expressed appreciation for the support it provided, both in easing the burden of their roles and offering reassurance that young people in distress had a clear pathway to help. School staff described how DBI had, to an extent, reduced their workload. By having DBI support, staff felt reassured that the young person was supported when their own time is limited.

It can sometimes reduce our workload because the plan that's been put in place and support that's been put in place has negated what the issue was for that young person; therefore, we don't then have to do our check-ins, and we don't need to then go and phone parents. We don't then need to do a referral to such and such because the DBI service has managed to plug that gap. (School-based Level 1 referrer)

Having the ability to refer to DBI had also given staff “peace of mind”. Participants described feeling comforted knowing that the young person was receiving immediate and available support rather than signposting to a service with limited availability. The limitations of their own role and the extent to which they can support a young person can impact on school staff’s own wellbeing. Referring to DBI as a source of support beyond themselves and their role within schools had a positive impact on staff.

To be honest, the main benefit from my point of view is my peace of mind that I've actually signposted to something that's really there, rather than signposted to some distant goal in the future, or somebody that will be too busy and lacks capacity. The fact that I can signpost to somebody that will give the child a call the next day is really valuable for me and my own ability to do my job and my own peace of mind, to be honest. (School-based Level 1 referrer)

Similarly, CAMHS staff shared that clinicians appreciated having DBI as a referral option. In cases where the young person was not appropriate for a referral to CAMHS, clinicians were aware and reassured that the young person was still receiving support for their distress. Another positive aspect highlighted by CAMHS staff was that DBI had also helped to avoid inappropriate referrals into CAMHS due to a lack of other options.

In terms of wider impacts of DBI, Level 1 referrers in schools discussed the impact of having DBI as a referral option within their schools. They described DBI as aligning with their school’s values and found that it had become an additional part of the wider support on offer. There was also a view that DBI resources could be embedded within their school’s personal and social education (PSE) to increase awareness among pupils.

The 24-hour response to DBI referral was also viewed positively. School staff highlighted that because they do not have to place children and young people on waiting lists, it improves the school’s relationships with parents and pupils.

They come to us and we're saying you have to wait [for support]. It breaks down that whole relationship in school for years to come, where this [DBI] keeps it. This really does help it. (School-based Level 1 referrer)

Despite these instances of DBI having a wider impact on schools, other Level 1 referrers felt it was too early to see impact beyond the young person receiving support. CAMHS referrers commented on how they could not report on whether DBI was preventing young people from re-presenting to A&E given the difficulty of accessing this information. There was also a view expressed that the impact of DBI and other mental health support on the mental health and wellbeing of young people was limited due to the impact of COVID.

It's across Scotland. It's not just our school. The mental health impact of that [COVID] has really, really, it shows. So we need as much help as we possibly can, I think. We've put in health and well-being groups, and we look at all the data and we put in place things that we think will help, but we're only marginally seeing a difference there year on year, no matter what we're putting in place. (School-based Level 1 referrer)

Level 2

In this section, we discuss data from interviews and focus groups with Level 2 providers and strategic stakeholders to address the research questions relating to whether those involved feel empowered to provide a compassionate and constructive response to young people seeking support, and the outcomes for Level 2 providers of delivering DBI. Findings are presented underneath each of the ToC outcomes for Level 2 staff members.

Theory of Change outcomes for Level 2 providers

Short term outcomes

• DBI Level 2 Level 2 staff members have the skills, competencies and confidence to deliver a level 2 intervention
• DBI Level 2 services have sufficient numbers of trained and supervised Level 2 staff members to respond to referrals
• DBI Level 2 staff members engage with the young person referred and offer accessible support for up to 14 days including developing a distress management plan

Medium term outcomes

• Delivering DBI to under 18s builds capacity in Level 2 services, and Level 2 staff members increase their confidence in supporting young people

DBI Level 2 staff members have the skills, competencies and confidence to deliver a level 2 intervention

In focus groups, Level 2 staff members discussed their experiences of delivering DBI. Similarly to Level 1 referrers, Level 2 staff members generally viewed the training as having increased their confidence and skills, particularly for those staff with no experience of working with a younger age group. Further details on the training provided to Level 2 are included in the section on the development of the under 18s elements of DBI.

Although there was initial uncertainty regarding supporting young people, the training gave Level 2 staff members reassurance that they were not being asked to do things differently, while informing them of the considerations needed when supporting young people. As part of building the skills to support young people, Level 2 staff members discussed how there was coaching, mentoring, supervising and shadowing involved.

Level 2 staff members highlighted a range of ways in which they developed their confidence to deliver a Level 2 intervention, with this building over time as they gained more experience. Those with less experience of working with young people shared how they used reflective practice, self-care techniques, and sought guidance from more experienced colleagues to build their confidence. Feedback from young people who were interviewed indicates that, in some instances, DBI Level 2 staff members lacked knowledge and confidence in response to disclosures of suicidality and sexual abuse, suggesting that these topics could be further explored in training.

Level 2 staff members also described the skills required to support children and young people. These included traits that were also applicable to adult support, such as demonstrating compassion by being empathetic, validating feelings, and having the ability to build rapport with the service user. Establish relationships with young people was also viewed as important, though Level 2 staff members added that it takes more time to build rapport and deliver the intervention with young people compared with adults.

With the adults you can basically just go in, they’re looking for the help, they’re really crying out for it, you can go straight in with it, right this is what we’re going to do, this is what I need you to do and are very much able to self-help and self-refer and things like that. Whereas a young person you’re working alongside them and you’re having to step a wee bit more gently with that especially with young people who have different needs and perhaps different neurodiversities and things like that going on. So it’s a bit more tricky. (Level 2 staff member)

That Level 2 staff members delivered a compassionate response to young people is supported by the DBI routine data, which shows that, when asked whether they received a compassionate response from their Level 2 staff member^[12], young people gave a very high average response of 9.5 (0: not at all to 10: completely, range 0 to 10) ( Data Tables 4.3 and 4.3).

Another consideration was the importance of establishing boundaries with the young person. There were Level 2 staff members who emphasised self-management as a key aim of the support and would explore barriers to this with the young person. In cases where additional support was needed, Level 2 staff members would encourage them to speak to their GP, parents, guidance staff and signpost to relevant services.

DBI Level 2 services have sufficient numbers of trained and supervised DBI Level 2 staff members to respond to referrals

Evidence from the DBI routine data that a contact attempt was made within 24 hours for almost all referrals suggested that services are sufficiently staffed to respond to referrals. Level 2 staff members did not highlight issues with capacity within the service to responding to referrals. There was also no mention of waiting lists for young people to receive support from DBI Level 2.

Level 2 staff suggested increasing the frequency of training sessions to ensure all relevant staff are equipped to deliver the under-18s element of DBI, noting that new staff sometimes had to wait for the next available session.

DBI Level 2 staff members engage with the young person referred and offer accessible support for up to 14 days including developing a distress management plan

DBI Level 2 staff highlighted the importance of ensuring support is accessible to the young person. They discussed using age-appropriate D-MaPs and identifying appropriate services for signposting. It was also common for Level 2 staff members to share their experiences of offering different modes of support to young people. While Level 2 staff members reported offering different options to young people to allow for greater flexibility to schedule sessions, there was a perception among Level 2 staff that young people preferred to receive in-person support, which often took place within schools. This involved coordinating with schools to book a suitable time and space to deliver the intervention.

So it’s entirely dependent on where the person is just now and what they want to do. Quite a lot of the young people feel comfortable doing it in the school because it’s familiar environments for them. So that’s what we’ll do we’ll curtail it to 50 minutes and that’s within their school period so we’re not interfering with their schoolwork either. (Level 2 staff member)

Level 2 staff members also highlighted their appreciation for schools and school staff and how they accommodate sessions for young people. Some services were working towards establishing set days within schools so Level 2 staff members can guarantee support on specific days. Other services reported already having Level 2 staff members who were more established within schools and had set days to offer support.

On the other side, I've not got set days yet. It is the plan moving forward, but at the moment, I'm just in and out as and when I have appointments with young people. If I'm not due to be in the school in a morning, I'm meant to be in the office or wherever, and a young person asks for an appointment, generally, just very flexible; we'll make it work, and I'll head over to see them. (Level 2 staff member)

The schools will go out of their way to make sure you’ve got a room, there’s never been an incidence where we haven’t been able to carry out support because there was nowhere for us to go. We’ve always managed to get a suitable room to deliver the DBI so that’s good. (Level 2 staff member)

Some Level 2 staff identified limited access to schools as a barrier to delivering DBI support. In certain cases, schools only offered a single day per week for sessions, which meant support sometimes had to be delayed until the following week.

I've found it kindae limiting because say a referral comes in on the Wednesday: then you're waiting until the Tuesday to go back to that school rather than...I just think it's a wee bit more difficult to do it on their time rather than when we have a space to make that work. (Level 2 staff member)

The availability of suitable spaces also varied by school, with private rooms particularly difficult to secure during exam periods. Additionally, there were challenges with finding appropriate spaces outwith schools, and Level 2 staff members reported having to be resourceful in finding suitable places in the local community.

Level 2 staff members raised a concern that 14 days was an insufficient amount of time to deliver a Level 2 intervention to children and young people. They would often extend support beyond 14 days and reported that their service was flexible to accommodate this extension. Despite this, there were Level 2 staff members who felt that support over 14 days should be an established part of the process to negate the need for extensions. As previously discussed, Level 2 staff members also reflected on the longer length of time it takes to build rapport and a trusting relationship with the young person in comparison with adults.

Level 2 staff members cited a wide range of tools and coping strategies, including a D-MaP, as part of delivering a Level 2 intervention. They often discussed using a person-centred approach that was tailored to the needs and ability of the young person and using their judgement and expertise, whether that involved listening and being compassionate or using more practical tools, to support a young person in distress. Level 2 staff members reported using grounding techniques, and self-esteem and confidence building tools as part of the DBI toolkit. In addition to these tools, they also used alternative strategies from their own organisations that were viewed as effective with young people, such as self-soothe boxes containing items young people can use to manage their own distress.

It's not just the tools, the DBI, because the team has built in a massive resource, different kinds of resources for children and young people as well. So, that's at a central point in teams for everybody to access as well, so everybody kindae shares. (Level 2 staff member)

There was also discussion of adapting D-MaPs to ensure they were age appropriate. This included signposting to appropriate services for children and young people. There was some variation in how a D-MaP was used, such as using the tool verbally rather than as a written document. There was also a perception that different young people respond to a D-MaP in different ways, which can affect the ability to build rapport. Variation in young people’s responses to a D-MaP was seen as applicable to any age group, but Level 2 staff members perceived young people as more likely engage less fully with the development of a D-MaP than adults. In these cases, Level 2 staff members described using distress management planning as an approach rather than filling in a form.

I think some people, if you pull out a tool, you've got your computer, you're taking notes, or there's paperwork, or anything like that, it can be really off-putting…It almost affects the working relationship and rapport building and things like that. So being able to do that in a way that helps someone continue to engage with us, same with the evaluation and questions, the questionnaire that we do that contributes to the data collection and all of that, it's very important people have the opportunity to engage with it, but we see a lot of people not wanting to. That's the last thing they want at that moment of our support. More so I think with young people. (Level 2 staff member)

Unintended consequences for DBI Level 2 referrers

In interviews, DBI Level 2 staff members discussed the impact that delivering a Level 2 intervention had on them. This was discussed in terms of actions taken to look after their own mental wellbeing when supporting young people in distress. They described using reflective practice in group settings and one-to-one sessions with supervisors, daily debriefs and using self-care tools.

Level 2 staff members highlighted the rewarding aspect of supporting young people. They described enjoying working with young people and the value it brings to their role by being able to support them.

Not that the adult pathway is not rewarding, but I think presented with the same kind of issue with an adult and a young person, they're definitely feeling more of an emotional impact when the young persons come forward, if that makes sense. (Level 2 staff member)

Considerations for future development

This section brings together insights from interviews with young people and stakeholders, the final reflections workshop, and the young people engagement session. It explores participants’ views on potential improvements to the under-18s elements of DBI, as well as ideas for future development.

Improvements to delivery

Level 1 referrers, Level 2 staff members and strategic stakeholders discussed a number of improvements that could be made to DBI for under 18s, such as introduction of additional methods of contacting young people, extending the length of DBI for under 18s, more consistent feedback on young people’s engagement and DBI practitioners based in schools for better integration and flexibility.

Young people suggested improvements to the preferred face-to-face support and highlighted the need for less focus on paperwork and more on relational elements. They would also have liked to be able to contact practitioners informally between sessions.

School staff who referred young people to Level 2 suggested that engagement with DBI could be improved by making multiple contact attempts using different methods. They recommended greater flexibility in how initial contact is made—whether by phone, email, text, or in person at school—as some young people feel uncomfortable speaking on the phone.

One member of school staff expressed discomfort at recording and holding a young person’s mobile phone number to pass on to DBI via the referral form and suggested that DBI could contact the young person by email to obtain their phone number. It was also suggested that a free-text field could be made available on the referral form for the referrer to confidentially share useful information about the young person’s circumstances with Level 2 providers.

I was really shocked at how little it [number of attempts to contact young person by phone] was! More of that, and going back to maybe the parents again and saying, look, I've tried to phone, is there a better time? Shall we do it face-to-face? Just give other options. She would have engaged if they'd come into school as well, but she'd obviously, at that moment in time said “oh, I'll have the phone calls” but… [she had] Forgotten about that! (School-based Level 1 referrer)

Stakeholders also suggested improvements to how DBI is delivered, the most common of which was to increase the length of support available to young people. While Level 2 staff members acknowledged the flexibility they had to extend support where needed, the 14 days of support on which the DBI model is based was, in many cases, seen as insufficient to meet young people’s needs, particularly given the view that it takes longer to build rapport and a trusting relationship with a young person compared to an adult. Initial support periods of 28 days or 4-6 weeks were suggested as alternatives.

The interviews with young people also suggested that young people would value an increase in the length of support they are offered through DBI, with most reporting that the contact was too brief and that, at the end of the 14 days, they were just getting to know their DBI Level 2 staff member. However, it was acknowledged by Level 2 staff members and strategic stakeholders that DBI is fundamentally a short-term intervention and providing longer term support to young people may compromise the fidelity of the DBI model. Furthermore, extending the length of support would have implications for workload planning and staff resourcing in Level 2 services.

The demands and emotional impact on Level 2 staff members of working with young people in distress was recognised and any increase in the length of support would need to be properly resourced with consideration given to the implications of possible oversubscription to the service, staff burn out, recruitment and retention.

Another suggestion made by Level 1 referrers was to maintain the length of the intervention but that it could be beneficial to include a check-in call between the Level 2 staff member and the young person 2-3 months following the end of DBI to discuss the tools and strategies the young person has been using.

I think that could be helpful because, for a lot of young people, having that adult that's invested in them, to be able to say, 'Right, that was good, how are you doing?' and they can say, 'Well, I've been using this strategy, and I've been doing this; I've been feeling overwhelmed by this, but this is how I've coped with that,' will be a success to celebrate. I think that would be almost like a little bit of an incentive for the kids to want to keep that up would be my only kind of thing. Again, it's good that it's short term, but it does end quite abruptly and there's not any follow up. (School-based Level 1 referrer)

There was also a desire on the part of Level 1 referrers in schools for more consistent feedback on the young person’s engagement with DBI. In particular, providing more information about the tools and strategies that had been developed with the young person would allow the young person’s guidance teacher, following the end of support from DBI, to continue to use these.

I don't need to know blow by blow. I just need to know, right, what can I do to help that or continue that so that they don't end up - so that they can stay on an even keel instead of dipping again? (School-based Level 1 referrer)

School staff suggested that communication could be improved by Level 2 staff members being based in schools for one or two days per week. This would increase the amount of face-to-face contact between Level 2 staff members and young people and allow young people to attend sessions at different times each week to prevent them from consistently missing the same lesson. It would also improve familiarity between Level 2 staff members and school staff.

It would be quite nice to have a designated people that I would know, you know, [name of Level 2 staff member]’s looking after our kids. Then we get to know them, and they can come into the school. Whereas I honestly don't know any of them. Their names mean absolutely nothing, and I haven't even clapped eyes on any of them, so it'd be quite nice to maybe meet some of them or have, as I say, a designated [Level 2 provider] for the area or something. That would be quite nice. (School-based Level 1 referrer)

Choice in how they engaged with DBI was crucial for young people. Several of the young people interviewed wanted increased face to face, rather than telephone support. Some wanted there to be greater flexibility in where they received in-person support, with school not necessarily providing the most suitable location for all.

So that’s what- I feel like that’s one of the downsides to it, I prefer to see people in person, I hate doing stuff over the phone, I just don’t like it but that’s kind of- I don’t know if they do see people in person or whatever, I never had that option….I don’t like- I don’t mind talking to people about stuff like that but I prefer to do it in person because I feel like you can’t, like not build a relationship but like I feel like it is easier to like trust someone and talk to someone when you see them in person, than over the phone. (Young person)

There was also a suggestion that the way that DBI engages with under-served groups - that is groups which experience disproportionately poorer health outcomes and less access to healthcare services compared to the general population - could be improved. Examples include care-experienced young people, young people experiencing poverty or homelessness, migrants and refugees, and those from certain ethnic or cultural minority groups.

The extent to which young people from under-served groups can be identified from the data collected by is limited. Care-experienced young people were highlighted as a particular example of a group which could benefit from support from DBI, though there was no field to record this information in the routine data captured by DBI.

We don’t have a field to record that [whether a young person is care-experienced] although there is some free text that indicates that we are doing that but anecdotally they [existing Level 2 providers] tell us that to an extent DBI would be appropriate for those young people who may have much more complex needs is certainly worthy of conversation… reflection… that’s something we need to think about. (Strategic stakeholder)

From the perspective of the strategic stakeholders, Level 2 staff members do not seem to routinely engage with parents. However, it was suggested that engaging parents in Level 2 support could be of benefit, as parents may be able to support their children with longer-term use of the tools and strategies that they develop during DBI.

Most of the young people interviewed felt that less focus should be placed on the use of standardised worksheets or other paperwork as this detracted from the relational element, which appeared to be the aspect they most highly valued.

Increased frequency and number of sessions (and duration of intervention) were also requested by several of the young people who reported valuing the check-in contact between formal sessions to see how they were getting on. Young people suggested that it would have been helpful to be able to contact their Level 2 staff member informally between sessions if they needed support and for this contact to be based on a conversation rather than the Level 2 staff member sharing paperwork or links to coping strategies.

…talk the person through the distress plan right at the start, and then only go through it at the end would have been a bit more… It wouldn’t have gotten in the way as much. (Young person)

Like maybe have smaller check-ins over the week with a message or something, because as I said they phoned me on like a private number. So, I couldn’t like, if I was in distress I couldn’t like phone them in a panic or anything, so like a message over the week would probably be nice along with the phone call. (Young person)

The final suggested improvement to the delivery of DBI was regarding onward referral and follow-on support. The lack of these options available to DBI Level 2 staff members was highlighted and both Level 2 staff members and Level 1 referrers would like to have access to a wider range of specialised services for young people. Young people also reported a lack of onward referral and follow-on support. They generally did not view telephone helplines and apps as sufficient, and it appeared most would be unlikely to access these resources. Independent counselling and talking therapy for young people were identified as particular gaps by Level 2 providers, though school counselling was not reported favourably by the young people and appeared unlikely to be taken up if offered.

Moving beyond improvements regarding delivery of DBI to those at a programme level, stakeholders would like to see longer term funding and greater sustainability of the test of change. It was acknowledged that even a small-scale roll out would increase demand on services and that this must be appropriately funded.

Stakeholders also spoke about the need for long term evaluation to be built into the future of the under 18s elements of DBI. Those working in schools discussed their reporting requirements to Local Authorities and the pressure to collect data on the impact of interventions.

Developments to the DBI programme

There were two key avenues for the future development of the under 18s elements of DBI which were suggested by stakeholders: expanding the age range for the test of change to include to S1 and S2 and introducing additional referral routes into the test of change.

There were mixed opinions expressed on the rationale for, and practicality of, extending DBI support to S1 and S2 within the test of change. School staff expressed a strong desire to be able to refer younger pupils, citing an unmet need and the opportunity for early intervention with this age group. There were Level 1 referrers from CAMHS who cited an increase in suicidality and self-harm among children under the age of 14 in general, indicating a need for support in this age group. Level 2 staff members also described receiving this feedback from those referring to their services.

Really we need it for S1s, S2s, and S3s, but you can only refer from S3 upwards. So it just doesn't fit perfectly into what we want to do because it's the younger ones that don't seem to have anything. The older ones, there are lots of avenues that they could go down and explore, but actually we're finding the younger ones, we just find that really difficult to get any help for them, and they're the ones that need it. Maybe just this short intervention that DBI can do, the younger ones are the ones that need that, whereas by the time they get into third year and above, which is what it's for, it's like they're too far gone and they need more help. (School-based Level 1 referrer)

Yes, and maybe that would bring new challenges and new training and stuff like that, but yes. I think the feedback we're getting is that it would be really beneficial if we could work with younger people. The staff as well, staff are saying, 'When can we work with younger people, or can we work with younger age ranges?'. (Level 2 staff member)

There was some difference of opinion as to whether the current DBI approach would be appropriate for S1 and S2 pupils and no consensus regarding how the programme would have to be adapted to meet the needs of this age group. It was acknowledged that younger children are a more challenging group with which to work and that they may need to be supported to engage with DBI in a different way to those in S3 and above.

Additionally, some concerns were expressed about the possibility of extending DBI to younger age groups.

Feedback from strategic stakeholders indicated that the current age limit had been set on the basis of evidence on psychological maturity and young people’s ability to engage one-on-one with the Level 2 staff member. A strategic stakeholder suggested that much of the distress experienced by young people in S1 and S2 has its root in issues outwith the young person’s control, such as poverty and family relationships. Therefore, to work productively with the young people in this age group, DBI would need to engage directly with the young person’s family, rather than solely focussing on the young person.

That is why we capped the age at second year and above - third year and above, that kind of 14 age range - because again, if you go below that, you need a more family support-based approach. (Strategic stakeholder)

There was also a desire for additional referral pathways to support those aged 14 and 15. School holidays were identified as a time when young people could not access support via schools and it was suggested that a route for GPs to refer young people to DBI could provide an alternative, both during holidays and for those young people who are not attending school or who are more comfortable seeking help via their GP. In one area, where DBI was delivered as part of the CDRS, GPs are already able to refer young people for support, and this route seems to be working well.

That could open a floodgate, but in holidays - I think the summer holidays are long. Six weeks is a long time for kids to be out of routine and for them to not have that support. (School-based Level 1 referrer)

Stakeholders also reported a particular interest from NHS 24 in referring young people to DBI. This would have to be carefully considered as generally parents call NHS 24 on behalf of their child, meaning that the young person may not be personally engaged with the referral and potentially would not receive a Level 1 intervention. In addition, DBI for 14 and 15 year olds is not currently a nationally available service, meaning that support may have to be provided virtually rather than face-to-face.

We’ve also heard for instance, from NHS 24 they’re always asking us about the evidence and asking us if and when they can begin to refer young people under 16 because of course right across the whole Scotland they can refer those aged 16 and over. NHS 24 have expressed a keenness at the first opportunity to be able to refer those aged 16 and under. (Strategic stakeholder)

Level 1 referrers and Level 2 staff members did not tend to speak about the other Level 1 referrers who are part of the adult programme, namely Police, Accident and Emergency and Ambulance staff. From the final reflections workshop, school nurses and campus-placed community police officers were suggested as potential referral routes.

Wider roll out of test of change

Evaluation participants were specifically asked about their views on whether the test of change should be rolled out more widely. This section discusses views on the further rollout of DBI through school and CAMHS referral pathways. It explores key concerns and considerations, including: maintaining fidelity to both the DBI and tripartite models; engaging with sites and services that may be less interested in implementing the test of change; ensuring DBI is fully accessible to young people; securing future funding; and identifying potential adaptations to the model.

Level 1 referrers and Level 2 staff members were generally very supportive of further roll out of DBI to schools, stating that they felt that all schools would benefit from DBI, that DBI should be available to all young people no matter which area they live in, and that DBI meets the needs of young people which are not being met by other services.

I think it should be national, I’m not just saying about Scotland, I think it should be national. (Level 2 staff member)

I would just love to see it, if possible, in lots of places. That would be really helpful. (CAMHS Level 1 referrer)

Strategic stakeholders also spoke positively about the potential to roll out the DBI test of change more widely, highlighting the principle of equality of access. Rolling out DBI to those aged 14 and 15 via NHS 24 was seen as a potential solution to the limited availability of services which young people can access by phone at a time of crisis.

If they were able to access DBI, I think that would be very, very valuable - with the usual safeguards of safeguarding and whatever that they have. (Strategic stakeholder)

Both those involved in the delivery of DBI and strategic stakeholders felt that a wider roll out of DBI to those aged 14 and 15 would be reflective of the Scottish Government’s stated commitment to prevention and early intervention.^[13]

However, participants identified several key issues and challenges which would need to be addressed if DBI was to be rolled out through the test of change or to those younger than 16 more widely. Some concerns were expressed that a wider roll out would lead to a loss of fidelity to the DBI model, particularly if the 24-hour response was diminished due to demand increasing.

Participants spoke about the need for a clear and well communicated DBI model, a robust governance structure and a set of implementation principles for local groups and schools to guide any future roll out as vital to ensure ensuring that a robust, consistent DBI model was maintained.

We need to be clear in terms of expectation around about fidelity to the model, around the core requirements, around evidence base, around supervision, around…I would hope around reporting, around…the way we currently do for DBI, around evidence guarding, around continuous improvement, around reflection, continuous growth. (Strategic stakeholder)

The tripartite model (whereby schools and CAMHS can refer to DBI, and DBI and CAMHS can refer to one another) was seen as central to the model of DBI for those aged under 16; consideration is also needed of how commitment to the tripartite model could be embedded in other areas, particularly as this is an unusual way of working for statutory and third sector services - in that third sector organisations cannot commonly refer into statutory services such as CAMHS. Local partnerships were seen as essential to developing relationships and connecting services. It was suggested that CAMHS staff and educational psychologists could sit on local implementation groups to ensure engagement.

…that local buy in, that local implementation group, whether that’s CAMHS or educational psychologists joining the Local Implementation Groups or whether that’s a specialist subgroup of that or another group that takes responsibility for seeing DBI embedded, that buy in and commitment to bring those elements together to me would be absolutely crucial. (Strategic stakeholder)

It was also highlighted that the areas and services which had been involved in the test of change were those with a strong interest and buy in to the DBI programme. It was therefore queried how best to engage with other sites which may not have as much interest in delivering DBI via the tripartite pathway or the capacity to implement a new pathway, or in sites which have their own pre-existing provision for this age group and do not see a need for DBI.

In scaling up the delivery of the DBI test of change, participants underlined the importance of understanding why some schools have low referral rates or are not referring at all and suggested that these schools may need more support to engage with DBI.

Obviously, you're rolling out; you would pick areas that were, as it were - that had capacity. So, there's something about going for areas that have capacity to be pilot areas, or areas who asked to become involved. So, they are obviously willing participants so what's harder to know is, what about the rest? Is that they lacked capacity? Or were unwilling? Or is it simply that they were just very naturally in a second or third phase? (Strategic stakeholder)

Participants also identified potential issues with staff capacity and training if the test of change was to be rolled out more widely. To scale up from the four providers which currently deliver the test of change to greater local or national coverage would require a significant investment in staff recruitment, training and development, with the acknowledgement that not all of those Level 2 practitioners who are currently delivering DBI to adults would be interested in, or suited to, delivering DBI to those aged under 16.

The Level 1 and Level 2 training packages would also need to be developed further and embedded in a training strategy, and consideration of who is best placed to deliver the training and how to meet the demand for training would be required. It was suggested that engaging third sector organisations which already provide services to children and young people as delivery partners may be valuable in using a workforce that already has the necessary skills in terms of working with this age group.

While DBI was described as accessible and appropriate for young people in the main, participants noted that it is important to consider the needs of those for whom DBI may currently be less suitable in any future development of the programme. Examples given of these included young people who are not currently attending school and those who have been excluded, young people who are care-experienced, and young people with asylum seeking status. In a previous section, care-experienced young people were identified as a group which may benefit from DBI, and it was suggested that engagement with this group could be improved.

Stakeholders also discussed their view that DBI is most accessible for those young people who are able to seek help and to talk about their thoughts, feelings and experiences, and that the needs of young people who have difficulty communicating their feelings should be considered. Different strategies may be required to engage with young people, and suggestions included delivering DBI through further education colleges and youth groups.

By definition, participation involves people with a voice. I suppose it's for - it's very hard to have the voice of people who don't comfortably talk, and to make sure that there are pathways for them as well. (Strategic stakeholder)

Future funding of the test of change was frequently raised as a challenge of greater expansion and this would need to be carefully considered, particularly given a background of constrained budgets within the Scottish Government and Local Authorities. It was suggested that the seed funding model that was used in the roll out of the adult DBI programme, whereby the Scottish Government provided funding to local areas, may provide a useful framework for this.

Some qualitative evidence from this evaluation suggests that DBI may be used by some practitioners as an alternative to statutory services such as CAMHS or as an additional service to support young people while they wait to receive clinical support. This was emphasised as an important gap in understanding the potential for DBI to alleviate pressure on other services.

… it would be really useful to know going into wider roll out whether DBI is being utilised alongside other options that the Pupil Support Teams might be using. Maybe referring to CAMHS and DBI around about the same time both working on kind of…different timelines. That would be an important consideration I think going forward, is to understand that more. (Strategic stakeholder)

Delivery and strategic stakeholders discussed the need for adaptations to be made to the DBI model to ensure that it was optimised for delivery to young people before any future roll out could be considered. There are some remaining logistical issues which require consideration, specifically the requirement for referring school staff to be issued with a secure email address, in addition to their school email address, to enable them to send referrals.

…so I think rolling out we would want to be reflecting on having…creating a more sustainable referral pathway, a more sustainable system for referral for our education colleagues related to the challenges of them not having secure emails as standard. (Strategic stakeholder)

As discussed previously, there was also a view expressed by Level 2 practitioners and school staff who refer to DBI that the length of support to be limited to 14 days was insufficient to support a young person in distress. This was particularly the case in relation to working with young people face-to-face in a school setting, which seemed to be the preference of many young people. The implications of an extended support period for young people for programme costs and staff resource would need to be carefully considered.

… it is pilot work, it is about learning and understanding if it’s appropriate, what the model of DBI should look like for children and young people if any going forward. We’re beginning to see some variation in delivery of the existing DBI model when it comes to children and young people.... So I think the important considerations are what is the optimal model of DBI for children and young people going forward without the assumption that it’s the same as the model for the broader program. (Strategic stakeholder)

Involving young people in the development of DBI

One of the detailed research questions (see Appendix 1) was regarding how children and young people could best be involved in the development of DBI for this age group. This section presents key points of the discussion from an engagement session conducted by members of the evaluation team from the University of Stirling and Children in Scotland, best practice for involving children and young people in the future development of DBI is then discussed.

Reflections from young people’s group

Emerging findings from the qualitative interviews were presented to a group of 3 young people with experience of accessing mental health support but not DBI, at an on-line session on Friday 24th of January 2025.

Young people were invited to share their views using a range of methods, including Mentimeter (an interactive presentation tool that engages participants in real time using their own digital device), to feedback their initial thoughts and reactions during the presentation. Early feedback related to how the intervention was delivered, lack of choice, and flexibility, and the need for better communication with the young person.

Following data analysis, the young people then took part in structured discussion to reflect on the findings in relation to their own experiences of accessing support for their mental health, and any suggestions or recommendations they would wish to make.

In summary the main points raised were as follows:

Overall, it seemed to the young people that DBI was a good thing when it is implemented correctly.

They told us they felt that the young people receiving DBI should be given a choice about whether they meet in person, or not.

Young people described having similar experiences with paperwork in other mental health services as those reported in this evaluation. They felt that completing paperwork was time-consuming and took time away from discussing what mattered most. In particular, checklists or the need to articulate their “level of risk” sometimes made them feel their problems were not perceived as serious enough.

The young people also stressed that it was important to take their feelings seriously. They urged practitioners not to dismiss young people’s feelings by saying things that they reported hearing in other programmes, such as: “it’s your hormones” or “you’re just a teenager” or “it’s because you’re on your phone all the time”.

The young people felt that being able to contact their support worker between sessions could be helpful for other young people: “Sometimes you have a bad day but don’t have another session for a week and can’t get to speak with them when you might most need their help”.

The young people felt that the relatively short time scale in which DBI is provided might not give young people enough time to talk about the things they need to and might put them off going for help again if they think it’s going to be just short term.

The young people emphasised the importance of having follow-on support options or referrals arranged by the DBI practitioner at the end of the intervention. They felt it could be too anxiety-provoking for a young person to contact an agency on their own. They also shared negative experiences of school counselling services.

Involving end users in service design—demonstrated during the development of the under-18s elements of DBI—is widely recognised as best practice^{[14],[15],[16]}. Future development should continue to prioritise meaningful engagement with children and young people, in line with established principles. The format, frequency, and structure of their involvement should be tailored to the purpose of the engagement and the intended impact of their contributions.

Careful thought should be given to whose perspectives are sought—for example, young people who have accessed DBI, those experiencing distress, young people more broadly, or a combination of these groups. Diversity and inclusion must also be ensured. Engagement should have a clearly defined purpose, framed in ways that minimise the risk of re-traumatisation. Young people should be informed of what they will gain from participation and how their contributions will be recognised and valued. A range of methods could be considered to strengthen their involvement:

• Development of a specific DBI youth advisory panel
• Engaging with existing youth panels or advisory groups established by third sector organisations delivering DBI
• Partnering with wider youth organisations to enhance future DBI developments and increase engagement with hard-to-reach populations