Are crisis responses for children and young people effective?

Edwards et al. (2024) provide an “elf-ing” hand in understanding crisis mental health support for children and young people (CYP)!

In England between December 2019 and April 2021, there was a 47% increase in new emergency referrals to Child and Adolescent Mental Health (CAMH) crisis care teams (Lewis, 2021). As the waiting times for mental health support increase, it is unsurprising that more CYP present in crisis (Lancet, 2020). The current demands on community mental health services mean that whilst hospitalisation rates for most paediatric conditions decrease, the number of admissions to child and adolescent inpatient mental health units are increasing (Torio et al., 2015). Mental health inpatient admissions can provide vital, intensive care for CYP – however, it is widely recognised that safe avoidance of hospital admission is favourable (Alderwick & Dixon, 2019; Edwards et al., 2015). Concerns have been raised about the impact of restrictive practices, use of the Mental Health Act and reliance on psychotropic medication on long term sustainable wellbeing for CYP admitted to hospitals (Cilsu et al., 2022; Clark & MacLennan, 2023; SAMHSA, 2022).

In order to provide timely and effective support for CYP, it is important that we understand the type of crisis support available and how this is experienced by young people and their families. This NIHR-funded review aims to summarise the crisis responses for CYP, synthesising literature on their effectiveness, the experiences of CYP, and service organisation (Edwards et al., 2024).

Lengthy waits for support mean that more children and young people are presenting at the point of mental health crisis, increasing the demand on emergency departments. This is a major public health concern.

Methods

This systematic review aimed to address the following objectives:

1. Investigate the organisation of crisis services for CYP aged 5-25
2. Understand their experiences and perceptions of crisis care
3. Assess the effectiveness of current crisis support models for CYP
4. Determine the goals of crisis intervention.

Seventeen databases and supplementary sources (including organisational websites and reference lists of included studies) were searched, with studies included based on the following criteria:

• CYP aged 5-25 years in an emotional/mental health crisis
• Crisis services and responses
• Organisation of crisis services; their effectiveness; experiences of CYP and their families; goals of crisis services.

Screening of titles, abstracts and full-texts was conducted independently by reviewers, with disagreements resolved by consensus.

Quality appraisal of research reports was performed using checklists appropriate for the study design. Among the assessed studies, one of the four randomised controlled trials (RCT) scored highly across all appraisal criteria, while three of four of the quasi-experimental studies also scored highly. Acceptable quality was observed in all cohort studies, nine out of ten descriptive cross-sectional studies, and all qualitative studies based on their respective appraisals.

1. For objective 1, data was synthesised narratively.
2. Objective 2 involved synthesising qualitative data using thematic analysis, with confidence assessment using the CERQUAL approach.
3. Thematic summaries were employed for objective 3 as a meta-analysis was not possible, with the GRADE approach used to assess confidence.
4. For objective 4, thematic summarised were used to determine the goals of crisis intervention, with cross-checking by multiple reviewers to ensure accuracy and reliability.

Results

The review provides a comprehensive overview of the findings from 138 reports, comprising primary research studies (n = 48), descriptive accounts of organisational services (n = 36) and UK-only grey literature reports (n = 54). The majority of primary research studies (n = 25) and descriptive accounts (n = 19) originated from the USA.

Objective 1: Organisation of crisis services

Different service models were identified: Triage/assessment, digitally mediated support and intervention approaches. Eligibility criteria were defined, excluding adult focused or non-crisis care studies. Thematic summaries highlighted the importance of age-appropriate initial assessments, community-based support, safe locations for crisis care, and general crisis response characteristics like timely, accessible and multi-agency support. Recommendations for crisis services included skilled professionals, proximity to home and avoiding adult mental health facilities or police involvement.

Objective 2: Experiences and perceptions of crisis support

Four themes were generated:

1. Barriers and facilitators to seeking and accessing appropriate support
2. What CYP want from crisis services
3. CYP’s and families’ experiences of crisis services
4. The challenges of service provision

Barriers included difficulty accessing specialist services and not knowing what support is available. CYP emphasised the importance of peer support and accessible communication channels such as phone lines and online services. Challenges in services provision included inappropriate admissions, inadequate crisis care outside of office hours and concerns about police involvement and facilities.

Objective 3: Effectiveness of crisis interventions for CYP

Despite a number of papers discussing the effectiveness of crisis interventions for CYP, these were based on moderate- to very low-quality evidence. These studies covered crisis services across a range of settings including emergency departments, home-based programmes, inpatient care, outpatient mental health services, telepsychiatry and mobile crisis teams. The results for these services varied, with different benefits (e.g., symptom reduction, improving family functioning, preventing hospital admission). However, there were mixed findings and limitations in certain areas.

Several studies were initiated in emergency departments and were found to reduce rates of hospitalisation and symptom improvement. However, emergency departments are not traditionally designed for managing mental health crises and it is not recommended that they become the principle setting for supporting CYP in mental health crisis.

Objective 4: Goals of crisis interventions

Seven goals of crisis interventions emerged from the literature:

1. Keeping CYP in their homes and avoiding admission to hospital
2. Assessing the needs of the young person and planning interventions
3. Enhancing engagement with community treatment
4. Linking families with additional mental health services
5. Providing peer support
6. Stabilising and managing the current mental health crisis
7. Training and/or supervising staff.

It appears that international goals of crisis care align with common goals of stabilising the current mental health crisis and identifying the ongoing mental health needs of that young person.

Conclusions

This systematic review concluded that there are a wide variety of crisis interventions for CYP that show beneficial outcomes across various settings and intervention types. The findings suggest that readily available support offered in different modalities (in person/online) prior to the point of crisis would be beneficial for CYP.

Barriers to accessing crisis support include financial constraints, eligibility thresholds and a lack of knowledge of existing services.

Although high-quality international studies are lacking, the results highlight the importance of offering support before CYP reach crisis point.

It is important that timely support is offered prior to crisis point and that young people and their families know what support is available and how they can access it.

Strengths and limitations

This systematic review robustly synthesised the research and identified important themes regarding crisis care provision that are pertinent to improving care for CYP. There were clear objectives for a complex systematic search and the wealth of information gathered was clearly communicated to the reader. However, employing an English language criterion will have limited the results from international crisis interventions. Approximately 90% of CYP live in Low- and Middle-Income Countries (LMICs), where mental health issues disproportionately impact those facing poverty and social disadvantage, yet mental health research in LMICs is often overlooked (Barry et al., 2013; Riberio et al., 2023). Exclusion of research in other languages may mean that information regarding CAMH crisis care for the global majority of CYP is missing from this review.

A strong methodological approach was taken to ensure thorough assessment of the quality for different study designs using established criteria. Due to the heterogeneity of interventions and outcome measures, meta-analysis was not an option, and the descriptive nature of most results made it difficult for the authors to assess how precise the results were; but it was important that the authors did not try to erroneously compare outcomes that did not align. The lack of high-quality studies in this area was reported in the review, which potentially limits the reliability of the conclusions drawn from the available evidence.

Most of the included studies originated in the USA. Comparing healthcare provision in the USA and other countries can be difficult due to the differences in healthcare structure and commissioning. The authors highlighted how this may limit the transferability of these findings to other health systems but emphasise that the results remain relevant for CYP internationally. This review sets the scene for crisis care provision and provides the rationale for high-quality studies that investigate the effectiveness, delivery and models of crisis care for CYP outside of the USA. This review has provided the foundations for future work mapping out crisis care in the UK and I look forward to reading the work being conducted by the team on the CAMHS-Crisis-2 project.

Watch the Mental Elf coverage of the #CAMHSsmallsteps webinar for a sneak peek at that, or read the tweets from the Mental Elf during that event for a quick summary.

Edwards et al. (2024) provide a robust evaluation of current crisis provision for child and young people internationally – but more work is needed, particularly in the form of high-quality studies conducted outside of the USA.

Implications for practice

This evidence provides an important summary of the available literature on crisis services for CYP. The demand for these services is increasing rapidly and the insights from this review can be used to encourage thorough evaluation of crisis services, inform service development, and help to align services with shared goals for crisis intervention.

The findings suggest that CYP and their families are often unaware of existing mental health support and how they can be accessed, indicating a need to find better ways of publicly disseminating information regarding CYP mental health services. However, when CYP did access crisis support, they found it easily accessible, readily available, and able to be provided via a range of modalities, all of which were seen as positive. These findings should inform service developments to ensure that the crisis care being provided is in-line with the wants of CYP. In the future, I hope that the findings of this review will encourage the development of interventions that are grounded in the voices of CYP.

In addition, this review highlighted the lack of high-quality international studies in this area. It is hoped that future research will investigate the organisation, delivery, and effectiveness of crisis services in the UK and globally. Further research should focus on exploring what types of crisis support would be most useful for CYP, and what proactive community support can be provided to prevent mental health crises (e.g., Australia’s HYPE programme; Chanen et al., 2014). This review found that a number of different interventions were beneficial for CYP in crisis;  however, further exploration of what works and for whom could help to establish the needs of different groups of CYP, ensuring that the right help is provided.

In my role as an inpatient CAMHS mental health nurse, it was difficult to read about the struggles CYP and their families face in accessing community support, leading to hospital admission during a crisis. Similarly, when assessing CYP in the community who have been waiting for several months, acknowledging their need for support but having to inform them that they will continue to wait for extended periods felt like a failure on my part. I hope that this review and future work in this area will help contribute to the development of effective crisis interventions for CYP and will highlight the need for a proactive approach to supporting young people prior to mental health crisis.

Statement of interests

None.

Links

Primary paper

Edwards, D., Carrier, J., Csontos, J., Evans, N., Elliott, M., Gillen, E., Hannigan, B., Lane, R., & Williams, L. (2023). Review: Crisis Responses for Children and Young People – a Systematic Review of effectiveness, Experiences and Service Organisation (CAMH‐Crisis). Child and Adolescent Mental Health, 29(1).

#CAMHSsmallsteps

In February 2024, The Mental Elf worked with researchers from Manchester and Cardiff Universities to share how we might improve children and young people’s mental health services. We disseminated research that explored these issues from the perspectives of young people who use services, their parents and carers, the professionals delivering and commissioning these services and the international literature.

As part of #ChildrensMentalHealthWeek 2024, we hosted a webinar, created videos and social media graphics, and disseminated this work across our social media channels using the hashtag #CAMHSsmallsteps. Drawing on three National Institute for Health and Care Research (NIHR) funded research projects led by Cardiff University (CAMH Crisis, CAMH Crisis 2) and University of Manchester (Blueprint), a panel of experts will lead a discussion on how these findings can be implemented into practice. These videos are aimed at policy makers, commissioners and funders, service providers, practitioners, researchers and anyone interested in children and young people’s mental health provision.

Watch the #CAMHSsmallsteps videos on our YouTube channel.

Other references

Alderwick, H., & Dixon, J. (2019). The NHS long term plan. BMJ, 364(184), l84. https://doi.org/10.1136/bmj.Barry, M. M., Clarke, A. M., Jenkins, R., & Patel, V. (2013). A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health, 13(1).

Chanen, A. M., McCutcheon, L., & Kerr, I. B. (2014). HYPE: A Cognitive Analytic Therapy-Based Prevention and Early Intervention Programme for Borderline Personality Disorder. Handbook of Borderline Personality Disorder in Children and Adolescents, 361–383.

Clark, J., & MacLennan, E. (2023). Measuring Experience of Inpatient Child and Adolescent Mental Health Services (CAMHS). International Journal of Environmental Research and Public Health, 20(11), 5940.

Clisu, D. A., Layther, I., Dover, D., Viner, R. M., Read, T., Cheesman, D., Hodges, S., & Hudson, L. D. (2021). Alternatives to mental health admissions for children and adolescents experiencing mental health crises: A systematic review of the literature. Clinical Child Psychology and Psychiatry, 27(1), 135910452110447.

Edwards, D., Evans, N., Gillen, E., Longo, M., Pryjmachuk, S., Trainor, G., & Hannigan, B. (2015). What do we know about the risks for young people moving into, through and out of inpatient mental health care? Findings from an evidence synthesis. Child and Adolescent Psychiatry and Mental Health, 9(1).

The Lancet (2020). Child mental health services in England: a continuing crisis. The Lancet, 395(10222), 389.

National Guidelines for Child and Youth Behavioral Health Crisis Care. (n.d.). https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/pep-22-01-02-001.pdf

Ribeiro, W. S., Grande, A. J., Hoffmann, M. S., Ziebold, C., McDaid, D., Fry, A., Peixoto, C., Miranda, C., King, D., Tomasi, C. D., Faustino, C., Leone, S., Moraes, S., Schäfer, A. A., Alves, V., Rosa, M. I., & Evans-Lacko, S. (2023). A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries. Comprehensive Psychiatry, 121, 152358.

Torio, C. M., Encinosa, W., Berdahl, T., McCormick, M. C., & Simpson, L. A. (2015). Annual Report on Health Care for Children and Youth in the United States: National Estimates of Cost, Utilization and Expenditures for Children With Mental Health Conditions. Academic Pediatrics, 15(1), 19–35.

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