Service design for children and young people with common mental health problems: literature review, service mapping and collective case study.

Background: The mental health of children/young people is a growing concern internationally. Numerous reports and reviews have consistently described United Kingdom children's mental health services as fragmented, variable, inaccessible and lacking an evidence base. Little is known about the effectiveness of, and implementation complexities associated with, service models for children/young people experiencing 'common' mental health problems like anxiety, depression, attention deficit hyperactivity disorder and self-harm. Aim: To develop a model for high-quality service design for children/young people experiencing common mental health problems by identifying available services, barriers and enablers to access, and the effectiveness, cost effectiveness and acceptability of such services. Design: Evidence syntheses with primary research, using a sequential, mixed-methods design. Inter-related scoping and integrative reviews were conducted alongside a map of relevant services across England and Wales, followed by a collective case study of English and Welsh services. Setting: Global (systematic reviews); England and Wales (service map; case study). Data sources: Literature reviews: relevant bibliographic databases and grey literature. Service map: online survey and offline desk research. Case study: 108 participants (41 children/young people, 26 parents, 41 staff) across nine case study sites. Methods: A single literature search informed both reviews. The service map was obtained from an online survey and internet searches. Case study sites were sampled from the service map; because of coronavirus disease 2019, case study data were collected remotely. 'Young co-researchers' assisted with case study data collection. The integrative review and case study data were synthesised using the 'weaving' approach of 'integration through narrative'. Results: A service model typology was derived from the scoping review. The integrative review found effectiveness evidence for collaborative care, outreach approaches, brief intervention services and the 'availability, responsiveness and continuity' framework. There was cost-effectiveness evidence only for collaborative care. No service model appeared to be more acceptable than others. The service map identified 154 English and Welsh services. Three themes emerged from the case study data: 'pathways to support'; 'service engagement'; and 'learning and understanding'. The integrative review and case study data were synthesised into a coproduced model of high-quality service provision for children/young people experiencing common mental health problems. Limitations: Defining 'service model' was a challenge. Some service initiatives were too new to have filtered through into the literature or service map. Coronavirus disease 2019 brought about a surge in remote/digital services which were under-represented in the literature. A dearth of relevant studies meant few cost-effectiveness conclusions could be drawn. Conclusions: There was no strong evidence to suggest any existing service model was better than another. Instead, we developed a coproduced, evidence-based model that incorporates the fundamental components necessary for high-quality children's mental health services and which has utility for policy, practice and research. Future work: Future work should focus on: the potential of our model to assist in designing, delivering and auditing children's mental health services; reasons for non-engagement in services; the cost effectiveness of different approaches in children's mental health; the advantages/disadvantages of digital/remote platforms in delivering services; understanding how and what the statutory sector might learn from the non-statutory sector regarding choice, personalisation and flexibility. Study registration: This study is registered as PROSPERO CRD42018106219. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/09/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 13. See the NIHR Funding and Awards website for further award information.

In this research study, we explored services for children and young people with 'common' mental health problems like depression, anxiety and self-harm. We aimed to find out what services exist, how children/young people and families find out about and access these services, what the services actually do, whether they are helpful and whether they offer value for money. We looked at the international literature (reports and research papers) to identify different approaches to providing support, and to find out whether certain approaches worked better than others and whether children/young people and families preferred some approaches over others. The literature provided very little information about the value for money of services. We also carried out a survey and used the internet to identify 154 relevant services in England and Wales. To explore services in more detail, and hear directly from those using them, we planned to visit 9 of the 154 services to interview children/young people, parents and staff. Unfortunately, coronavirus disease 2019 stopped us directly visiting the nine services and so we conducted phone and video interviews instead. We still managed to speak to, and hear the experiences of, more than 100 people (including children/young people and parents). We combined information from the literature with information from the interviews to create an evidence-based 'model' of what services should look like. This model considers some basic things like how quickly children/young people could access a service, what information was available, the importance of confidentiality and whether staff make the service fit with the child/young person's needs and interests. It also considers whether the service helps children/young people learn skills to manage their mental health and whether staff at a service work well together. We hope our model will help existing and new services improve what they offer to children/young people and families.

A collaboratively produced model of service design for children and young people with common mental health problems.

BACKGROUND: Little is known about the effectiveness of, and implementation complexities associated with, service delivery models for children and young people (CYP) experiencing 'common' mental health problems such as anxiety, depression, behavioural difficulties and self-harm. This paper outlines how a model for high-quality service design for this population group was developed by identifying available services, their effectiveness, cost-effectiveness and acceptability, and the barriers and enablers to access. METHODS: Sequential, mixed-methods design, combining evidence syntheses (scoping and integrative reviews of the international literature) with primary research (a collective case study in England and Wales). Data from these two elements were collaboratively synthesised in a subsequent model-building phase. RESULTS: The scoping review yielded a service model typology. The integrative review found effectiveness evidence only for four models: collaborative care (the only service model to also have cost-effectiveness evidence), outreach approaches, brief intervention services and an organisational framework called 'Availability, Responsiveness and Continuity'. No service model seemed more acceptable than others. Three case study themes were identified: pathways to support; service engagement; and learning and understanding. The model-building phase identified rapid access, learning self-care skills, individualised support, clear information, compassionate and competent staff and aftercare planning as core characteristics of high-quality services. These characteristics were underpinned by four organisational qualities: values that respect confidentiality; engagement and involvement; collaborative relationships; and a learning culture. CONCLUSIONS: A consistent organisational evidence-base for service design and delivery in CYP's mental health spanning many years appears to have had little impact on service provision in England and Wales. Rather than impose - often inflexible and untested - specific local or national models or frameworks, those commissioning, designing and delivering mental health services for CYP should (re)focus on already known, fundamental components necessary for high-quality services. These fundamental components have been integrated into a collaboratively produced general model of service design for CYP with common mental health problems. While this general model is primarily focused on British service provision, it is broad enough to have utility for international audiences.

Staff responses to self-harm by children and young people in mental health inpatient settings: Experiences and views of children and young people, parents and staff.

This study aimed to understand the views of children and young people (CYP), parents and staff on how staff should respond to incidents of self-harm carried out by CYP in mental health inpatient settings. Semi-structured interviews were conducted with CYP (n = 6), parents (n = 5) and mental health professionals (n = 6) with experience of this issue. Data were analysed using reflexive thematic analysis. Two superordinate themes were identified: (1) The threshold for intervening; and (2) Interpersonal attributes of staff. There was general agreement among participants about the interpersonal skills that staff should possess to work safely and effectively with this population. There was disagreement between staff and parent participants about the appropriate threshold for using restrictive interventions to manage incidents of self-harm for this group. Our findings suggest that further work is needed to develop effective approaches for addressing self-harm in this population which are considered acceptable to all key stakeholders. The results of this study could be used to inform future intervention development.

Non-restrictive interventions to reduce self-harm amongst children in mental health inpatient settings: Systematic review and narrative synthesis.

Rates of self-harm amongst children appear to be increasing. This presents challenges for practitioners responsible for maintaining the safety of children admitted to mental health inpatient settings. Policy guidelines recommend that practitioners should aim to avoid the use of restrictive practices for children. It is currently unclear, however, what evidence-based alternatives to restrictive practices are available. We aimed to identify what non-restrictive interventions have been proposed to reduce self-harm amongst children in mental health inpatient settings and to evaluate the evidence supporting their use in clinical practice. A systematic search of five databases (CINAHL, Embase, Ovid MEDLINE, APA Psycinfo, and Cochrane) was conducted to identify articles reporting on non-restrictive interventions aimed at reducing self-harm amongst children in mental health inpatient settings. Articles were quality assessed and relevant data were extracted and synthesized using narrative synthesis. Searches identified relatively few relevant articles (n = 7) and these were generally of low methodological quality. The underlying theoretical assumptions and putative mechanisms of change for the interventions described were often unclear. Despite concerns about the rates of self-harm amongst children in mental health inpatient settings, there is a lack of high-quality research to inform clinical practice. There is an urgent need to develop effective non-restrictive interventions aimed at reducing self-harm for children using inpatient mental health services. Intervention development should be theoretically informed and be conducted in collaboration with people who have lived experience of this issue.

Mapping review of interventions to reduce the use of restrictive practices in children and young people's institutional settings: The CONTRAST study.

Restrictive practices are often used harmfully with children in institutional settings. Interventions to reduce their use do not appear to have been mapped systematically. Using environmental scanning, we conducted a broad-scope mapping review of English language academic databases, websites and social media, using systematic methods. Included records (N = 121) were mostly from the United States and contained details of 82 different interventions. Children's participation was limited. Reporting quality was inconsistent, which undermined claims of effectiveness. Overall, despite a multitude of interventions, evidence is limited. Leaders should consider the evidence, including children's perspectives, before introducing poorly understood interventions into children's settings.

Mental health problems in childhood and adolescence.

The emotional health and wellbeing of children and young people is of fundamental importance. Unmet mental health needs during childhood lead to difficulties in adolescence and problems in adulthood. The need to develop comprehensive prevention, early recognition and timely intervention services is essential. Despite this, many mental health problems go unnoticed or are only treated when advanced. Late intervention can often be associated with severe impairments for children and young people as well as their families. This article aims to improve nurses' understanding of children's emotional wellbeing and mental health, and identifies some of the risk and protective factors that combine to produce positive or negative outcomes. Individual and family-based psychological treatments that are available to support children are summarised. The learning activities offer nurses helpful interpersonal and practical strategies to promote emotional wellbeing and mental health in children.

Nursing children and adolescents with bipolar disorder: assessment, diagnosis, treatment, and management.

TOPIC: The role of the mental health nurse in the assessment, diagnosis, treatment, and management of children and adolescents with bipolar disorder in community and hospital settings. PURPOSE: In many areas of clinical practice, mental health nurses have more contact with service users than any other professional group. They are therefore well placed to support children and adolescents with bipolar disorder during first contact with primary care services, through engagement with specialist mental health services, and in accessing early intervention and crisis services. This paper summarizes the contribution that child and adolescent mental health nurses make to the care of children and adolescents with bipolar disorder. SOURCES: This paper is based on evidence from systematic reviews; meta-analyses and best practice evidence from CINAHL; EMBASE; MEDLINE, PsychINFO; Cochrane Collaboration; National Institute for Health and Clinical Excellence; National Collaborating Centre for Mental Health; NHS Centre for Reviews and Dissemination; Oxford Centre for Evidence Based Medicine; United States Agency for Healthcare Research and Quality. CONCLUSIONS: Child and adolescent mental health nurses work with children and adolescents who have bipolar disorder in a range of settings. These include community mental health services, hospitals, and schools. Due to the multidisciplinary nature of the treatment and management of bipolar disorder during childhood and adolescence, nurses have a major role to play in providing frontline assessment services, monitoring treatment, and delivering psychosocial interventions.

Safeguarding vulnerable children.

Some of the following children and young people are particularly vulnerable and require additional safeguarding: those in local authority care ('looked after' children), those who have disabilities, those who are in custody, and those who are affected by domestic violence. Recent reviews of the nursing contribution to safeguarding vulnerable children in all four countries of the UK were intended to improve the capacity and capability of the nursing workforce to safeguard and promote the welfare of children. Extensive statutory and non-statutory guidance exists to help ensure that staff in all healthcare settings understand their role in safeguarding and have the skills and competence to protect and promote the welfare of children and young people. Despite these developments, strong strategic and inspirational clinical leadership is still required to bring about the significant cultural change required to ensure that safeguarding children becomes part of everyday nursing practice.

Tier 4 Child and Adolescent Mental Health Services (CAMHS) - Inpatient Care, Day Services and Alternatives: An Overview of Tier 4 CAMHS Provision in the UK.

This paper addresses Tier 4 services for children and young people whose needs require highly specialised services, and describes the range of provision which is currently available for this group. Although the evidence base is in its infancy, what is known about clinical outcomes, cost effectiveness and the views of users is summarised. The current shortfalls in tier 4 provision are highlighted, the drivers for change are identified and recommendations are made for future service improvements.

Child and adolescent mental health services in the UK: nurse consultants.

TOPIC: Children's mental health services in the UK are transforming. Innovations in health, social welfare, education, and youth justice agencies have all got emotional literacy at their core. The changing face of children's services has called for partnerships and new ways of planning and delivering services in statutory and voluntary sectors. Alongside this, nursing is evolving and developing new ways to meet the challenges that modernization brings. Nurse consultants are children's champions who have a leading role in helping lead children's services into the 21st century. PURPOSE: The following article explores the role of nurse consultants in child and adolescent mental health services (CAMHS).