The future of mental health services for children and young people are at a turning point. There is increasing recognition that there is huge unmet need. In the UK only approximately 25% of children and young people with a mental health disorder receive treatment, but demand to access care is increasing. At the same time evidence is building on what treatments are effective. This has not been matched by equivalent research evidence on what service configurations are most effective. In their systematic review of ‘the impact of pediatric mental health care provided in outpatient, primary care, community and school settings on emergency department use’, Kirkland et al (2018) found only limited evidence to suggest that the provision of services in the community impact on the use of emergency departments. The absence of robust RCT evidence should not prevent us from improving the outcomes and experience of children and young people facing a mental health crisis. Much is known about the value of early intervention and effective community interventions. Action should be taken now to prioritise the use of scarce resources where they are needed most to reduce unnecessary and sometimes unhelpful attendances at emergency departments and avoid potentially harmful mental health admissions.
The future of mental health services for children and young people are at a turning point. There is increasing recognition that there is huge unmet need. In the United Kingdom, only approximately 25% of children and young people with a mental health disorder receive treatment (Future in Mind, 2015) but demand to access care is increasing. At the same time evidence is building on what treatments are effective with good guidance on how to deliver treatments such as produced by the National Institute for Health and Clinical Excellence (NICE). This has not been matched by equivalent research evidence on what service configurations are most effective, at least not from well conducted randomised controlled trials.
In their systematic review of ‘the impact of pediatric mental health care provided in outpatient, primary care, community and school settings on emergency department use’, Kirkland, Soleimani, and Newton (2018) found only limited evidence to suggest that the provision of services in the community impact on the use of emergency departments. So, what does this tell us?
Unfortunately, Kirkland's review does not tell us as much as we might like, except to show us what we do not know and where further research is needed. The review is an attempt to look at the evidence that developing one aspect of a children and young people's mental health pathway (community services) impacts on another part of that pathway (emergency departments). The importance of this approach cannot be understated. Although there is no RCT evidence, there is increasing evidence through service evaluations that scarce resources allocated to children and young people's mental health services around the world are not always deployed in the most effective way. Take an example from another part of the crisis pathway. In the United Kingdom, which has relatively few inpatient beds per head of population compared to many other developed countries, we are still admitting young people who could be treated as well, if not better, in the community with intensive crisis intervention or home treatment (Kwok, Yuan, & Ougrin, 2015). For some, we admit there is evidence that we may be doing more harm than good (Dubicka et al., 2017; Hannigan et al., 2015; Ougrin et al., 2017). Where effective community services do exist to manage complex and/or high-risk presentations, admissions are reduced and/or lengths of stay shortened (Ougrin et al., 2017). It is reasonable to think that this principle will apply to other parts of children's and young people's mental health pathways and that children and young people who receive a community intervention for their difficulties might be better able to cope in a crisis and therefore less likely to attend an emergency department (ED) for help.
Kirkland revealed a notable absence of good quality trials looking at the effects of well-designed community services on the use of EDs by children and young people with mental health difficulties. The studies they reviewed did not offer equivalent alternatives to an ED and were not services that would normally respond to children and young people in crisis. The use of the ED was not a primary outcome measure for most of the studies. Furthermore, the timescales for ED use were not concurrent to the community service attendance, but 1–5 years post intervention in three of the six studies, reducing the likelihood of a direct impact. Of the three remaining studies, one school based intervention did show a reduction in ED attendance. Clearly, further research is needed here. However, we can be encouraged by the adult literature, where we can find support for the hypothesis that effective community mental health interventions reduce crisis presentations to mental health services.
The lack of robust RCT studies in this field of children and young people should not put us off planning for service developments. While there has been a dramatic rise in the presentation of young people who self-harm over recent years, and an increase in numbers of children and young people attending EDs, patient experience in EDs remains generally poor. In the United Kingdom, mental health crisis services provided for children and young people in EDs are often delivered by all age or adult based services by staff who do not have training or specialist competencies to manage children and young people. This is especially true outside normal working hours. When asked, most young people state that they would prefer not to be seen in an ED when in crisis. Furthermore, many say that if they had received help when they first wanted it they may not have required a crisis intervention. Services need to be available to meet this challenge and in the absence of a preferred evidence-based service model, it falls on expert opinion provided by children and young people, parents and carers, clinicians and other stake holders, informed by service evaluations, to agree a consensus for the most effective way to meet these children and young people's needs.
Following the Crisis Care Concordat in 2013 and Future in Mind in 2015, NHS England commissioned the National Collaborating Centre for Mental Health to develop a range of evidenced based care pathways in mental health for children and young people, including a pathway for children and young people experiencing a mental health crisis. The work on this has been completed and is now awaiting publication. The mental health care pathway guidance sets out key principles for good services and describes key functions that should be delivered to effectively meet the needs of children and young people in crisis. The guidance builds on the previous work such as the National Service Framework (2004) and Future in Mind (2015). It was also informed by models such as the Choice and Partnership Approach (York & Kingsbury, 2013) and THRIVE (Wolpert et al., 2016). The details of the crisis (and non-crisis) pathways will not be described here, but there are some emerging themes that are shared by the most effective services, as outlined below.
There is a growing consensus that more should be done to prevent or intervene early in the course of an individual's difficulties. When effectively delivered, early interventions can reduce the demand on crisis services. We should be deploying our most experienced and competent clinicians at the point when a child or young person first presents to a service, whether in crisis or not. This function is sometimes provided in services described as the ‘first point of contact’ or ‘single point of access’. Where possible, there should be flexibility on how the young person makes contact or is seen. For some, new technologies such as web based contact or texting are preferred. When face to face contact is needed, there should be some flexibility where this takes place, for example, whilst some may find contact in school to be the most convenient, for others the potential loss of privacy or confidentiality makes the school a place where they would wish to avoid contact with mental health professionals. After contact is made a systematic triage of the child or young person's needs, and where appropriate, advice and support given and/or a thorough biopsychology assessment should follow. Without such a systematic assessment, many young people complain that they do not receive the right help at the right time, sometimes having to wait for things to get worse before they receive a proper assessment and formulation of their needs.
Services should be accessible. Children and young people and/or their families/carers should be able to seek specialist help without the need for a referral from a nonspecialist, like a GP. The first contact should be timely, without a long wait, and then followed by a timely appropriate evidence-based intervention. In the case of children or young people in crisis, this response must be immediate or at least within an hour or two, and available 24 hours a day.
Treatment should be collaborative. Clinicians and service providers should work with children and young people and their parents/carers to design and deliver a service that provides both good outcomes and a positive experience. The principles of shared decision-making should be embedded in every contact. Services should also be collaborative, or better still integrated. Many children and young people have a range of needs that are best met by a combination of interventions that may historically have been delivered by different services and agencies. At times this can lead to a poorly coordinated response, or needs in one area not being met. The advantages of otherwise fragmented services collaborating and integrating, including across agencies such as health and social care are manifold.
The role of the police should not be overlooked in children and young people's crisis care. They may be the first professional to become involved and need to be able to access immediate specialist mental health advice and support through street triage or other direct access service to help ensure an appropriate intervention and avoid unnecessary use of the Mental Health Act or it is equivalent outside the United Kingdom.
Finally, we should measure what is important. The only way we will know if services are providing the care that is needed is if we measure them. Measurement should include key quality metrics to ensure that the service is effective, safe and provides a positive patient experience. Clinical outcome measures are a necessary part of quality measurement, but not sufficient in themselves.
Where does this leave the role of EDs in a mental health crisis pathway for children and young people? Kirkland et al. sites ‘inadequate responses’ to children and young people presenting in ED in the United States and Canada, and this is certainly echoed in the United Kingdom. Is the answer to improve the response from EDs, or provide alternative emergency responses for children and young people in crisis. The answer has to be both. Children and young people who have self-harmed may need a medical assessment and intervention. If this is the case a hospital setting is often the most appropriate. NICE guidance for self-harm (2004) in the United Kingdom recommends that under 16-year olds presenting to hospital following self-harm should be admitted allowing for medical treatment and a measured mental health assessment. But for those in high distress that do not need a medical intervention, a busy ED is often not the best environment to be seen in.
If we listen to children and young people who have experienced a mental health crisis they want a range of options to access help, in terms of how that help is delivered and where it is provided. They do not want the default to be ‘go to the emergency department’.
AC is a Consultant in Adolescent Psychiatry, Cheshire and Wirral Partnership NHS Foundation Trust; Chair of the Tier 4 CAMHS Clinical Reference Group, NHS England; and National Clinical Advisor, National Collaborating Centre for Mental Health (NCCMH). As National Clinical advisor at NCCMH, he was involved in the development of a number of the mental health care pathways, including the crisis mental health care pathway for children and young people referred to in this editorial.
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