Mental health crisis care for children and young people aged 5 to 25 years: the CAMH-Crisis evidence synthesis

Arm 1: children and young people

The additional terms discussed at the SAG for this arm focused on trying to identify studies in which our population group may have been referred to by terms more related to setting than the terminology already identified as relevant to defining CYP. The SAG was concerned that CYP, particularly within educational, juvenile and other settings, may be missed. Additional suggestions that were discussed were the words and phrases ‘pupil’, ‘student’, ‘undergraduates’, ‘learner’, ‘apprentice’, ‘young offender’ and ‘adults aged 18–25 years’. A particular mention was made of adverse childhood experiences and whether or not this could be incorporated into this arm. The suggestions were evaluated by an information specialist (EG) and reported back to the project team. The words that were included within the final search strategy were ‘pupil’, ‘student’ and ‘young offender’. Other terms were considered to be too broad (e.g. ‘learner’ and ‘apprentice’), problematic to search given the constraints of the databases (e.g. ‘age 18–25 years’ and ‘minor’) or would already be retrieved through the use of existing key terms (e.g. ‘adverse childhood experiences’ and ‘children in care’).

Arm 2: crisis

At the outset, the decision was made not to search for specific crisis events, as it was felt that this potentially could have led to an endless list of presenting clinical situations and that certain crisis events, not thought of, could be missed. Our strategy was to use the keywords ‘crisis’ or ‘crises’ in arm 2 and ‘mental health’ or ‘psych*’ in arm 3. However, when the search strategy was being tested to ensure that all recognised relevant papers were being retrieved, Elizabeth Gillen found that several already-identified key papers were missing. This was because these papers used the term ‘rapid response’ and ‘suicide’ to define the crisis event with no mention of the terms ‘crisis’ or ‘mental health’. After discussion at a later project team meeting, it was felt that the terms ‘suicide’ and ‘self-harm’ were so synonymous with a crisis that they should be included as specific examples in the mental health arm. The term ‘rapid response’ was then added to arm 2.

Arm 3: mental health

The general use of a mental health arm was discussed at length, as the SAG was concerned that this could make the search very medicalised and that the project needed a strategy to ensure the retrieval of non-health sector articles. It was recognised, however, that without this third arm the search would be unwieldy. A discussion followed that, although in practice episodes of crisis happen in many sectors, it is likely that any write-up of research undertaken in the area would refer to mental health in some capacity and so this arm was included and expanded on, as detailed above. To address the concerns, and to increase the sensitivity of our search, a fourth arm was introduced that encapsulated alternative terminology that could be used to define a mental health crisis, which could then be combined with arm 1 to provide us with a second search methodology.

Arm 4: mental health and crisis

Positional operators were used within our new arm 4 to retrieve articles using alternative terminology to describe a mental health crisis. The terms discussed with the SAG included the terms ‘severe’, ‘extreme’, ‘intense’, ‘emergency’, ‘critical incident’, ‘urgent’, ‘distress’ and ‘trauma’. ‘Trauma’ was removed, as it was felt that this term would retrieve too many irrelevant records related to physical trauma. Following further discussions, it was decided to proceed with four of these terms (i.e. ‘emergency’, ‘critical incident’, ‘urgent’ and ‘distress’) in proximity to the terms ‘mental’ and ‘psych*’. Trials combining this new arm with arm 1 showed the strategy to be successful in increasing the sensitivity of our search, pulling in alternative literature, without excessively compromising precision or making the search unmanageable.

Population

This evidence synthesis considered all relevant evidence specifically relating to support for CYP (aged 5–25 years) in emotional/mental health crisis.

For the purposes of the current study, CYP will included individuals within the age range of 5–25 years. A number of mental health services for CYP in the UK and internationally now cater for this age range. Imposing an age limit of 18 years would, therefore, have risked excluding valuable studies concerning those aged 18–25 years.

Intervention and phenomena of interest

This evidence synthesis considered all relevant evidence on the:

• organisation of services relating to crisis support

• effectiveness of current models/interventions that provide support to CYP in mental health crisis

• views and experiences of CYP, families and staff

• goals of services.

Building on the definition used in Crisis Intervention for People with Severe Mental Illnesses,28 for this proposed review a crisis response for CYP was defined as follows:

The provision of a service in response to extreme psychosocial distress, which for children and young people may be provided in any location such as an emergency department, a specialist or non-specialist community service, a school, a college, a university, a youth group, or via a crisis support line.

Comparators

No comparators were used in the study.

Outcomes

The following outcomes were considered: the organisation of crisis services and their effectiveness (i.e. all outcomes as described across the primary studies), the experiences of CYP and their families, and the goals of crisis services.

Context

All records were considered with regard to the organisation of crisis services, their effectiveness and the experiences of CYP and their families in any setting, including virtual.

Study design/types of evidence

Types of evidence sought included both quantitative and qualitative research, and UK-only grey literature. Reports published in the English language since 1995 were considered.

Country of origin

The majority of the research reports were conducted within the USA (25 studies across 30 reports32,34,57–84), followed by Canada (eight studies across nine reports85–93), the UK (n = 394–96) and Australia (n = 291,92), and one study from each of the following countries: Ireland,97 the Netherlands,98 New Zealand99 and Sweden. 100 The descriptive accounts of the organisation of crisis services were mainly from the USA (19 descriptions across 15 reports33,101–114) and Canada (n = 10115–124). Three reports125–127 were from Australia and one report from each of the following countries: Germany,128 Switzerland,129 the Netherlands130 and the UK. 131

Study designs and methods

For the research studies, there were 31 quantitative studies (reported across 37 reports32,34,57–69,71–75, 77–89,92,93,98,132) and 11 qualitative studies. 70,76,90,91,94–97,99,100,133 The quantitative studies included a prospective cohort study (n = 132), retrospective cohort studies (n = 1234,62,65–68,71,72,74,75,87,89), quasi-experimental studies (four studies across six reports82,83,86,92,93,132), randomised controlled trials (RCTs) (four studies across eight reports57,61,64,78–81,84) and descriptive cross-sectional studies (n = 1058–60, 63,69,73,77,85,88,98).

Participant characteristics

Participants across the research studies were:

• CYP experiencing, or who had experienced, a crisis (31 studies across 34 reports32,34,58–63,65–75,77,82–84,86,87,89,91–95,97,98,100,132)

• CYP experiencing crisis and their family members (two studies across six reports57,64,78–81)

• family members/parents of CYP experiencing crisis (n = 276,88)

• caregivers and siblings of CYP experiencing crisis (n = 190)

• family and close friends bereaved by suicide of a CYP (n = 1133)

• youth counsellors (n = 1134)

• staff members from project sites (n = 194)

• emergency department medical staff (n =285,96).

Participant group sizes for CYP ranged from two134 to 253262 participants. One qualitative study91 had a large number of participants (n = 1449), but data from only one-third of these participants were analysed.

Some studies did not identify the ages of the CYP, labelling them as adolescents,34 young people,134 child psychiatry patients,71 elementary school students77 or high school students. 60,69,73,77 Three studies71,94,100 included young people aged > 16 years only (i.e. 16–24 years,100 16–25 years94 and 18–25 years70).

The majority of research studies included a mix of male and female CYP. One study included only males58 and a further study (across two reports) included only females. 82,83 A further seven studies34,66,71,77,90,94,99 did not report gender.

Symptoms of depression

Levels of depression were reported in three studies (across four reports57,78,82,83) and were measured using the Beck Depression Inventory,82,83 the Brief Symptom Inventory,78 the anxiety and depression subscale of the Child Behaviour Checklist (CBCL),78 the Hopelessness Scale for Children of the Youth Self-Report Scale78 or the Centre for Epidemiological Studies Depression Scale (CES-D). 57

Psychiatric symptoms

Psychiatric symptoms or symptomatology was addressed in three studies (across four reports64,79,87,98) and were measured using the Global Severity Index of the Brief Symptom Inventory,64,79 the functioning subscale on the Childhood Acuity Psychiatric Illness Scale (CAPI)87 or the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). 98

Behaviour

Three studies (across four reports57,61,64,79) investigated internalising and externalising behaviour using the CBCL. The internalising behaviours measured reflected mood disturbance (including anxiety and depression) and social withdrawal. The externalising behaviours reflected conflict with others and violation of social norms.

Psychosocial functioning

Psychosocial functioning was investigated in four studies (across five reports61,64,79,86,87) and was measured using the Child and Adolescent Functional Assessment Scale,61 the Children’s Global Assessment Scale (CGAS),86 youth and/or caregiver reports on the social competence subscales of the CBCL,61,64,79 youth reports on the antisocial friends and conventional involvement of friends subscale of the Family, Friends, and Self Scale (FFS)64,79 and through tracking school attendance. 64,79 Greenham and Bisnaire87 measured the levels of functioning of those with psychiatric symptoms using the functioning subscale on the CAPI.

Hospitalisation rates

Nine studies (across 12 reports32,64,68,74,75,79,80,84,86,89,92,93) investigated the effectiveness of a number of different crisis-based interventions or assessment processes on hospitalisation rates. These interventions/processes were explored at the time of the crisis,68,86 within 72 hours of the crisis,75 within 30 days of the crisis,68,89 at 1-month follow-up,84 at 2-month follow-up,86,93 at 3-month follow-up,32 at 6-month follow-up,86,93 up to 1-year follow-up64,79,80 or at an unspecified time frame. 74,92

Costs

Costs were addressed in seven studies. 58,65,67,72,74,81,93 The types of analysis that were conducted included cost savings (n = 658,65,67,72,74,93), cost-effectiveness (n = 281,93), cost-efficiency74 and opportunity costs. 67 Five studies58,65,67,72,74 reported significant cost savings and one study93 found no significant differences. Of the studies reporting cost savings, four58,67,72,74 out of the five58,65,67,72,74 studies reported that these savings were reflective of reduced lengths of stay (LOSs).

Discharge destination and referral pathways

The destination to which CYP were discharged or referred on to was reported across 11 studies,32,58,59, 61,63,65,74,85,87,92,98 and are reported as follows:

• home (biological or foster family) or the residence they were previously living in (n = 5;58,59,61,74,87 and, when reported, the percentage of those discharged ranged from 65%65 to 86%61)

• new living situation (n = 1;87 6%87)

• residential treatment facilities (n = 2;59,65 2%65 and percentage not reported59)

• detention centres (n = 1;59 percentage not reported59)

• outpatient mental health services (n = 3;32,63,98 and, when reported, the percentage ranged from 43%32 to 90%63)

• intensive outpatients (n = 1;32 21%32)

• day services (n = 1;65 9%65)

• discharged against medical advice (n = 1;65 12.2%65)

• hospital/inpatient psychiatric units (n = 10;32,58,59,61,63,65,74,85,87 and, when reported, the percentage ranged from 8%61 to 35%32)

• out of home placement (n = 1;61 5%61)

• no further specialised treatment needed (n = 2;85,98 with the percentage ranging from 16.7%98 to 82%85)

• other services, which included outpatients or other psychiatric facilities (n = 1;65 12.2%65).

Emergency department visits post discharge

Repeat emergency department visits post intervention were addressed in nine studies32,34,62,66,72,74,75,86,89 at the following time points post discharge: within 72 hours,74,75 within 1 month,32 within 30 days,66,89 within 6 months,86 within 12 months34,72 or within 18 months. 62

Family functioning/empowerment

Six studies (across seven reports33,61,64,79,82–84) addressed family functioning or empowerment. This was measured using the Family Adaptation and Cohesion Scales – Version II (FACES II),61 the Family Adaptation and Cohesion Scales – Version III (FACES III),64,79,82,83 caregiver self-reports on the Global Severity Index of the Brief Symptom Inventory,64,79 the Family Empowerment Scale84 or the Conflict Behaviour Questionnaire. 57

Length of stay

Two studies59,87 provided descriptive information regarding LOS across the inpatient crisis programmes/interventions and ten studies58,65,67,71,72,74,75,86,89,132 investigated the impact of a variety of interventions on LOS.

Completed suicide and suicide attempts

Four studies32,57,78,86 investigated the incidence of attempted or completed suicide at different follow-up points post intervention.

Suicidality

Five studies (across six reports32,57,82,83,86,87) reported on levels of suicidality measured using the Harkavy–Asnis Suicide Scale (HASS),57,82,83 the risk factors subscale of the CAPI,87 the Spectrum of Suicidal Behaviour Scale (SSBS)86 and the Reasons for Living Inventory for Adolescents. 84

Post-discharge use of services/resources

Four studies (across six reports57,82,83,86,89,93) investigated the effects of interventions on resources and/or patient treatment accessed post discharge.

Self-esteem/self-concept

Three studies (across five reports61,64,79,82,83) investigated the impact of the intervention on levels of self-esteem64,79,82,83 or self-concept. 61 The instruments used included the Rosenberg Self-esteem Scale,82,83 the self-esteem subscale of the FFS64,79 and the Piers–Harris Children’s Self-Concept Scale. 61

Impulsivity

One experimental study (across two reports82,83) investigated the impact of the intervention on levels of impulsivity using the Impulsiveness Scale.

Satisfaction with mental health crisis services/programmes

Aspects of satisfaction with mental health crisis services/programmes were reported in nine studies64,74,75,77,84,85,88,92,132 and one organisational report. 96 Five studies64,74,84,92,132 looked at client satisfaction defined as satisfaction with the mental health crisis service/programme by patients, their parents or guardians, which was measured using Lubrecht’s Family Satisfaction Survey (LFSS),64 the Client Satisfaction Questionnaire,61 a telehealth satisfaction survey74 or satisfaction questionnaires developed specifically for the studies. 92,132

Health-care staff satisfaction with mental health crisis services/programmes

Four studies74,75,85,96 investigated health-care staff satisfaction with the service. Satisfaction was measured with a telehealth satisfaction survey74 or with satisfaction questionnaires developed specifically for the studies. 75,85,96

Satisfaction with clinicians who delivered the mental health crisis service/programme

Satisfaction with the clinicians who delivered the mental health crisis service/programme was explored in two descriptive cross-sectional studies. 77,88 Satisfaction was measured using a satisfaction questionnaire developed specifically for the study77 or using an adapted version of the Quality of Care Parent Questionnaire. 88

Randomised controlled trials

The methodological quality of each of the four RCTs (reported across eight reports57,61,64,78–81,84) was judged against the relevant 11 quality criteria used in the CASP checklist and each is summarised in Table 7. Five reports64,78–81 reported on different elements of the same multisystemic therapy (MST) intervention and were appraised as one study. Only one study57 scored highly, answering ‘yes’ to all the questions on the checklist. Two studies61,84 did not provide enough information to determine if true randomisation had taken place (question 2), stating that randomisation had been performed, but no further details were provided. In one study,61 not enough information was provided to determine whether or not all participants had been accounted for at the end of the trial (question 3). Two studies57,84 blinded recruitment and assessment staff (question 4). For one study,64,78–81 the experimental and control groups were not treated identically because of the nature of the intervention and control (question 6). All of the studies reported results for all the outcomes (question 7). Only one study57 reported confidence intervals (CIs) with regard to the precision of the estimate of the treatment effect (question 8). Owing to the way the sample was recruited, it was difficult to say whether or not the results were generisable across two studies (question 9). 61,64,78–81 It was not evident whether or not the benefit of the intervention was worth the harms and costs in one study57 (question 11).

Quasi-experimental studies

The methodological quality of each of the four quasi-experimental cohort studies (reported across six reports82,83,86,92,93,132) was judged against the nine quality criteria used in the Joanna Briggs Institute checklist and each is summarised in Table 8. When multiple reports existed for the same study, these were appraised as one study. Three studies82–83,86,92–93 scored highly, with one pilot study132 included that had a lower score. For one study,92 there were some differences between the study group and matched comparison group (question 2). Another study86 did not delineate between the control group and the experimental group in terms of loss to follow-up (question 6), but, overall, this was low (3% at 2 months and 8% at 6 months). For one other study,132 all carers who were able to be contacted took part in the survey and differences between groups were taken into account in the analysis.

Cohort studies

The methodological quality of each of the 13 cohort studies32,34,62,65–68,71,72,74,75,87,89 was judged against the relevant quality criteria derived from the Scottish Intercollegiate Guidelines Network Methodology Checklist 3: Cohort Studies46 and each is summarised in Table 9. All 13 studies were judged to be of acceptable quality, indicating that some flaws in the study design were present with an associated risk of bias. For two studies,34,67 it was not possible to determine if the two groups being studied were from the same source population and for a further one study74 the two groups were from different populations (criterion 2). The retrospective cohort study conducted by Maslow et al. 66 did not have a comparison cohort (criterion 2). Four studies66,75,84,89 did not identify any confounders and in one further study34 it was not possible to determine this information (criterion 13). Only three of the studies62,68,75 provided CIs as part of the statistical analysis (criterion 14). Although the study by Greenham and Bisnaire87 was a retrospective study, 89.8% of parents/guardians gave informed consent for the use of their clinical information for research purposes. Three studies34,71,89 utilised both retrospective and prospective samples, with the retrospective data used as the control group.

Descriptive cross-sectional studies

The methodological quality of 10 descriptive cross-sectional studies58–60,63,69,73,77,85,88,98 was judged against the 12 quality criteria used in the Specialist Unit for Review Evidence tool47 and each is summarised in Table 10. Five studies60,63,69,73,77 failed to clearly state the study design. All studies addressed clearly focused questions apart from one73 in which it was unclear. All studies selected participants fairly and all provided details on participant characteristics, apart from Walter et al. 77 who provided details of students attending schools in general rather than of those in crisis. Two studies63,98 did not provide adequate details of their methods of sampling and in a further two studies77,85 it was unclear whether or not the outcome measures were appropriate. One evident weakness of most studies was description of statistical methods, which was good in only four studies. 77,85,88,98 Results were well described in all 10 studies. 58–60,63,69,73,77,85,88,98 One study77 failed to provide information on participant eligibility. No studies reported any sponsorship/conflict of interest and three studies60,63,73 failed to identify limitations.

Qualitative studies

The methodological quality of each of the 11 qualitative studies70,76,90,91,94–97,99,100,133 were judged against the 10 quality criteria used in the CASP qualitative checklist44 and are summarised in Table 11. Only one study100 discussed whether or not the relationship between researcher and participants had been adequately considered, indicating an overall weakness in reporting this concept. Across four studies,90,91,96,99 not enough information was provided to state definitively whether or not the research design was appropriate to the aims of the research (question 3). The recruitment strategy was unclear for two studies91,94 (question 4). Three studies76,96,97 did not state whether or not they had ethics approval (question 7). Six studies90,91,94–97 failed to identify whether or not the data analysis was sufficiently rigorous, with a lack of in-depth description (question 8).

Emergency departments

Eight reports89,110,115–117,119,123,124 described mental health assessment tools for paediatric emergency department clinicians, which included the HEADS-ED,110,116,117 HEARTSMAP89,119,123,124 and a Mental Health Assessment Triage Tool. 115 Four reports88,120–122 described urgent follow-up models after initial assessments had taken place at the emergency department. Two reports67,85 described the addition of involving trained mental health workers within a medical emergency department setting. Another report132 described Kids Assessment Liaison for Mental Health (KALM), which sought to build extra capacity for an emergency department medical officer to complete the assessment and to link with an on-call psychiatrist regarding an assessment and management plan. A further two reports71,74 described videoconference-based psychiatric emergency consultation programmes (i.e. telepsychiatry). One further report110 described the enhanced care co-ordination model for all CYP aged 0–21 years presenting with mental health concerns. The model involves a comprehensive needs assessment, a review of the CYP’s current use of services, and a package of medical and behavioural health follow-up with support for the family. 110

A case example95 described a 24 hours per day, 7 days per week (24/7), service that used a model in which the crisis response home treatment team worked together with Rapid Assessment Interface Discharge professionals. CYP were assessed by mental health practitioners in emergency department within 2 hours and then linked with onward support. 95 Another case example135 described a crisis service that provided assessments in the emergency department within 4 hours and appropriate follow-up care, which was available beyond normal office hours. The aim of the service was to prevent admission, and support could be provided for up to 6 weeks. 135

Educational settings

Four reports60,69,73,136 investigated CYP who presented within educational settings, of which three60,69,73 explored the use of the Prevention of Escalating Adolescent Crisis Events (PEACE) protocol within US high schools. This protocol involved an in-school facility in which high school-aged children could be assessed by psychology services before referral on to appropriate mental health services. The fourth report136 presented an urgent evaluation service for students, which aimed to provide ambulatory psychiatric evaluation within school hours, offering same-day assessment, co-ordination of care and linkage to the emergency department within the same hospital if required.

Telephone triage

Two reports102,110 described crisis telephone services within the USA in which onward referrals were made to appropriate services. One case study110 described a triage approach that responded to CYP presenting with mental health crises. This allowed for all referrals to access care via a single point of access telephone number between 9 a.m. and 9 p.m. The response time was determined by the location of the CYP and so ranged between 4 and 24 hours. Further assessment was carried out by either a consultant or the crisis team.

Out-of-hours mental health services

One report130 described an out-of-hours mobile crisis team for child care/custody protection services, as well as mental health-care providers in the region. One case study130 described a street triage model that enabled police officers to seek immediate consultation, advice or face-to-face support from a specialist mental health practitioner in making an assessment between 6 p.m. and 2 a.m. about anyone they encountered with an apparent mental health crisis. This triage model was for all ages and was not specifically for CYP. The aims of this model were to reduce the use of Section 136 Mental Health Act 1983137 and to provide more appropriate response to people’s mental health needs. (In England and Wales, Section 136 of the Mental Health Act 1983137 refers to powers that police have to move a person from a public space, when they appear to be suffering from mental disorder, to a place of safety.)

Telephone support/counselling

One report101 described a telephone-based approach for CYP experiencing crisis, with which follow-up, emergency support and telephone tracing for those feeling suicidal were made available. The case example138 described Childline139 and the Samaritans,140 which provide support for people in mental health crises, particularly those who feel suicidal, with Childline in particular aimed at CYP aged < 19 years. Although both Childline139 and the Samaritans140 offer support via telephone and e-mail, Childline139 also has a live webchat facility.

Text-based support/counselling

Three reports99,104,109 described text-based support for CYP experiencing any type of crisis. All three reports99,104,109 involved possible onward referrals or further support following initial contact. The case example138 described a 24-hour text messaging service for young people in crisis called SHOUT. SHOUT used artificial intelligence to assist the prioritisation of messages before young people making contact were assigned to a volunteer.

Telephone and text support/counselling

One report127 described a joint telephone and text-based support service for university students in crisis with possible onward referrals to general practitioner (GP) medical services and university support services.

Online mutual-help groups

One report118 described peer-run online support for young people experiencing mental health issues, including suicidality. Responses were provided by trained volunteers within 24 hours of posting.

Inpatient services

Eight reports70,72,87,106,108,128,129,131 described inpatient models of care in response to CYP experiencing crisis. There was a number of theoretically informed therapeutic approaches employed, including psychoanalytic therapy,128,129 solution-focused brief therapy131 and motivational therapy,131 as well as a broader approach to brief crisis intervention. A case example141 described a purpose-built inpatient unit that also contained a dedicated S136 facility alongside the specialist intensive care and generic wards. Section 136 of the Mental Health Act 1983 (2008) gives the police the authority to remove people from a public place of they believe that they need immediate help and are suffering from a mental disorder. The police then transport the person to a place of safety.

Outpatient mental health programmes

Seven reports34,63,66,86,92–93,110 explored outpatient mental health programmes. One study110 involved an outpatient crisis programme for CYP with high levels of mental health risk or behavioural difficulties experiencing a crisis. Three studies34,86,93 involved rapid response outpatient models for adolescents presenting to paediatric emergency departments following suicide attempts. One study63 described an adolescent crisis service within an outpatient clinic for those in rural areas and a further study66 described an integrated paediatric mental health outpatient clinic that was designed to enhance capacity for urgent assessments.

Mobile crisis services

Four reports62,68,113,114 described mobile crisis services. One report113 explored a mobile crisis intervention service, which involved rapid deployment to home or community locations, warm telephone lines (i.e. a crisis line run by peers), crisis stabilisation, crisis safety planning and short-term treatment. Two reports62,114 described emergency mobile psychiatric services that provide crisis stabilisation and support, screening and assessment, suicide assessment and prevention, and a brief solution-focused intervention. One of these reports114 was a description of the programme and the other62 examined whether or not the programme was associated with reduced behavioural health emergency department visits for those who had used the service. One study68 described a mobile response team for CYP at risk of endangering themselves or others. All services provided referral and linkage to ongoing care within community or inpatient settings.

Crisis services or interventions initiated within the emergency department

Two reports105,110 explored crisis services initiated within emergency departments. One report105 described a paediatric psychiatry crisis service that included post-discharge monitoring for those experiencing suicidality, including onward referral to outpatient services. The other publication described a response model110 for CYP presenting to the emergency department in psychiatric crisis. In this model, referral for additional mental health services could be provided, including long-term crisis stabilisation treatment (up to 6 months).

Three reports considered family-based crisis interventions (FBCIs). 32,84,107 FBCIs are interventions conducted in the emergency department that look to stabilise suicidal adolescents within a single visit so that they may return home safely with their families. One report107 presented a detailed description of the intervention and a further two reports32,84 explored the feasibility and safety of FBCIs32 and detailed the efficacy outcomes. 84 Six reports33,57,82,83,111,147 explored Family Intervention for Suicide Prevention (FISP). FISP was designed to be used during emergency department visits and sought to deliver an intervention improving outcomes for suicidal youths and enhance motivation for follow-up treatment. Two reports33,83 presented in-depth descriptive details of the intervention and a further three57,82,111 reports described a RCT that tested the effectiveness of the intervention across different periods of follow-up.

Increasing paediatric mental health expertise in the emergency department

In the specific context of the emergency department, two reports65,75 described services with the goal of increasing the availability of specialist mental health staff as a route to responding more effectively to CYP’s crises. The first report65 involved additional training for psychiatric professionals in an emergency department for those presenting in crisis. The second report75 described the implementation of a dedicated mental health team within an emergency department for children presenting with psychiatric complaints (excluding self-inflicted injuries).

Home- or community-based crisis programmes

Two reports61,103 described three models of intensive in-home services: (1) home-based crisis intervention (HBCI), (2) enhanced HBCI (HBCI+) and (3) crisis case management (CCM). One of these reports103 described the three services and a further report61 sought to determine the effectiveness and compare all three models across a range of outcomes for children in psychiatric crisis. Home-based MST for CYP presenting to emergency departments or inpatient services with psychosis, or with suicidal or homicidal ideation or threat, was the focus of six reports. 64,78–81,112 One of these reports112 described the adaptation of MST for use in youths presenting with psychiatric emergencies and a further five reports64,78–81 tested the effectiveness of MST compared with hospitalisation across a range of outcomes and different periods of follow-up.

The case examples142,143,146 described a number of different approaches to home-based crisis care within the UK. The first case example142 set out CYP mental health local transformation plans, including the development of a number of intensive home treatment services in the UK. The service was designed to help CYP at risk of admission by providing direct care through daily visits at home. The service also aimed to support other non-specialist professionals who care for CYP in crisis by providing consultation, for example in emergency departments. The publication by the National Collaborating Centre for Mental Health on ‘All Age Crisis Care’143 provided a description of a CAMHS home treatment team as an example of positive practice. Young people who had been identified as requiring an inpatient admission were offered care at home, and the team then worked to discharge them as soon as possible and to provide them and their family with practical support. 143 Five areas from the east of England provided information on their current crisis service, their responses to mental health crises of CYP and three case examples that detailed home-based services. 146 One home treatment team was designed as a hospital avoidance service in which the home treatment team provided a service to CYP aged 2–18 years with complex needs who would otherwise have been admitted to hospital, or to CYP discharged early. An intensive community outreach service offered intensive home-based care following a rapid assessment. This service was aimed at CYP aged 11–17 years with severe, enduring or complex mental illness, or at those who found engaging with services difficult. Both mental and physical health needs were addressed by this service. The aims of these services were to reduce costs associated with inpatient care and to keep the CYP as close to home as possible. A tertiary service provided CYP aged 12–18 years with additional support alongside other involved providers at transitional points, such as following discharge after self-harm, before a planned admission or following discharge from inpatient care, or to avoid admission.

Four reports125,126,141,143 provided descriptions of services that were organised and located within CAMHS. The reports described the safety first assessment intervention (SFAI), which provides an assessment and family-focused intervention delivered by CAMHS clinicians working within an intensive care and assessment team for high-risk CYP. The focus of the SFAI is to assist the young person and their family to achieve both physical and emotional safety. 125,126 One report presented a description of the SFAI and a further report described the safety first model that underpins the intervention. A case example presented within the Care Quality Commission report, A Safer Place to Be,141 also described how safety planning was integrated into existing processes, including liaising with police to avoid the application of Section 136 Mental Health Act 1983. 137,141 The report by the National Collaborating Centre for Mental Health, All Age Crisis Care143 provided a description of a CAMHS Crisis, Liaison and Intensive Home Treatment Team as an example of positive practice. The focus of this service was to provide comprehensive mental health and risk assessments to CYP in crisis, including follow-up support, intervention options and transition to adult services. The service collaborated with CYP, their families or carers and relevant professionals to co-produce personalised crisis care plans. This collaborative model was also described as being used for future service developments.

School–hospital partnerships

One report77 evaluated the implementation of a school–hospital partnership using a model of multitiered systems of support to deliver crisis management in acute mental health crisis.

Crisis programmes located within residential treatment centres

Two reports58,59 described an on-campus crisis residence programme as an alternative to hospital treatment for boys aged 5–17 years who were experiencing a psychiatric crisis while residing in a RTC.

Multicomponent or multiagency services

Three reports113,148,149 described the use of multicomponent approaches to crisis care. The Ventura County Children’s Crisis Continuum is a continuum of services providing three levels of care:113 (1) a mobile crisis team offering de-escalation and safety planning at home or in the community, (2) a crisis stabilisation unit providing a brief admission of < 24 hours for assessment and safety planning and (3) a crisis resolution team offering therapeutic treatment for a few months for two CYP at a time. The Solar community crisis resolution team offer both a working hours and an out-of-hours service 7 days per week. 149 The service aims to triage CYP within 1 hour of referral and to complete assessments with 4 hours in which both home and community treatment are offered. Ribbers et al. 148 described a crisis and transition services model that was an emergency department diversion programme that provided transitional clinical care and offers safety planning, lethal means restriction counselling, 24-hour crisis support and care co-ordination. Other services variably included in-home individual and family therapy, psychiatric evaluation and medication management, and family peer support.

A case example from the HoNOSCA crisis team described a multiagency team that offered wraparound 24/7 care to CYP in crisis at their homes. 143 Another case example144 offered a range of different approaches, including out of hours, self-referral ‘havens’, targeted intervention for vulnerable CYP, a day service, and a specific out-of-hours and weekend crisis service offering assessments, home visits and a residential unit for up to 10 days. The final case example145 provided 24/7 multiagency crisis response teams, all-age Rapid Assessment Interface Discharge teams, intensive home treatment teams, access to safe zones, enhanced community support over 7 days and 72-hour crisis beds.

Generic crisis services

One report94 provided information on three generic services that contained components addressing crisis care. The first generic service was a city centre providing early intervention in crisis that took referrals from GPs and CAMHS and self-referrals for CYP aged 13–25 years with a range of mental health problems. Another generic service was for CYP aged 16–25 years experiencing distress/crisis with referrals accepted from professionals, families and friends, and self-referrals. A large variety of interventions was provided for those experiencing distress/crisis, including drop-in support with attending other services, intensive support and child care for 24–48 hours. A third generic service involved self-referral support and catering for CYP aged 16–21 years already using other services. The service provided a rapid response to those suffering from crisis, with onward referral and signposting to other agencies, with referrals also accepted from the organisation’s support workers.

Recommendations for initial assessment in the emergency department

Several recommendations relating to initial assessment in the emergency department were evident in the literature, including:

• national development of all-age liaison psychiatry services in accident and emergency departments3

• assessments to be undertaken in a separate age-appropriate area of the emergency department, thereby reducing the impact of the environment on CYP’s mental health135,143,150,151

• assessment undertaken by professionals with expertise with this client group135,150–152

• assessment to be conducted in a non-judgemental manner and to be developmentally appropriate135

• assessment to be sensitive to the needs of the CYP135,153

• both a physical health and a mental health assessment to be included150,154

• alternative locations for crisis assessments to be identified, such as crisis cafes. 143

In line with National Institute for Health and Care Excellence guidance,150 after being assessed in the emergency department, CYP (especially those who have harmed themselves) normally require admission to an inpatient paediatric or medical ward for a full physical and psychosocial assessment. 150,152–154 Sometimes admission is required because of safeguarding or social concerns. 135 However, the Royal College of Emergency Medicine disputes this practice because of the lack of evidence of its benefit. 152 It is also important that clear follow-up pathways are developed with multidisciplinary CAMHS input. 135,151,154

It is considered essential that all emergency department staff have the appropriate skills and understanding about the mental health needs of CYP,135,154 especially those who are vulnerable because of family instability and mental health stigma. 135,151 Specialist liaison professionals can be available to offer support, supervision and advice to emergency department staff,135,151,154 and where this is not available contact with local on-call mental health services has been suggested. 135 Paediatric liaison teams provide crisis assessments within acute hospital settings and this can include short stays, including multidisciplinary interventions, to avoid admission for inpatient psychiatric care. 146 However, although liaison improves links between CAMHS and emergency department staff, the commissioning and provision of these services in acute settings in some regions in the UK has been reported to be varied. 155

The importance of providing home- or community-based crisis support

It is recognised that the first port of call if a CYP needs help for a mental health crisis should be in the home or the community and that admission to hospital should be avoided if possible. 24,145,156 If CYP do need to be admitted, then this should be as close to home as possible so that local teams can maintain contact with families and carers,24,145 unless they are factors in the crisis. 24 Families are acknowledged as being able to make an important contribution to the planning and provision of care to CYP in crisis. 145,157,158

In the UK, services can follow the CYP from hospital to home, such as the tier 3.5 or tier 3 + teams,146 crisis care home treatment teams146 or intensive outreach services,159 which are designed to support early discharge from hospital by offering intensive home treatments with the goal of preventing re-admission. Alternatively, intensive home treatment is designed to help avoid admission by providing a home-based intervention. 17,146,157,160

With regard to CAMHS, a recent NHS benchmarking exercise identified that only 40% of CAMHS networks currently have community-based crisis response services. 146 There are several different models available, such as clinic based, assertive outreach, home treatment155 or intensive community treatment,21,146,155,161 which are provided by professionals with appropriate training in risk assessment,153 who receive supervision162 and adhere to best practice principles. 163

From the literature in this chapter, examples of innovations in crisis care include locating a CAMHS in an emergency department that operates 7 days per week from 8 a.m. to 11 p.m. to ensure that CYP can be seen in a timely manner by specialists,164 a CAMHS-operated telephone support service,164 ‘crisis plans’ or ‘crisis cards’ so that CYP and their families know what to do in a crisis situation164 and Saturday morning clinics for CYP on the waiting list. 164 Services also needed to ensure that an assertive approach to follow-up of those who do not attend appointments was undertaken. 146 It has been suggested that CAMHS should use their webpages to inform CYP and families of what support is available to them, including information on support available in a crisis, which should contain details of out-of-hours services. 165

Places of safety

In the UK, all people experiencing mental health disturbances (including CYP) to a degree that might be harmful to themselves or others can be moved to a ‘place of safety’ by the police. Section 135 or 136 of the Mental Health Act 1983 for England and Wales137,162 gives police the authority to act in these situations and move the person to an appropriate location.

The creation of dedicated Section 136 facilities for CYP is recommended,141,145,166 as long as this is linked with other facilities with adequate staffing. 158 These facilities should have separate entrances, have sufficient staff who are appropriately trained, have been checked through the national Disclosure and Barring Service, and have access to additional support should de-escalation or restraint be required. 158 Such facilities can be located across a variety of settings and include adolescent mental health inpatient units, hospitals, paediatric wards or any other suitable places. 158,167 An example of one such place of safety is a designated under-sixteens safe space attached to one local inpatient CAMHS unit. The safe space is staffed by experienced professionals, in a suitable environment, who can access a dedicated on-call consultant psychiatrist as required. The safe space has resulted in a dramatic reduction in the numbers of CYP being inappropriately held in police custody. 141 There are some specific suites for CYP in emergency departments,155,158,167 but these are not widespread. 155

The inappropriateness of the places of safety that are sometimes used for CYP, such as adult mental health facilities24,141,158 and police cells,24,25,159,162,168,169 has been widely reported. Police cells should be used in only very exceptional circumstances when the immediate safety of a CYP requires it. 24 In these instances, a protocol needs to be developed between relevant services to guide practice in that situation. 155

Several recommendations exist for the exceptional situations in which CYP are detained under Section 136 in a police cell:

• an assessment should be carried out by professionals suitably qualified and experienced in working with CYP167

• a review should be undertaken, ideally with an multiagency approach of the CYP’s care, within 7 days158

• the detention should be reported as a ‘serious untoward incident’ for governance purposes. 25,141,158

Ideally, the police would work proactively with mental health-care professionals (HCPs) to plan how the needs of CYP presenting in mental health crises are collaboratively addressed. 20,155 Whenever CYP have been detained under Sections 135/136 of the Mental Health Act, these data should routinely be collated and reported for quality assurance and monitoring. 158

In some areas of the UK, where no specific places of safety are identified,3 it is acknowledged that there is a need for a clear pathway for those CYP detained under the Sections 135/136 of the Mental Health Act137,143 other than a police station. This pathway needs to be age appropriate and used only as a short-term measure (up to 72 hours) while a longer-term plan for that CYP is developed. 141,145,158,159 It is acknowledged that there might be a difference in what can be considered suitable in an emergency compared with longer-term care. 170 Sometimes the police do not know how to access mental health care and it has been suggested that there needs to be some form of advanced agreement about how police can access the facility or pathway. 135,141,155,162,167

General characteristics of a crisis response

Service eligibility

Participants in one study70 described how having diagnostic-specific eligibility criteria in place for free or reduced-cost care had prevented them previously accessing the service. Other services had a threshold, such as suicidality, before offering a service to CYP. 76 Families of CYP who had accessed a crisis helpline felt that their definition of crisis was not the same as that of the call handlers and as a result felt dismissed by the service. 76 Across the UK, it was noted that those with less severe mental health problems were not eligible for specialist CAMHS and, consequently, these CYP felt that there was nowhere to turn to other than the emergency department when they needed help. 188

Knowing where to go when in crisis

Being unsure as to what relevant services exist, where to locate them and how to access them was found to prevent CYP from getting help. 100 Some CYP had heard of mental health services but did not know what they provided or how to get in touch with them. Although services may have had a web presence, with details of a mobile psychiatric team,100 this was too vague and more information about how the service worked was wanted. The lack of direct telephone numbers made it difficult to make contact or several attempts were needed to navigate through a web of services before accessing the right one. 70,100 Friends and relatives of those who had taken their own lives commented that they had been unaware of how to manage or help people at risk of suicide before it had become an issue for them. 133 Stakeholders in the UK felt that this lack of information for family members could be one of the reasons why there was an increase in use of the emergency department when CYP were experiencing crisis. 146 Knowing of friends and/or family members who had already accessed services was also described by some interviewees as an important means of finding out what support was available. 70 Some CYP initiated initial contact via walk-in crisis services or hotlines, or through meetings that had been previously scheduled if they were already known to mental health services. 76 The lack of information for parents/carers was highlighted as a factor that potentially had an impact on the increased use of emergency departments. 146

Access to mental health services and professionals

Children and young people frequently described wanting easier access to inpatient and outpatient mental health services and specialist professionals. 94,97,146 Suggestions included more informal walk-in/drop-in services without having to have an appointment,94,97 24/7 provision,94,146 and clear and single points of access. 146 Some CYP described wanting immediate help, as they found that they had to wait too long for appointments after initial contact was made and felt that their condition deteriorated as a result. 95,100,146 One report146 explored what parents would like to happen when CYP were experiencing crisis, and responses included timely support, service cohesiveness and ease of access. Parents reported wanting to be able to access appropriate and timely support or advice at all times, including out of hours. Having a single point of access to services was noted as helpful, as opposed to having numerous different services with different means of accessing these. 146

Support from others during times of crisis

Having someone to talk to in times of crisis, whether this was a friend or family member, was seen as important. 97,100 Some CYP felt that talking to someone in confidence outside the family, such as a teacher, school counsellor, community nurse, emergency department staff, priest or GP, who could be trusted and provide a non-judgemental atmosphere, was also crucial. 97,99

However, some CYP described feelings of hopelessness and being unable to confide in others. 97,133,172 Some CYP did not want help at times when they felt suicidal, and young men in particular identified that they struggled to open up to others. 97 From the perspective of family and friends of those who had taken their own lives, people reported that the CYP had found it difficult disclosing the details of their emotional state to their GP, partly because of the short consultation time, their lack of relationship with the GP or the GP’s perceived insufficient knowledge. 133

Some families felt that one of the key facilitators that enabled them to access support was existing relationships with professionals, such as school personnel, police, parole officers, counsellors and child protection agencies. 76 Having support from significant people in their lives (family, friends, teachers, etc.) was seen as being key to accessing support for some, particularly during times of poor mental health and diminished capacity, making it difficult for individuals to actively seek help on their own behalf. 70,100 Parents, and other family members, in particular, were important, as they could provide practical help and accompany CYP to their appointments. Parents were also able to provide information, as well as signpost to appropriate services and community resources. 70

External factors that influence access

The external factors that influenced a child or young person’s and/or their parents’ ability to access crisis services included financial concerns and difficulties with transportation. Financial concerns were evident in US studies for those who were not covered by insurance or who had poor financial resources. 70,76

It was reported by CYP that transportation to the crisis service in some instances was provided by the police, other service providers, secure transport companies and family members or significant people in their lives,70,76 and in other cases CYP walked or took public transport. 70 For some, not having access to transportation was considered a barrier70,76 and parents with a child displaying challenging behaviour who did not have their own transport described avoiding public transport because of the inherent difficulties with it. 76

Transitions across services

In a study70 that looked at uninsured young adults, other social service organisations, such as domestic violence counsellors, homeless services, criminal justice and substance use services, facilitated access to help by providing referrals or transport. However, it was often reported that there was a lack of continuity in mental health service provision following a young person’s discharge from the criminal justice system where mental health care had been provided. 70 Another study76 described lack of communication and collaboration between child welfare, school systems and mental health providers as a common barrier exerting an effect on service quality. Findings from interviews with young people told of a young person being ‘shuttled around groups’ and ultimately taking their own life. 172 In other studies,146 youths stated that they did not want to be ‘passed around’ services when they are in crisis. Where specific crisis intervention teams had been created, there was an improvement in their willingness to collaborate with specialist CAMHS, accident and emergency services, and paediatric services, and this resulted in noticeable differences. 20 Where investment had been made into specific crisis services (e.g. emergency liaison, crisis outreach), the collaboration between CAMHS, emergency department and crisis care was improved and, therefore, more accessible. 20,146 Parents viewed the sharing of information between agencies and sectors as important, enabling all involved professionals to have access to the same information about young people and their families. This helped avoid having to repeatedly keep providing the same information. 146

Importance of lived experience and peer support

Some young people identified the importance of peers, who have experienced mental health difficulties in the past, working alongside HCPs and counsellors in any service. Moreover, being able to meet up and share with others who had had similar experiences was crucial. 97 Peer support in schools and youth work settings was also seen as important, along with more training for teachers in mental health issues so that teachers could become more aware of how best to support young people when in mental health crisis. 94

Services specifically for young people

Many CYP felt that there should be services catering specifically to them. 94,97,146 Specific types of crisis support were also needed, and older youths felt that it would be helpful if there were services targeted specifically at 16- to 25-year-olds that are ‘young people-friendly’ in design and approach. 94 In one area, there was a request for services for the under-fourteens because there was no crisis care for this group. 146

Attributes of health professionals

Parents wanted health professionals to understand that a crisis for a young person was also a crisis for parents. 146 CYP felt that when they are in crisis they would like a choice of workers so that they can build rapport with someone. 94 CYP wanted those caring for them to be sensitive94 and compassionate to their needs,146 to listen to what they say146 and to exhibit transparency. 146 CYP also wanted to be seen as a ‘real person’ and to feel understood. 146 Skilled support was also highlighted as being important, specifically the ability to ask the right questions, to navigate the system and to be clear on next steps. 146 Many CYP wanted drop-in crisis services to be staffed by youth workers with knowledge of mental health. 94 Others had concerns that staff within other crisis services were not sufficiently trained to help those with mental health issues, especially in the emergency department. 146,164 A potential solution suggested by CYP with experience of crisis services was for them to become involved in staff training94,146 so that a more sensitive service could be provided. 94

Need for different forms of support and pathways to services

The need for different forms of support and pathways to services was identified by CYP, including through telephone,94,97,100,146 text99,146 and e-mail. 100 Those who preferred to use the telephone to make contact said that they would want to have access to a direct number, as being passed back and forth was found to be frustrating. 100 Others wished for an out-of-hours telephone helpline staffed by skilled counsellors who also knew the available local services to signpost people to. 94 Those CYP who wanted to remain anonymous felt that being able to access staff this way would be helpful. 97 Texting services were seen as positive, and CYP described what they liked about them, which included immediate support, convenience, comfort, anonymity, having control, low cost, a distraction from rumination and negative thinking, and having the ability to store and refer back to the messages at a later date. 99

Parents felt that the telephone counselling services that their children had used did not provide timely services and that the duration of crisis counselling via a hotline was found not to be long enough. 133 There were some occasions when there was a mismatch between what a telephone hotline was offering and what parents wanted. 76 Hotline services worked well when parents could transport their children to the mental health centre or other location for assessment. However, hotline services were not helpful in resolving an immediate crisis with a child’s violent or dangerous behaviour and parents were often told to phone the police. 76 On other occasions, some families reported that hotline responders told them to ‘call back during business hours’. 76

Lack of support before crisis is reached

A general lack of support before crisis is reached was described by CYP. 94,95,133,172 This included being moved around services,95,172 not being taken seriously by GPs who often put CYP concerns down to age or hormones95,172 and HCPs being dismissive of the urgency of the situation and prioritising other issues. 172 Long wait times for mental health appointments after making initial contact with GPs70,95 and a lack of information for parents/carers on where to go if their child was in mental health crisis146 have also been reported by CYP and their families. In this context, the emergency department often became the default option for CYP when faced with a mental health crisis, particularly in instances of self-harm and/or overdose. 20,95,188 Calls have been made for crisis services to work with young people who feel that they are at risk of falling into crisis, helping them to develop strategies and access resources at an earlier point. 94

Stakeholders in the UK acknowledged that CYP often experience difficulties in accessing support from specialist CAMHS and/or primary care. 20,76,188 In some cases, it is because CYP are not considered eligible188 or because there are gaps in the availability or accessibility of appropriate care,76,188 in particular out of hours or crisis responses. 188

Assessment, management and follow-up in the emergency department

Family and friends of those who had taken their own lives felt that there had been a lack of appropriate hospital management of people with suicidal behaviour, with care often involving the patient just being given medication. 133 Parents and CYP reported that there were often long wait times in the emergency department, including during the triage process, often resulting in delays in receiving specialist mental health support. 76,95,100,146 Other negative experiences that CYP reported with regard to emergency department visits included the lack of suitability of the environment (specifically the noise, brightness and large numbers of people),146 the lack of mental health professionals 24/7,146 no privacy146 and poor attitudes of staff. 94,97,146 CYP, their friends and their families, and other stakeholders in the UK frequently raised concerns about the level of follow-up care after discharge from emergency department following a crisis. 20,95,97,133 However, some CYP described that staff were supportive and understanding in the emergency department. 97,153

Processes leading to inpatient admission and experience of inpatient care

The processes leading to admission when a child/young person was in mental health crisis were found to be overly complicated, lengthy and frustrating for both the child/young person themselves and their families. 70 This process may have occurred in community mental health centres, criminal justice locations or in emergency departments. The apparent lengthy wait appeared to be linked to the need for agencies to share information and for practitioners to be able to access previous medical records. The experience of receiving care, however, was reported by CYP as being positive,153 including CYP finding health-care practitioners to be positive and reassuring, and treatment relating to self-harming behaviour and the prescribing of medication to be effective. However, other CYP felt that they were being treated like a patient rather than a person. 94

Views of CAMHS and crisis teams

There were mixed views from CYP about CAMHS, with some finding them exceptional95 after an initial wait and others not pleased with their service. 133 The use of crisis plans as a contingency agreement was not common, even though it was felt that these plans were important. 146 Where crisis plans existed, they were insufficiently detailed, suggesting such interventions as calling the case manager, crisis hotline or police. 76

A further area in which views were expressed was in relation to the naming of ‘crisis services’. Some CYP reported that the term ‘crisis’ may deter some CYP from receiving help, as they felt that it assumes that they were already on a pathway to crisis, as opposed to actually being in crisis. 94

Inappropriate admissions to adult wards

When experiencing crisis, some CYP were sometimes admitted to adult or paediatric wards. 20,94,146 Front-line crisis mental health practitioners noted that, although considered inappropriate,20,146 when CYP needed admission, successful adaptations could sometimes be made for accommodation on adult mental health wards. Service providers from the UK in the report by Garcia et al. 94 described an example of a third-sector organisation that worked with adult mental health services to raise awareness of what the third sector can offer, and to connect with all young persons on adult wards during their admission. 94

Availability of a crisis team outside traditional office hours

It was acknowledged that demand also presents during evenings and weekends, and at these times crises could be exacerbated because of insufficient services. 20 The lack of availability of a crisis team and/or specialist CAMHS outside traditional office hours was frequently reported and, as a consequence, the emergency department was often the first port of call for CYP experiencing a crisis. 20,96,146,164 However, when CAMHS experts were available, this was seen by both service providers and CYP to be helpful. 96 The tension for commissioners was described as providing accessibility where demand dictates, without being wasteful with underused resources. 20 Young people often reported that they had to wait a long time to be seen out of hours. 146

Geographical boundary issues and variable service provision across different regions

Other barriers identified by both stakeholders and CYP across the UK were about accessing a service when the CYP originated from a different locality from where the service was sited,20,94 or where the CYP was 16–17 years and the age appropriateness of a service was unclear. 146 Although some areas had crisis services for CYP, availability in different areas was variable, with some services operating within office hours only. 146 Some CYP were admitted into hospital as a strategy to avoid breaching emergency department waiting times targets. 146 Referral onto statutory services by third-sector organisations was difficult when the child/young person lived outside the district and so involvement of a GP was sometimes necessary to facilitate this process. 94 Different processes to manage safeguarding were described, with some processes involving liaison nurses checking the reason for the CYP’s attendance at emergency departments. 146

CAMHS

Stakeholders in the UK presented a variety of views regarding CAMHS provision. It was felt that there needed to be fully supported community mental health provision for CYP to reduce the need for inpatient care and to reduce LOS. 20,141 It was also felt that developing community-based resources,141,146 such as assertive outreach,20 and early intervention were critical to reduce the need for admission into crisis beds. 20 Emergency department clinical leads and emergency department mental health departmental leads from across the UK reported that CYP did not have access to CAMHS in the emergency department and the only way that a child/young person could be assessed by CAMHS was for them to be admitted. 96

Police involvement and places of safety

Analysis of memos from police encounters with CYP in mental health crisis, and interviews with caregivers and siblings, revealed that the main reason for contact was to de-escalate situations such as self-harming, harming others and aggression. In such cases, the child/young person would be escorted to the emergency department for further mental health assessment. 90,91 Families of CYP admitted to a mental health ward stated that police officers had been involved as part of the crisis response to homes or schools, although families did not like the use of police in these situations. 76

InWales, UK police representatives reported that, despite an increase in the frequency of police having to manage mental health crises with CYP, there was optimism that increased resources would become available following government investment and through the introduction of the Mental Health Crisis Care Concordat. 20 The Mental Health Crisis Care Concordat is a national agreement setting out how services and agencies will work together to support people in crisis. This approach helps to address police concerns about their lack of suitable resources and appropriate training to be able to effectively help CYP in mental health crises. 20 One suggestion of how this could be applied is the introduction of a mental health practitioner in police control rooms to advise officers when they are faced with a CYP in crisis. 20

The police also have a role to play when CYP need a place of safety, and staff have raised concerns about the lack of appropriate facilities, suggesting that alternatives are needed. 141,146 Staff were aware that in some instances CYP were reviewed in police cells, although the police did seek alternatives, such as in residential units or emergency departments, where available. 141 In one area, it was reported that 41 CYP had been detained in police cells over the previous year. ¹⁴¹ Although this is ordinarily regarded as an unsuitable environment, there is an acknowledgement that there is a difference between what a suitable environment is for CYP in an emergency situation and what a suitable environment is in the longer-term provision. 141

Symptoms of depression

Two experimental studies (across three reports57,82,83) investigated symptoms of depression. Adolescents in a specialised emergency department programme conducted by Rotherham-Borus et al. 82,83 reported significantly lower levels of depression when assessed after the emergency room intervention (post-discharge assessment) than those who received standard care (mean Beck Depression Inventory score: intervention 12.6 ± 11.0 vs. control 15.9 ± 10.0; p < 0.01). For the emergency department-based FISP intervention conducted by Asarnow et al. ,57 there were significant improvements in levels of depression from baseline to follow-up post intervention [total CES-D score p < 0.05; odds ratio (OR) for severe depression 0.24, 95% CI 0.14 to 0.41].

Behaviour

One experimental study57 investigated behaviour. The study by Asarnow et al. 57 found that the FISP intervention did not lead to significant improvements in internalising and externalising behaviour (CBCL total problems in clinical range OR 0.52, 95% CI 0.30 to 0.90; p = 0.02).

Hospitalisation rates

Two experimental studies32,84 explored hospitalisation rates. Wharff et al. 32 conducted a pilot study of a FBCI for suicidal adolescents and their families and reported that none of the patients for whom data were collected at the 1-day follow-up required inpatient hospitalisation. At the 3-month follow-up, 12.7% of patients reported that they had been hospitalised since the initial emergency room visit, and of these patients only two (3.6%) were hospitalised because of suicidal complaints. Adolescents in the pilot cohort were significantly less likely to be hospitalised than those in the comparison group (36% vs. 5%; p < 0.0001). The same intervention was then tested by Wharff et al. 84 in a RCT, and adolescents who had received FBCI were significantly less likely to be hospitalised than those who received treatment as usual (TAU) (FBCI 38% vs. TAU 68%) (OR 3.4, 95% CI 1.7 to 6.8; p < 0.005).

Discharge destination

One experimental study that explored a FBCI, which was conducted by Wharff et al. ,32 looked at discharge destination. Wharff et al. 32 found that CYP in FBCI were significantly more likely to be referred to intensive outpatient than those in the TAU comparison group (FBCI 21% vs. TAU 5.3%; p < 0.001). 32

Emergency visits post discharge

An experimental study conducted by Wharff et al. 32 looked at the number of emergency visits post discharge. 32 No significant differences were reported in CYP needing another crisis evaluation since their initial visit to the emergency department between CYP receiving FBCI (13%) and CYP receiving TAU (4%) (p = 0.07).

Family functioning/empowerment

Three experimental studies (across four reports57,82–84) explored family functioning/empowerment. Wharff et al. 84 investigated the effectiveness of FBCI for suicidal adolescents and their families. Significantly higher ratings of family empowerment were reported post test by parents in the FBCI group than parents who received TAU (mean change in Family Empowerment Scale score: intervention group 2.7 ± 3.8, control group 1.0 ± 3; p < 0.005), which were maintained at the 1-month follow-up period (p < 0.001). Another study conducted by Rotherham-Borus et al. 82,83 reported that there were no significant differences in levels of family adaptability (p > 0.05) or family cohesion (p > 0.05) between receiving specialised emergency department care or standardised emergency department care at initial follow-up83 or 18 months later. 82 For an emergency department-based FISP intervention conducted by Asarnow et al. ,57 there were significant improvements in levels of family functioning from baseline to follow-up post intervention (p < 0.001).

Completed suicide and suicide attempts

Two experimental studies looked at the number of completed suicides and suicide attempts. 32,57 In a study conducted by Asarnow et al. ,57 for those receiving the FISP within an emergency department, it was reported that this did not lead to significant decreases in suicide attempts [intervention group n = 4 (6.4%), control group n = 5 (6.5%), OR 1.0, 95% CI 0.3 to 3.8]. Wharff et al. 32 reported on the implementation of a specialised family-based intervention conducted within the emergency department (FBCI) and found no incidence of attempted or completed suicide within 3 months of the intervention.

Suicidality

Three studies (across four reports57,82–84) explored suicidality. In a study by Rotheram-Borus et al. ,82,83 adolescents who took part in a specialised emergency department intervention had significantly lower mean scores for levels of suicide intent at post-discharge assessment than adolescents who received standard care (mean scores on the HASS: intervention group 1.4 ± 2.38, control group 2.1 + 2.86; p < 0.05). The emergency department-based FISP intervention conducted by Asarnow et al. 57 found no significant differences in levels of suicide intent at follow-up post intervention [mean scores on the HASS: intervention group 13.6 ± 13.3, control group 12.1 ± 12.2; adjusted odds ratio (aOR) (note that baseline suicide attempts were adjusted for site, gender, age and baseline CES-D, and that the follow-up analyses included additional variables of time to follow-up, baseline suicide attempts and baseline CBCL total problem score) 1.7, 95% CI –2.7 to 6.2] or suicidal behaviour (mean scores on the HASS: intervention group 3.2 ± 4.8, control group 3.6 ± 4.7, aOR –0.3, 95% CI –1.9 to 1.3). Findings from a study by Wharff et al. 84 indicated that all participating adolescents, whether in the intervention or control groups, reported lower levels of suicidality at post test and at 1-month follow-up than at baseline assessment. Further analysis did not find any significant differences between the groups (mean change in the Reasons for Living Inventory for Adolescents: intervention group 0.07 ± 0.44, control group 0.15 ± 0.45; p = 0.24).

Post-discharge use of services/resources

Two experimental studies (across three reports57,82,83) looked at post-discharge use of services/resources. One of the goals of the emergency department intervention (FISP) conducted by Asarnow et al. 57 was to link paediatric suicidal patients with follow-up mental health treatment. The findings showed that patients who received FISP were significantly more likely than those in the control group to be linked to outpatient treatment after discharge [intervention group 92%, control group 76%, aOR (adjusted for baseline score for the same outcome, days between baseline and follow-up, site, age, gender, CBCL total problems and CES-D) 6.2, 95% CI 1.8 to 2; p = 0.004] and to receive significantly more outpatient treatment visits (intervention group 5.3 ± 7.0, control group 3.1 ± 5.5, aOR 2.0, 95% CI 1.3 to 3.2; p = 0.003). The aim of the specialised emergency department intervention conducted by Rotheram-Borus et al. 82,83 was to assess the impact of the intervention on outpatient treatment adherence. Those CYP who received the specialised programme were significantly more likely than those who received standard care condition to return to the clinic for any outpatient treatment following their discharge from the emergency department (intervention group 95.4%, control group 82.7%, χ2 5.56, degrees of freedom 1; p = 0.018). However, there was no significant difference in the number of treatment sessions attended by both groups (intervention group 5.73 ± 3.40, control group 4.67 ± 3.71; p = 0.079). Logistic regression analysis was conducted to determine which variables predicted adherence to outpatient treatment. Higher suicidal behaviour scores (OR 1.30, 95% CI 0.00 to 0.46; p < 0.05) and higher self-esteem were significant predictors of completing treatment. It was also determined that those in specialised care intervention were three times more likely to complete outpatient treatment than youths in the standard care condition (OR 3.11, 95% CI 1.20 to 16.98; p < 0.02). Baseline suicidal ideation (OR 1.09, 95% CI 1.00 to 7.43; p < 0.05) was also associated with treatment completion, with the more ideation the CYP reported, the more likely they were to complete treatment. 82,83

Self-esteem/self-concept

One study (across two reports82,83) explored self-esteem. The introduction of a specialised emergency department programme in the study by Rotheram-Borus et al. 82,83 had no significant impact on levels of self-esteem immediately post discharge (mean score on the Rosenberg Self-esteem Scale: intervention group 29.0 ± 5.61, control group 27.6 ± 5.32; p > 0.05).

Impulsivity

One study (across two reports82,83) explored impulsivity. Rotherham-Borus et al. 82,83 reported that the introduction of a specialised emergency department programme had no significant impact on levels of impulsivity (mean score on the Impulsiveness Scale: intervention group 10.8 ± 4.69, control group 11.7 ± 4.37; p > 0.05).

Client satisfaction

One experimental study84 looked at client satisfaction. Wharff et al. 84 compared a family-based intervention conducted in the emergency department (FBCI) with usual care. Post test, parents/guardians whose CYP had been randomised to FBCI reported significantly higher levels of patient satisfaction than their usual care counterparts (mean score on the Client Satisfaction Questionnaire: intervention group 30.4 ± 2.4, control group 28.6 ± 3.3; p < 0.001).

Health-care staff satisfaction with mental health crisis services/programmes

Two descriptive cross sectional studies85,96 investigated health-care staff satisfaction with the service. Dion et al. 85 explored the emergency department staff satisfaction with the crisis intervention programme, which was collected in terms of both numeric data and open-ended responses highlighting satisfaction with all aspects of the programme, apart from availability of crisis intervention workers and, in particular, coverage during weekends and nights. Frequently reported strengths included reduction of emergency department physician workload, skills of the crisis intervention worker at managing and assessing patients, prompt access to mental health services and crisis intervention workers’ awareness of community resources. The Royal College of Emergency Medicine conducted a national survey with all of its members regarding the services and quality of care that CYP in the emergency department receive (93/240 members responded). 96 Sixty-two per cent of respondents reported that they felt that emergency department services for CYP presenting with an acute mental health problem were ‘poor’ or ‘awful’, with wide variability in availability of CAMHS and other specialist services, particularly at evenings and weekends. 96

Summary

What this evidence synthesis has shown is that crisis services/interventions initiated within the emergency department are effective in reducing depression (very low to moderate GRADE rating) and improving family functioning (moderate GRADE rating) or family empowerment (very low GRADE rating) between recruitment and follow-up periods. Mixed findings are reported regarding the number of outpatient visits attended, with one61 out of two studies reporting that those in the intervention group attended more outpatient treatment sessions (moderate GRADE rating). Mixed findings are also reported for suicidality, with only one82,83 study (across two reports) out of three studies reporting that the intervention was effective in reducing levels of suicidality (very low to moderate GRADE rating). CYP receiving crisis services initiated within the emergency department are more likely to be linked or referred to intensive outpatient care (moderate GRADE rating), to attend for outpatient treatment (very low GRADE rating) or to complete outpatient treatment (very low GRADE rating) and are less likely to be hospitalised (very low GRADE rating). CYP receiving crisis services initiated within the emergency department also report greater satisfaction with services than those in a control group (moderate GRADE rating). No differences are reported for behaviour (moderate GRADE rating), family adaptability (very low GRADE rating), family cohesion (very low GRADE rating), impulsivity (very low GRADE rating), self-esteem (very low GRADE rating), likelihood of repeat emergency department visit post discharge (very low GRADE rating) and number of completed suicides or suicide attempts between recruitment and follow-up periods (very low to moderate GRADE rating). Health-care staff are satisfied with some aspects of mental health crisis services/programmes that they provide, but are generally dissatisfied around the lack of out-of-hours availability.

Symptoms of depression

One experimental study, conducted by Huey et al. ,78 investigated symptoms of depression. A significant linear time effect (p < 0.001) for reduction of depression symptoms (across all measures) was found for those CYP receiving home-based MST at the time of crisis up to 1 year post treatment.

Psychiatric symptoms

One descriptive cross-sectional study98 and one experimental study (reported across two reports64,79) investigated psychiatric symptoms. Muskens et al. 98 investigated changes in the type and severity of mental health symptoms from admission to 2 and 4 months post discharge following a period of intensive home treatment combined with admission to psychiatric high and intensive care. A 53% reduction on mean HoNOSCA total scores after 4–5 months of treatment was observed (mean HoNOSCA total scores: admission 18.82 ± 5.18, 2 months 13.03 ± 5.06, 4 months 9.4 ± 5.16; p < 0.01). There were no significant moderating effects found for gender, age, primary diagnosis, clinical admission, home treatment time, additional therapy and medication. 98 Henggeler et al. 64,79 investigated differences in emotional distress in those receiving home-based MST compared with those who received usual services (i.e. emergency hospitalisation) at the point of crisis. Henggeler et al. 64,79 reported that CYP in both groups demonstrated clinically significant reductions in emotional distress over time (p > 0.05). 64 For those CYP in the MST condition, levels of emotional distress sharply declined during the first few weeks of treatment, levelled during treatment and improved slightly during follow-up. Those CYP in the emergency hospitalisation condition demonstrated a steady improvement in symptoms that levelled off during follow-up. 79

Behaviour

Two experimental studies (across three reports61,64,79) investigated behaviour. The study by Evans et al. 61 investigated the effectiveness of three models of intensive in-home services. Significant reductions in both internalising behaviour and externalising behaviour scores were reported from admission to 6 months post discharge for all programmes (p < 0.05). Henggeler et al. 64 compared MST with usual services (i.e. emergency hospitalisation) and found that at the time of completion of MST at 4 months, MST was significantly more effective than emergency hospitalisation at decreasing youths’ externalising behaviour (mean scores on the CBCL externalising caregiver report: MST 63.7 ± 12.4, hospitalisation 64.3 ± 14.2, p < 0.05; mean scores CBCL externalising teacher report: MST 67.8 ± 15.1, hospitalisation 38.0 ± 13.0, p < 0.05). However, these differences were no longer significant at 12–16 months’ follow-up. 79 Henggeler et al. 64,79 also reported that caregiver and teacher reports for internalising problems for the youths were similar between treatment conditions and that no significant differences were observed for internalising behaviours at any time point (p > 0.05).

Psychosocial functioning

Two experimental studies (across three reports61,64,79) investigated psychosocial functioning. Henggeler et al. 64 investigated differences in psychosocial functioning between youths receiving home-based MST and youths receiving usual services (i.e. emergency hospitalisation) at the point of crisis. At the time of MST completion, youths in the MST condition spent significantly fewer days out of school than their counterparts in the hospitalisation condition (mean days: MST 14 ± 36.8 days, hospitalisation 37 ± 58 days; p < 0.05). However, at 12–16 months post recruitment, it was reported that these group differences were no longer statistically significant, with both groups of youths having spent significantly fewer days in a regular school setting than at baseline. 79 There were also no significant differences in psychosocial functioning as measured by the CBCL social youth report (p > 0.05), the CBCL social caregiver report (p > 0.05) or the FFS (p > 0.05) between those in the MST condition and those in emergency hospitalisation condition. 64 Evans et al. 61 found no significant changes in social competency scores from admission to discharge or post 6 months discharge across three models of intensive home services. In a study of HBCI by Evans et al. ,61 data from the Child and Adolescent Functional Assessment Scale were not included in the final analysis because of the poor quality of the responses obtained at follow-up.

Hospitalisation rates

One experimental study (across three reports64,79,80) investigated hospitalisation rates. Henggeler et al. 64 demonstrated that home-based MST resulted in only 44% of youths being hospitalised within the 1-year study time period. Overall, youths in the home MST intervention had 72% fewer days in hospital than those in the control group. 80 Between the time when the control group was discharged from hospital and when the MST group had completed their treatment (at approximately 4 months), 13% of those in the control group had been re-hospitalised for an average of 8.5 days. 79 It was found that MST was significantly effective (p < 0.001) in preventing admission to hospital for 75% of youths assigned to the MST arm of the study during the 2-week period following referral. 80

Costs

One experimental study81 compared the costs of an intervention with usual care to determine whether or not the intervention was cost-effective. Sheidow et al. 81 calculated insurance expenditures for those in receipt of MST or usual services to determine whether or not MST was cost-effective and showed significant savings from the time treatment was started to when it was completed 4 months later [mean ± standard deviation (SD): MST US$8236 ± US$6680, usual care US$11,725 ± US$5065; p = 0.004]. However, from the period when treatment finished to the 12-month follow-up point, costs were comparable (mean ± SD: MST US$11,709 ± US$13,396, usual care US$13,451 ± US$16,351; p = 0.556). Risk-adjusted models of costs were also calculated and adjusted for the youth’s age, the caregiver’s age, caregiver’s educational level, number of caregivers in the household and a variable representing the interaction between the treatment duration, the treatment and differences in symptoms levels, as measured by the Global Severity Index. This analysis showed that MST demonstrated better short-term cost-effectiveness for each of the clinical outcomes than usual care (i.e. inpatient care followed by community aftercare). 81

Discharge destination

Two experimental studies61,80 looked at discharge destination and destination following discharge from home-based programmes and found that between 57%80 and 86%61 of CYP were able to continue living within the community, depending on the type of intervention. Evans et al. 61 explored the difference across three different home-based interventions and found that there was no significant difference between each of the models in relation to CYP remaining in the community (CCM, 78.4%; HBCI, 83%; HBCI+, 85.7%). Schoenwald et al. 80 demonstrated that CYP receiving home-based MST spent fewer days in out-of-home placements than CYP in the hospitalisation comparison group (MST group 644 days, comparison group 1490 days; no further statistical analysis). CYP receiving home-based MST also had fewer days in foster care, supervised independent living, group home, RTC, hospital care and detention, but more days in therapeutic foster care (no statistical details provided).

Family functioning/empowerment

Two experimental studies (across three reports61,64,79) explored family functioning. Henggeler et al. 64 investigated the effects of home-based MST compared with usual services (i.e. emergency hospitalisation) and found that family functioning significantly improved for the youths in the MST condition. More specifically, youths reported significant greater family adaptability than those in the hospital condition from baseline to 12–16 months’ follow-up (p < 0.039), but no changes in levels of family cohesion (p > 0.05). Families in the MST condition had become more structured, whereas families in the hospitalisation condition had become less structured (p < 0.009). 64 Caregiver reports of family cohesion showed significant treatment effects (p < 0.001) in that family cohesion significantly increased for those in the MST condition and significantly decreased for those in the hospitalisation condition (p < 0.004). 64 Over time, youths receiving MST reported a slight increase in adaptability, whereas youths receiving emergency hospitalisation reported a slight decrease in family adaptability, resulting in a significant linear between-group effect. Youth reports of family cohesion differed significantly between groups, with emergency hospitalisation families evidencing no significant change and MST youths reporting a steady decrease during MST treatment followed by a rise in family cohesion (i.e. a U-shape effect). A further report79 from the same study showed that caregiver reports of cohesion were generally stable, with only a slight linear increase over baseline among MST families but no significant between-group differences in patterns. In the study conducted by Evans et al. ,61 for those children receiving home-based care across three different programmes (i.e. HBCI, HBCI+ and CCM), all reported significant gains from admission to discharge in family adaptability (p < 0.01). With regard to family cohesion, only those children in the HBCI and HBCI+ groups showed significant gains (p < 0.05). Families of children who received HBCI or HBCI+ services also showed significant admission to discharge gains in cohesion (using the FACES II), although these gains were not noted for families of children assigned to CCM (main effect for admission to discharge p > 0.05).

Completed suicide and suicide attempts

One experimental study conducted by Huey et al. 78 looked at the number of completed suicides and suicide attempts. The results indicated that both MST and psychiatric hospitalisation were significantly associated with a reduced incidence of attempted suicide, as rated by the youths themselves (p < 0.001) and their caregivers (p < 0.001). However, MST was significantly more effective than psychiatric hospitalisation at reducing attempted suicide over the course of 16 months following recruitment. Results also indicated that age (p < 0.05), gender (p < 0.01) and ethnicity (p < 0.01) each moderated the effects of MST on caregiver-rated attempted suicide incidence. 78

Self-esteem/self-concept

Two studies (across three reports61,64,79) explored self-esteem. In a study by Henggeler et al. ,64 differences in self-esteem were explored for youths receiving home-based MST compared with youths who received usual services (i.e. emergency hospitalisation) at the point of crisis. For those in the MST condition, there were no significant differences in levels of self-esteem from baseline to completion of the MST (mean scores on the FFS: baseline 2.57 ± 0.9, completion of MST 2.55 + 1.1). 64 At the time of completion of MST, youths who were in the hospitalisation condition reported significant improvements in self-esteem compared with youths in the MST condition (mean scores on the FFS: MST 2.55 ± 1.1, hospitalisation 2.73 ± 0.9; p < 0.05). 64 However, at the 1-year follow-up time point, these treatment effects were no longer observed (mean scores on the FFS: MST 2.50, hospitalisation 2.22; p > 0.05). 79 In the study conducted by Evans et al. ,61 children assigned to each of three models of intensive home services showed significant improvement in self-concept from admission to discharge (p < 0.05) and these improvements were still present at 6 months post discharge (p < 0.01).

Client satisfaction

One experimental study64 looked at client satisfaction. Evans et al. 64 compared home-based MST with usual services (i.e. emergency hospitalisation). Youths who received MST and their caregivers reported significantly greater treatment satisfaction at the time MST was completed compared with those who received emergency hospitalisation (mean score on the LFSS: youth MST 15.7 ± 4.4, youth hospitalisation 13.3 ± 4.2, p = 0.007; caregiver MST 17.6 ± 3.2, caregiver hospitalisation 16.5 ± 3.4, p-value not reported) and at 1-year follow-up (mean score on the LFSS: youth MST 15.5 ± 4.5, youth hospitalisation 12.0 ± 4.6, p-value not reported; caregiver MST 17.9 ± 3.4, caregiver hospitalisation 16.4 ± 3.9, p = 0.044).

Summary

Effectiveness of home- or community-based programmes was the focus of three studies (across seven reports61,64,78–81,98). The findings showed that home- or community-based programmes were effective in reducing depression (moderate GRADE rating), psychiatric symptoms (moderate GRADE rating) and the number of completed suicides and suicide attempts (moderate GRADE rating) between recruitment and follow-up periods, improving self-concept (moderate GRADE rating), family adaptability (moderate GRADE rating) and family cohesion (parents’ perspective) (moderate GRADE rating), and were more cost-effective. Mixed findings were reported for behaviour, with one out of two studies reporting that the intervention was effective in reducing levels of internalising and externalising behaviour (moderate GRADE rating). CYP receiving these services were more likely to remain in the community after treatment (moderate GRADE rating), less likely to be hospitalised (moderate GRADE rating) and reported greater satisfaction with services than those in the control groups (moderate GRADE rating). No differences were reported for psychosocial functioning (moderate GRADE rating), self-esteem (moderate GRADE rating) and family cohesion (CYP perspective) (moderate GRADE rating) between recruitment and follow-up periods.

Psychiatric symptoms

One experimental study87 investigated psychiatric symptoms. During admission to an inpatient crisis stabilisation programme, Muskens et al. 87 reported significant reductions in the severity of psychiatric symptoms regardless of the type of services received [mean change in score: crisis group 10.4 ± 9.3, assessment group 10.7 ± 7.8, transition group 9.8 ± 11.5; p > 0.05 for both univariate and multivariate analysis of variances (ANOVAs)].

Psychosocial functioning

One experimental study87 investigated psychosocial functioning. During admission to an inpatient crisis stabilisation programme, Greenham and Bisnaire87 demonstrated improvements regardless of the type of services received (mean change in score: crisis group 5.3 ± 9.1, assessment group 5.8 ± 9.5, transition group 4.8 ± 11.2; p > 0.05 for both univariate and multivariate ANOVAs).

One experimental study conducted by Rogers et al. 72 investigated costs. There were significant cost savings after the CARES (Child & Adolescent Rapid Emergency Stabilization) programme was established, which the authors felt was reflective of a reduction in LOS. Specifically, the average charge for patients significantly decreased (from US$1472.20 before CARES to US$903.15 after CARES, i.e. a decrease of US$569.05; p < 0.0001) and the total cost per patient also significantly decreased (from US$1472.20 before CARES to US$903.15 after CARES, i.e. a decrease of US$569.05; p < 0.0001). However, there were no significant differences in the payments per patient (before CARES US$923.88 vs. after CARES US$812.29, i.e. a decrease of US$111.59; p < 0.06).

Length of stay

Two experimental studies72,87 investigated LOS. Greenham and Bisnaire87 reported that the median LOS in an inpatient crisis stabilisation programme and assessment service was 4 days, with a mean of 6.2 ± 6.9 days. Another study conducted by Rogers et al. 72 evaluated LOS before and after the introduction of the CARES unit and found that LOS was significantly shorter post CARES than with the former emergency department provision [mean LOS: pre CARES 19.7 ± 32.6 hours, post CARES 10.8 ± 19.9 hours (a reduction of 47.3%); p < 0.001].

Suicidality

One experimental study conducted by Greenham and Bisnaire87 explored suicidality. During admission to an inpatient crisis stabilisation programme, reductions in levels of suicide risk were demonstrated regardless of the type of services received (mean change in score: crisis group 11.4 ± 10.0, assessment group 12.6 ± 9.1, transition group 7.7 ± 7.9; p > 0.05 for both univariate and multivariate ANOVAs). 87

Summary

Two studies72,87 explored the effectiveness of specific inpatient programmes for CYP requiring crisis care. The evidence synthesis72,87 found that specific inpatient programmes were effective in reducing psychiatric symptoms (moderate GRADE rating) and suicidality (moderate GRADE rating), and improving psychosocial functioning (moderate GRADE rating) between recruitment periods and follow-up. These inpatient programmes could also decrease LOS (moderate GRADE rating) and, subsequently, costs (moderate GRADE rating) at the time of the crisis. No differences were reported in the rate of emergency department visits for up to 1 year post discharge (moderate GRADE rating).

Psychosocial functioning

One experimental study86 conducted by Greenfield et al. 86 investigated psychosocial functioning. No significant differences were reported in levels of psychological and social functioning after the introduction of a rapid response outpatient model at 2 months’ follow-up (mean score on the CGAS: intervention group 13.12 ± 14.6, control group 13.48 ± 15.5; p > 0.05) and at 6 months’ follow-up (mean score on the CGAS: intervention group 14.86 ± 15.29, control group 13.26 ± 17.52; p > 0.05).

Hospitalisation rates

One experimental study (reported across two reports86,93) explored hospitalisation rates. A rapid response outpatient model was effective in reducing hospitalisation rates (defined as hospitalisation at least once at any hospital for reasons related to suicidality). Adolescents in the intervention group were 71% less likely than adolescents in the comparison group to be hospitalised immediately after assessment in the emergency department for suicidality [intervention group 11% vs. comparison group 40%, RR (relative risk) 29, 95% CI 0.18 to 0.46; p < 0.001] and 59% less likely to be hospitalised over the 6 months after an emergency assessment in the emergency department for suicidality (intervention group 18% vs. comparison group 43%, RR 0.41, CI 0.28 to 0.61; p < 0.001). 86,93

Costs

One experimental study93 investigated costs. Latimer et al. 93 investigated cost savings from the treating hospital’s perspective and a societal perspective for those receiving a rapid response treatment intervention compared with those without a rapid response in the control group. There were no significant differences (difference of US$1886; p = 0.11) in hospital costs per person between the intervention (US$2114, range £134 to US$46,273) and the control (US$4000, range US$150 to US$127,998). There were also no significant differences (difference of US$991; p = 0.67) in societal viewpoint costs per person between the intervention (US$10,785, range US$1424 to US$107,406) and the control ($11,775, range US$559 to US$164,134). The point estimates indicated that the intervention would save the treating hospital approximately US$1208 and society approximately US$636 for every additional point improvement on the CGAS functional scale, compared with the control intervention. However, the control intervention would save the treating hospital approximately US$13,780 and society approximately US$7238 for every additional point improvement on the Suicide Severity Scale compared with the intervention. 93

Emergency visits post discharge

Three experimental studies34,66,86 looked at the number of emergency visits post discharge. Greenfield et al. 86 reported no significant differences within the 6-month follow-up period after the introduction of a rapid response outpatient team and initial presentation to the emergency department (p > 0.05). In addition, Greenfield et al. 34 reported no significant differences within 12 months after the introduction of a specialised outpatient service with an emergency room follow-up team (p > 0.05). A further study conducted by Maslow et al. 66 reported on the first year after opening an integrated paediatric mental health outpatient clinic for acute mental health crisis. Examination of electronic health data indicated a reduction in the rate of emergency department visits within 30 days after patients’ initial contact with the clinic (reporting 333 emergency department visits in 30 weeks before vs. 172 emergency department visits in the 30 weeks after). However, no further statistical analysis was conducted to confirm this finding.

Length of stay

One experimental study conducted by Greenfield et al. 86 investigated LOS. No significant differences were reported in LOS in the emergency department after the introduction of a rapid response outpatient model at recruitment (mean days: intervention group 6.6 ± 5.6, control group 3.9 ± 3.8; p > 0.05), at 2 months’ follow-up (mean days: intervention group 7.1 ± 6.1, control group 4.1 ± 3.9; p > 0.05) and at 6 months’ follow-up (mean days: intervention group 7.8 ± 9.9, control group 5.1 ± 6.8; p > 0.05).

Completed suicides and suicide attempts

One experimental study conducted by Greenfield et al. 86 looked at the number of completed suicides and suicide attempts. 86 No significant differences in the numbers of suicide attempts made were reported during the 6-month follow-up period, excluding those at the time of recruitment, as a result of the implementation of a rapid response outpatient team (p < 0.05).

Suicidality

One experimental study conducted by Greenfield et al. 86 explored suicidality. No significant differences were reported in levels of suicidality after the introduction of a rapid response outpatient model at 2 months’ follow-up (mean scores on the SSBS: intervention group –1.64 ± 1.26, control group –1.63 ± 1.27; p > 0.05) and at 6 months’ follow-up (mean scores on the SSBS: intervention group –1.40 ± 1.26, control group –1.54 + 1.21; p > 0.05). 86

Post-discharge use of services/resources

One experimental study (reported across two reports86,93) looked at post-discharge use of services/resources. Resource use during the 6-month follow-up period after the introduction of an outpatient rapid response model for those presenting in crisis to an emergency department was investigated and was found to be similar for those in the intervention and control groups for the majority of services. However, those from the control group, on average, had more meetings with outpatient psychotherapists (mean number of meetings: intervention group 0.06 ± 0.47, control group 0.44 ± 1.60; p < 0.01) and social workers (mean number of meetings: intervention group 0.13 ± 6, control group 0.57 ± 1.91; p < 0.01) than those from the experimental group. Time from first telephone contact with a health professional following discharge from an emergency department varied from 1.5 days [interquartile range (IQR) 1.0–6.0 days] for the patients in the experimental group to 4 days (IQR 1.0–7.5 days) for patients in the control group. Time to first appointment was 6 days (IQR 1.0–11.0 days) for the patients in the experimental group and 10 days (IQR 5.0–17.0 days) for patients in the control group. 86,93

Satisfaction with clinicians who delivered the mental health crisis service/programme

One descriptive cross sectional study88 explored satisfaction with clinicians who delivered the mental health crisis service/programme. Lee and Korsak88 explored parents’ satisfaction with an outpatient urgent care clinic consultation. It was noted that there was a significant association between parental satisfaction and the degree to which parents felt listened to by consultants (p < 0.05), the amount learned from the consultation, and time between referral and consultation and appointment length (p < 0.05). Over 52% of parents implemented consultant recommendations, with a significant association between satisfaction and adherence (p < 0.05).

Summary

The effectiveness of outpatient mental health programmes was explored in three studies (across four reports66,86,93,120). This evidence synthesis found that CYP receiving outpatient mental health programmes were less likely to be hospitalised than CYP in a control group (very low GRADE rating) and could experience quicker access to additional resources (very low GRADE rating). An association also exists between parental satisfaction and increased adherence to outpatient treatment (very low GRADE rating). No differences were reported for psychosocial functioning (very low GRADE rating), in the number of emergency department visits for up to 1 year post discharge (very low GRADE rating), LOS in the emergency department before discharge to a rapid outpatient service (very low GRADE rating), number of suicide attempts (very low GRADE rating), suicidality (very low GRADE rating) and post-discharge use of resources (very low GRADE rating).

Hospitalisation rates

One experimental study conducted by Martin68 investigated hospitalisation rates. There were no significant differences in the percentage of CYP who were hospitalised within 30 days of attending a mobile crisis intervention or a walk-in hospital-based crisis intervention (OR 1.01, 95% CI 0.54 to 1.92). 68 However, regardless of service provision, CYP aged 6–11 years were 298% more likely to be hospitalised within 30 days after a crisis stabilisation than CYP aged 15–17 years (OR 3.98, 95% CI 1.66 to 9.51; p < 0.002).

Emergency visits post discharge

One experimental study conducted by Fendrich et al. 62 looked at the number of emergency visits post discharge. It was reported that youths who had attended an emergency mobile crisis service for a behavioural health need (defined as one in which any psychiatric diagnosis was provided during an emergency department service encounter) had significant reductions in further visits to the emergency department in the next 18 months compared with youths in a comparison sample (incident rate ratio 0.75, 95% CI 0.66 to 0.85; a reduction of 25%).

Summary

Two studies62,68 investigated the effectiveness of mobile crisis services and reported that CYP receiving mobile crisis services were less likely to attend emergency department post discharge than CYP in a control group (very low GRADE rating), but that there were no differences in the rates of hospitalisation (very low GRADE rating).

Hospitalisation rates

Two experimental studies74,92 investigated hospitalisation rates. Roberts et al. 92 explored outcomes between telepsychiatry or face-to-face emergency consultations for CYP from rural and remote communities, finding that there were no differences in admissions (telepsychiatry, n = 18; face to face, n = 5; p > 0.05). However, Thomas et al. 74 reported that CYP who received telepsychiatry as opposed to usual care were significantly less likely to be admitted to hospital [aOR (adjusted for patient variables, but no further details provided) 0.59, 95% CI 0.40 to 0.86; p < 0.001).

Costs

One experimental study conducted by Thomas et al. 74 investigated costs. The use of telepsychiatry consultations was compared with usual care and total patient charges were significantly lower for those who received telepsychiatry consultations than those who received usual care (US$3493 vs. US$8611; p < 0.001). A cost-efficiency analysis concluded that although telepsychiatry was more expensive than usual care, the improved efficiency of telepsychiatry resulted in lower charges and shorter LOSs. 74

Discharge destination

One experimental study92 looked at discharge destination. Roberts et al. 92 explored outcomes between telepsychiatry and face-to-face emergency consultations for CYP from rural and remote communities, finding that there were no differences in referral pathways (telepsychiatry, n = 37; face to face, n = 32; p > 0.01).

Emergency visits post discharge

One experimental study conducted by Thomas et al. 74 looked at the number of emergency visits post discharge. 74 No significant differences in the 72-hour emergency department visit return rate were reported among patients who received a telepsychiatry emergency consultation (85%) compared with those who received usual care (90%) (p > 0.05).

Length of stay

Two experimental studies investigated LOS. 71,74 Reliford and Adebanjo71 demonstrated a significantly reduced monthly LOS in the paediatric emergency department for those who did not need admission (pre intervention 285 hours, post intervention 193 hours; p = 0.032). However, there was no significant difference in monthly LOS for those who required admission (pre intervention 168.5 hours, post intervention 161.7 hours; p > 0.05). The second study conducted by Thomas et al. 74 showed a significant reduction in monthly LOS in the paediatric emergency department (pre intervention 5.5 hours, post intervention 8.3 hours; p = 0.001).

Client satisfaction

Two experimental studies74,92 looked at client satisfaction and reported high patient or parent/guardian satisfaction with telepsychiatry emergency assessments in terms of overall acceptability (i.e. user friendliness of the technology) and efficiency (i.e. time saved from not having to travel). Parents and guardians expressed appreciation for not having to travel to access main services, which saved them time and money, and stated that they would use the service again. 74,92

Health-care staff satisfaction with mental health crisis services/programmes

One experimental study74 investigated health-care staff satisfaction with a telepsychiatry service. Thomas et al. 74 conducted a survey both before and after the introduction of telepsychiatry. Satisfaction survey scores significantly increased on questions regarding the process for evaluating and managing patients with mental health concerns (p < 0.05), family satisfaction (p < 0.05), making appropriate disposition decisions (p < 0.05) and process safety (p < 0.05). No change occurred in faculty members’ levels of comfort around, or when assessing, patients with mental health concerns (p > 0.05).

Summary

The effectiveness of telepsychiatry initiatives was reported across two studies. 74,92 Telepsychiatry initiatives were effective in decreasing LOS (very low GRADE rating) and costs (very low GRADE rating). Parents reported high levels of satisfaction (very low GRADE rating) and levels of staff satisfaction were improved (very low GRADE rating). No differences were reported in the rate of repeat visits to the emergency department (very low GRADE rating) or in referral pathways after the introduction of telepsychiatry (very low GRADE rating). Mixed findings were reported for the rate of hospitalisation with one74 out of two studies reporting that telepsychiatry was effective at reducing the likelihood that a person would be hospitalised (very low GRADE rating).

Hospitalisation rates

Two experimental studies65,75 explored hospitalisation rates. Uspal et al. 75 reported that there were no significant increases in admission rates (pre intervention 23% vs. post intervention 22%; p < 0.01) or the 72-hour return rate (pre intervention 2.1% vs. post intervention 3.6%; p < 0.01) after the implementation of a dedicated mental health team in the emergency department. Holder et al. 65 found that as a result of introducing additionally trained psychiatric professionals fewer CYP were admitted to a paediatric treatment unit (p < 0.005). However, there was a significant increase in the number of CYP discharged to a psychiatric hospital post intervention as opposed to pre intervention (p < 0.05).

Costs

One experimental study65 investigated costs. Holder et al. 65 implemented a programme that added CYP psychiatrists and psychiatric social workers to the paediatric emergency department, but did not find any significant differences in cost before and after its introduction (before US$602 vs. after US$588, i.e. a decrease of US$14; p = 0.451). The authors concluded that this was attributable to the costs of the additional staff, even though LOS had decreased.

Discharge destination

One experimental study conducted by Holder et al. 65 looked at discharge destination. Introducing additionally trained psychiatric professionals to a paediatric emergency department significantly increased the number of CYP returning to the home environment after the initial crisis (pre addition 65% vs. post addition 65.2%; p < 0.05). 65

Emergency visits post discharge

One experimental study conducted by Uspal et al. 75 looked at the number of emergency visits post discharge. No significant differences in the 72-hour emergency department return rates were reported after the introduction of a dedicated mental health team based in the paediatric emergency department (p = 0.13). 75

Length of stay

Two experimental studies65,75 investigated LOS. Holder et al. 65 reported a significant reduction in LOS from triage to discharge (mean LOS: pre intervention 14.7 hours, post intervention 12.1 hours; p < 0.001) and the other study conducted by Uspal et al. 75 found a significant reduction in overall LOS in the paediatric emergency department [mean LOS: pre intervention 332 (95% CI 309 to 353) minutes, post intervention 244 (95% CI 233 to 254) minutes; p < 0.01].

Health-care staff satisfaction with mental health crisis services/programmes

One experimental study investigated health-care staff satisfaction within a paediatric emergency department. Findings from the retrospective cohort study conducted by Uspal et al. 75 reported that those working within a paediatric emergency department after the introduction of a dedicated CYP mental health team reported significant improvements:

• Staff felt that the system supported making appropriate disposition decisions regarding discharge plans or on admissions for patients with acute mental health concerns (p < 0.05). 75

• Staff were satisfied with the paediatric emergency department process for evaluating and managing patients with mental health concerns and felt that the system was safe for patients (p < 0.05). 75

• Families were satisfied with the paediatric emergency department processes for evaluating and managing patients (p < 0.05). 75

However, there were no significant differences in the levels of comfort around patients or in assessing patients with acute mental health concerns before and after the introduction of the intervention (p > 0.05). 75

Summary

When a dedicated mental health team was implemented in the emergency department, CYP were less likely to be hospitalised (very low GRADE rating) and more likely to return to a home environment (very low GRADE rating). LOS were also decreased (very low GRADE rating). No differences were reported in the 72-hour return rate to the emergency department (very low GRADE rating) or in the costs of implementing the service (very low GRADE rating).

Hospitalisation rates

One experimental study conducted by Lee et al. 89 explored hospitalisation rates. Lee et al. 89 used a tool known as HEARTSMAP to assess and manage CYP within the paediatric emergency department and reported that it was reliable at identifying CYP requiring psychiatric admission. During pilot implementation, 62 patients received HEARTSMAP assessments. Of the 62 patients, 46 (74%) received a recommendation for emergency department psychiatry assessment, 39 (63%) were evaluated by psychiatry and 13 (21%) were admitted. For those patients hospitalised for further psychiatric care, either at their index visit or at their return visit within 30 days, all (100%) were initially identified by HEARTSMAP at the index visit as requiring emergency department psychiatric consultation. 89

Costs

One experimental study conducted by Mahajan et al. 67 investigated costs. Costs were described as an average cost per hour of occupied emergency department room as a result of the addition of a full-time psychiatric social worker who evaluated all CYP with mental health needs. A reduced LOS for those CYP who presented to the emergency department with a mental health crisis was reported and the associated cost savings were calculated to be US$10,651. Opportunity costs of extended LOS of visits for mental disorders (VMD) in the emergency department after the addition of a full-time psychiatric social worker were also calculated to establish the average revenue foregone had a non-VMD emergency department patient occupied the same room.With average LOS longer for VMD than non-VMD visits, lost revenue due to extended LOS for VMD was estimated at $201,173.30. 67

Length of stay

Three experimental studies67,89,132 investigated LOS. Mahajan et al. 67 described the addition of a full-time psychiatric social worker as part of a child guidance model and found that the overall LOS in the emergency department was significantly reduced (pre 259.49 ± 171.12 minutes vs. post 216.39 ± 152.95 minutes, mean difference of 43.10 minutes; p = 0.001). The time taken for physician disposition to be undertaken (pre 169.31 ± 140.83 minutes vs. post 218.10 ± 171.02 minutes, mean difference of 48.79 minutes; p = 0.00) and for triage were also significantly reduced (pre 45.67 ± 40.72 minutes vs. post 41.56 ± 35.83 minutes, mean difference of 4.11 minutes; p = 0.08)67 as a result of the addition of a full-time psychiatric social worker.

Another study, conducted by Nagarsekar et al. ,132 implemented KALM, which sought to build in extra capacity for an emergency department medical officer to complete the assessment and then to link with an on-call psychiatrist regarding an assessment and management plan. There was no significant difference (p = 0.1407) in median LOS for those on the KALM pathway [4.13 hours (minimum 0.46 hours, maximum 11.55 hours)] compared with those on the TAU pathway [5.09 hours (minimum 0.21 hours, maximum 19.12 hours)]. The National Emergency Access Target stipulates that a patient should be treated and leave the emergency department within 4 hours. Fewer patients breached the National Emergency Access Target when the KALM pathway (56%) was used, but differences were not significant (OR 0.68, 95% CI 0.36 to 1.31; p = 0.252) when compared with those in the TAU pathway (64%).

Lee et al. 89 found that the introduction of the assessment-based approach HEARTSMAP did not have any significant effect on LOS in the paediatric emergency department (median minutes: pre HEARTSMAP 288 minutes, post HEARTSMAP 297 minutes; p = 0.89).

Emergency visits post discharge

One experimental study conducted by Lee et al. 89 looked at the number of emergency visits post discharge. No significant differences in the 30-day emergency department return rate were reported after the introduction of HEARTSMAP in the paediatric emergency department (p > 0.05).

Post-discharge use of services/resources

One experimental study conducted by Lee et al. ,89 in which the HEARTSMAP assessment tool was implemented in a paediatric emergency department, looked at post-discharge use of services/resources. 89 In addition to HEARTSMAP, an emergency outpatient follow-up service was created for families with unmet mental health needs (i.e. the ‘LINK’ clinic). All CYP for which HEARTSMAP triggered recommendations for further community services accessed resources within 30 days. The resources included access to social workers, primary care providers, private psychiatry, private counselling, private psychology, school counselling, substance misuse/detox services, youth clinics, non-urgent community mental health services and urgent community mental health services.

Client satisfaction

One experimental study132 looked at client satisfaction. Nagarsekar et al. 132 assessed how satisfied carers were with the newly implemented KALM pathway compared with the TAU pathway. There were no significant differences between the two care pathways. However, the number of carers answering the survey for the KALM pathway was small (n = 16) and so findings should be treated with caution. 132

Summary

Carrying out assessment approaches within the emergency department was successful at triggering recommendations for further community services, which were accessed; however, there were no differences in the 30-day return rate to the emergency department (very low GRADE rating). Mixed findings were reported for LOS, with one67 out of three studies67,89,132 reporting a reduced LOS (very low GRADE rating). There were also no differences in client satisfaction with the newly implemented KALM pathway compared with the TAU pathway (very low GRADE rating).

Costs

One descriptive cross-sectional study conducted by Baker and Dale58 investigated costs. The daily cost of total treatment across the entire sample at a crisis programme within a RTC was US$300 per day for a total of 2628 days, compared with US$550 per day for a total of 2628 days if the sample of boys had been treated in a nearby hospital (thereby saving US$650,000). However, hospital stays were, on average, 15 days longer and on accounting for this scenario the savings were calculated to be US$1,490,250.

Length of stay

One descriptive cross-sectional study (reported across two reports58,59) investigated LOS. Baker et al. 59 reported that the LOS for youths admitted to a crisis residence programme varied depending on from where they had been referred (biological family 4.17 ± 4.08 weeks, foster homes 3.77 + 3.01 weeks, RTC 6.68 weeks). Baker and Dale58 reported that LOS was significantly shorter (on average by 15 days) for youths treated at a crisis residence for their first crisis than for those treated in hospital (mean LOS: crisis residence 24.30 ± 20.72 days, hospital 39.04 ± 33.18 days; p < 0.04), despite this group being more at risk.

Summary

Only one study (reported across two reports58,59) focused on RTCs and found that they were effective in reducing LOS and, subsequently, costs at the time of the crisis (GRADE rating not applicable).

Discharge destination

Three descriptive cross-sectional studies60,69,77 looked at discharge destination. Both Michael et al. 69 and Capps et al. 60 focused on students’ risk of harm following assessment using the PEACE protocol. Both studies60,69 reported that decisions on referral options were based on the severity of the crisis or family preference and included comprehensive school mental health services that offered assessment support and a counselling centre (ranging from 26%60 to 33%69) or community mental providers (ranging from 14.3%69 to 26.9%60). Michaels et al. 69 also reported that around 12% of students who were felt to be a significant risk of self-harm were hospitalised after the initial assessment (either straight away or within 2 weeks). Walter et al. 77 investigated the outcomes of a school–hospital partnership that delivered crisis interventions to students and found that in 26% of encounters the partnership was able to avoid referrals to more acute levels of care.

Completed suicide and suicide attempts

Three descriptive cross-sectional studies60,69,73 that implemented the PEACE protocol, including initiation of a response/safety plan, looked at the number of completed suicides and suicide attempts. All studies found that there were no completed suicides or suicide attempts that necessitated medical intervention immediately after (i.e. within the same day) the protocol administration was completed. 60,69,73

Satisfaction with clinicians who delivered the mental health crisis service/programme

One descriptive study77 explored satisfaction with clinicians who delivered a mental health crisis service/programme.Walter et al. 77 explored a school–hospital partnership that sought to provide multitiered levels of support. Walter et al. 77 reported high levels of school staff satisfaction with the ways in which crisis services were provided by programme clinicians and across the different aspects of support offered.

Summary

Assessment approaches within educational settings were reported across four studies. 60,69,73,77 No completed suicides or suicide attempts were reported within educational settings when assessment approaches were introduced (GRADE rating not applicable). A variety of referral destinations were noted and in some cases referrals to more acute levels of care were avoided. Moreover, levels of staff satisfaction were high (GRADE rating not applicable).

To keep children and young people in their home environment as an alternative to admission

Twelve services described in 22 reports32,34,58,59,61,63,64,68,78–81,84,93,98,103,107,110,112,113,122,148 explicitly have the goal of keeping CYP in their own homes and avoiding admission to psychiatric hospital.

Examples include services that aim to reduce inappropriate admission, defuse crises and also reduce frustration among community and emergency department staff in securing access,122 along with single-session FBCI delivered in the emergency department, aiming to improve mutual understanding of CYP’s suicidal behaviour and avoid admission. 32,84,107 Other services with the goal of avoiding admission include WAARM, which provides immediate access to home care for CYP initially seen in the emergency department and a service consisting of five sessions of family-based interventions along with ‘rapid response’ follow-up following a paediatric emergency department visit. 110 The emergency room follow-up team is an outpatient crisis service, beginning with the receipt of referrals from the emergency department and involving initial contact within 24 hours of presentation, with the purpose of avoiding admission. 34,93 The crisis and transition services model diverts CYP from the emergency department for home-based care. 148 MST is a family-based strengths-oriented intervention that has also been proposed and tested as an alternative to hospital admission for CYP experiencing severe emotional distress,64,78–81,112 with other services including short-term intensive home-based care mobilised within 24 hours of receipt of referral and offered for typical periods of 4–6 weeks. 61,103 Avoiding hospitalisation, and the dislocations this brings, has also been the goal of services providing intensive residential services in the community. 58,59 In addition, solution-focused intensive home treatment and psychiatric high and intensive care (combining work on improving relationships, reducing self-harming behaviour and reintegration into school, work and leisure) involves up to 4 months of home-based care, potentially following a purposefully short hospital admission. 98 The HBCI combines crisis resolution, relationship-building and skills-teaching, including in contexts where cultural competency is important. 61,103 Other community programmes with hospital-avoidance goals include multidisciplinary crisis intervention, combining family therapy, psychiatric care and school consultation. In resource-limited rural settings, outpatient-based services have been proposed as an alternative to admission. 63 Two different mobile crisis services were described, which respond wherever in the community the need arises and also have the explicit goal of helping CYP remain at home. 68,113

To assess need and to plan

Forty-five services described in 61 reports32–34,57,60–62,66,68,69,72–75,77–84,87–89,92,93,98,102–120,122–126,129–132,136,147–149,171 either explicitly identify the goals of assessing the needs of CYP and their families and/or planning interventions, or infer to them as necessary precursors to providing care and treatment.

In emergency department, triage involving the use of specific assessment tools or scales by nurses was described. 115 The ‘HEADS interview’ is a professional-led interview approach that focuses on home, education (eating), activities/ambition, drugs and drinking, sexuality, and suicide and depression. 116,117 Variants include HEADS-ED (a clinician-rating tool),87,110 HEADDS (an assessment tool)96 and the online HEARTSMAP tool, which are designed to support comprehensive assessment by emergency department clinicians informing recommendations for onwards intervention outside the emergency department environment based on staff members’ estimations of urgency. 119,123,124 Examples were also reported of an emergency department diversion service in which assessment and safety planning are key,148 and of mental health teams being located in emergency departments75 as a way of enabling expert mental health assessment (including in remote emergency departments). Two different examples were described of telepsychiatry supporting remote assessment. 74,92 To support the goal of enabling expert child psychiatrist assessment following emergency department visits, a combination of a telephone and face-to-face appointments have also been used. 122 Another service involves mental health professionals visiting and assessing CYP within hours of their arrival in emergency department after a suicide attempt. The aim of this approach is to promote longer-term inpatient treatment. 129 Another innovation involves the use of a ‘soap opera’-format video in the in emergency department. The video is shown to CYP who have attempted suicide, and their families, by therapists as a precursor to the shared planning of responses to future suicide-eliciting circumstances. 82,83,111

Specific clinical interventions introduced into the emergency department context, which presuppose assessments of need and care planning, include the family systems approach underpinning the FISP. 33,57,147 These interventions include the goal of decreasing the risks of repeat suicidal behaviour by promoting the uptake of follow-up appointments. FBCI is a further emergency department-based approach, which has the single-session goal of assessing, safety planning and intervening through the construction of what is described as a ‘joint crisis narrative’. 32,84,107

Brief assessment-oriented hospital-based services include the children’s comprehensive psychiatric emergency programme, which combines brief inpatient stabilisation and/or outpatient care following a thorough assessment. 106 Other examples involving the use of short-stay hospital beds for the purposes of initial assessment include a service beginning with interdisciplinary assessment87 and the CARES unit, which provides short-stay assessment and stabilisation. 72 Further examples of suites of services combining inpatient and outpatient care, beginning with assessment, are the comprehensive assessment and response training system108 and a programme potentially beginning with up to 2 weeks of admission (if needed) for assessment, initial planning and treatment followed by intensive home treatment. 98 One further model involves the use of an evaluation centre, through which triage assessments and outpatient care are provided. 66

Services offering alternatives to emergency department interventions for CYP in crisis also exist. The goal of meeting mental health crisis needs, beginning with the triage of referred CYP, is a component of an inclusive mental health service for all 0- to 19-year-olds provided by the Solar community crisis resolution team. 149 Out of a variety of initiatives described in a single publication,110 all involve some aspect of assessment:

• The Lifespan paediatric behavioural health emergency services brings together combinations of hospital-based and community crisis responses, with suites of integrated services, including a telephone triage line for the rapid assessment of need called KidsLink.

• The Nationwide Children’s Hospital created the outpatient crisis programme, which provides outpatient urgent assessments within 72 hours of presentation.

• The Allina Health system provides an acute response model (WAARM), which provides expert mental health assessment in the children’s emergency department to reduce waits for urgent interventions and time spent in the emergency department.

• The enhanced care co-ordination initiative involves expert mental health assessment within 48 hours of paediatric emergency department discharge and linking to follow-up.

Multiple examples exist of specific models or intervention approaches that begin with crisis assessment and/or planning components (including outside the hospital environment). The HBCI is a model of home-based crisis care set up to prevent hospital admission, beginning with care initiated within 24 hours of referral and extending for a period of 4–6 weeks,12 to which HCBI+ adds training in cultural competence. 61,103 The safety first model approach emphasises community-based support to promote safety and begins with formulation and collaborative planning. The service operates on a ‘safety not cure’ ethos and begins with assessment in the home and family environment. 125,126 A further model begins with the addressing of ‘disorganisation’ in families through systemic functional analysis. 131 MST begins with a comprehensive plan underpinned by the use of an ‘ecological framework’, which locates the young person in their family, peer and neighbourhood environment. 64,78–81,112 Another example from a mobile crisis service is the emergency mobile psychiatrics service, which also begins with stabilisation, support and assessment, followed by care for up to 45 days. 62,114

In the case of schools and universities, the PEACE protocol is a school-based approach to self-harm, suicide assessment and response planning. 60,69,73 The multitiered system of support programme is another tiered school-based approach, beginning with the training of staff to identify crisis and extending to clinical assessment and planning. 77 Reports also exist of universities developing specific crisis responses, which begin with stabilising and assessment and, when necessary, referring on. 171 Moreover, there was a report of a model for school-aged young people in which triaging and assessment of safety concerns is offered as an alternative to visits to the in emergency department. 136

The model of providing same-day mental health professional assessment and treatment planning was commonly reported. Telephone referral from emergency department (or community) staff was reported,105 along with urgent outpatient assessment within 72 hours of emergency department attendance88,120 or proactive telephone contact followed by an appointment in the case of CYP presenting to emergency department. 73,86,93 The emergency room follow-up team is a service receiving referrals for assessment and intervention following emergency department presentation, beginning with contact with the family within 24 hours. 34

Examples of telephone, text and internet services as vehicles for the direct assessment of CYP in crisis exist and include the screening, assessment and support services programme, which takes calls from concerned adults or directly from CYP in crisis, with telephone operators then able to direct people onward for face-to-face assessment as necessary. 102 Similar services exist for students, underpinned by the idea that out-of-hours telephone contact, involving safety assessment and crisis planning with people associated with the university, is less stigmatising than contact with external agencies. 102 Two text-based services were also described, providing assessment and safety planning. 104,109 In addition, internet-based services provide both information and message boards for CYP to share their concerns, with the content monitored by peer volunteers trained in suicide prevention. 118

Other crisis response models providing assessment and planning include mobile services offering outreach after hours. 130 One mobile crisis response is part of a combined suite of services also including 24-hour stabilisation, a crisis residential team and outpatient care, with safety planning the goal of the mobile team. 113 The mobile response team aims to prevent admission by offering rapid stabilisation and safety planning. 68

To improve children and young people’s and/or their families’ engagement in community treatment

A specific goal identified in 10 crisis response services described in 16 reports32,33,57,61,82–84,103,107,110,111,113, 125,126,129,147 is to improve the engagement of CYP and/or their families in community treatment.

Examples include the FISP,33,57,147 HBCI,61,103 FBCI,32,84,107 KidsLink,110 WAARM,110 the enhanced care co-ordination initiative,110 an emergency department-based innovation involving the use of videotape, with the explicit purpose of improving adherence to follow-up,82,83,111 the Ventura County Children’s Crisis Continuum,113 the safety first model125,126 and an inpatient crisis unit for adolescents and young adults service, which seeks to overcome resistance to ongoing support. 129

To link children and young people and/or their families to additional mental health services

Forty services in 52 reports32,33,57,61,62,66,68,69,72,73,75,77,82–84,86–89,93,98,102–107,109–111,113,114,116–127,129,132,136,147–149,171 have one of their stated goals as connecting CYP and families to ongoing mental health support.

Emergency department-based services described goals such as the arrangement of post-emergency department follow-up, with examples including referral to a variety of inpatient, outpatient and community care services. 121,122,132,148 More specifically, the literature described:

• the FISP in seeking to link young people in the emergency department with ongoing care33,57,147

• the FBCI, including the creation of a joint crisis narrative and identifying what needs to be carried out to avoid future crises32,84,107

• a family treatment approach that involves the use of a ‘soap opera’-style video and includes the facilitation of outpatient follow-up82,83,111

• a model of locating a dedicated mental health team in the emergency department, which looks to support young people and families to access ongoing support75

• a model that combines triage and outpatient services, which seeks to connect young people to community services66

• a paediatric psychiatry crisis service that refers suicidal CYP for additional therapy either to one of the subspecialty clinics within the outpatient department or to an outside agency. 105

Rapid response outpatient models described the goal of connecting young people to ongoing care, with one model involving referring patients with ‘urgent’, but not ‘emergent’, needs from the emergency department to a follow-up service that is able to respond within 3 days. 88,120 A second model was also described in which all emergency department assessments for crisis are followed by immediate referral to a rapid response outpatient team, which then initiates telephone contact and ongoing care. 86,93 Publications that focused on assessment in the emergency department also described a focus on discharge and disposition arrangements, such as the HEADS-ED intervention110,116,117 and HEARTSMAP. 89,119,123,124

Outside the emergency department, a number of services with mobile, hospital and community components describe linking young people and families to ongoing services as part of their goals. Mobile crisis services aim to provide links to ongoing care after a period of crisis stabilisation. 62,68,113,114 Crisis services located in the community also describe the goal of linking young people and their families to ongoing support in either hospital or community settings. As part of the systematic family-based SFAI, therapists work purposefully with support networks in the community. 125,126 Likewise, the screening, assessment and support services intervention is a crisis telephone line that links callers to hospital or community crisis care. 102 Services that provide home-based programmes, such as the HBCI model, aim to avoid hospitalisation, including through connecting young people and families to existing mental health services, whereas the HBCI+ adaptation also ensures that staff are culturally competent. 61,103 Enhanced care co-ordination linking young people onward was described in a US initiative,110 as was the linking work provided by the WAASH model. 110 CCM has the goal of assessing in the home and linking young people and their families to existing services. 61,103 Integrated services were also described, where a goal arising from short hospital admission and intensive home-based care is to increase motivation for therapy. 98 Two-way communication between urgent care providers and rural outpatient clinics was also described, enabling decisions to be made on onward care and support. 63 In an inclusive mental health service, crisis care is provided as one component, with the goal of integrating this with ongoing services. 149

Descriptions exist of inpatient care linking young people to ongoing services. For example, the children’s comprehensive psychiatric emergency programme provides immediate crisis care plus connects young people and families onward to additional services. 106 Onward referral to other mental health services was also described elsewhere. 129 Evaluations described inpatient services that include the goal of mobilising resources in the community during preparation for discharge. 87 The comprehensive assessment and response training system unit provides crisis stabilisation, but also aims to connect young people to ongoing services in either community or hospital settings. 72

Services provided in educational settings, including examples organised using telephone and text responses, include the option of opening up routes for onward referral and long-term support. 77,127,171 The PEACE protocol, used in the high-school setting, supports systematic assessments of risk and helps guide decision-making, and includes the option in individual plans of action to mobilise external services or to arrange follow-ups. 60,69,73 A service running as an alternative to the emergency department for school students in crisis has the goal of linking young people to ongoing services. 136

Support-based crisis response services involving the use of technology similarly include goals of linking young people to other services where necessary. For example, a website and online message board service in which messages are monitored by trained volunteers who make onward referrals as needed,118 and text-based services that include, in their goals, the direction of people who make contact towards longer-term help. 104,109

To provide peer support

Two services in two reports101,118 described the goal of providing peer support. One report101 described Teen Line, which is a telephone service in which carefully selected, trained and supported high-school student volunteers respond to calls received by other young people in crisis. 101 Another report118 described an internet-based service in which young people are able to read information and also participate in an online message board addressing ‘suicide’. Messages are monitored by trained peers and serve as a means of providing and receiving support. 118

To stabilise and manage crisis

A stated goal of 35 crisis response services cited across 50 reports32–34,57,60–62,64,66,68–70,72,73,75,77–84,86–88,93,98, 102,103,105–107,110–114,120,122,125,126,129–132,136,147–149,171 is to stabilise and manage the young person’s crisis in the immediate period, using combinations of emergency department-based interventions, hospital care and care on an outpatient or community basis.

Responses located in the emergency department setting with the clear aim of immediately stabilising and managing a crisis include services linked to the goal of avoiding admission. 122 FISP aims to directly minimise the risk of suicidal behaviour. 33,57,147 The FBCI, as a single-session intervention, aims to assess and stabilise, with a focus on safety planning and non-judgemental collaboration. 32,84,107 The soap opera-style videotape approach aims to immediately plan for foreseeable suicide-eliciting scenarios in the future,82,83,111 whereas rapid response models to follow-up from the emergency department have been used to stabilise and manage the crisis. 34,86,88,93,120 Led by emergency department medical officers, one model begins with the structured assessment of need to inform decision-making. 132 The location of a mental health team in the emergency department is also described in a service that has the goal of working with the emergency department medical team to de-escalate crises and promote safety. 75 The crisis and transition services programme aims to stabilise crises while aiding transition to community services. 148

Three services described in a single descriptive paper,110 that is, KidsLink,WAARM and the enhanced care coordination initiative, all centre on the provision of responses to stabilise. 110 Triage within an evaluation centre receiving referrals from the emergency department and other sources is described in a service in which safety planning and suicide risk reduction are initial goals. 66 Crisis services as part of an all-inclusive approach to young people’s mental health care aims to offer rapid management of crisis. 149 In a further service, crisis workers have options to refer to either inpatient or intensive community care, with the aim of providing an immediate response. 102 Multiple descriptions62,68,113,114,130 are also found of mobile crisis services that aim to stabilise and manage the immediate crisis.

Specific models of intervention include examples explicitly identifying the initial aim of managing the crisis or, for example, providing ‘containment’. 131 Other service goals include ensuring physical, emotional and relational safety, including through partnerships with wider networks, as with the safety first model. 125,126 Brief stabilisation is also the goal of models preventing hospital admission, such as the HBCI and HBCI+ approaches61,103 (i.e. services offering daily contact105 and MST64,78–81,112).

In hospital settings, acting swiftly to respond to crisis following a suicide attempt has been identified as a goal so that young people do not trivialise their self-harm attempt. 129 The options to provide inpatient care as a stabilisation response or to immediately refer for community care are also described in an integrated model. 106 The MST approach, when used in the inpatient setting, has the goal of resolving crisis, using an ecological approach that locates the individual in their broader context. 112 The CARES programme describes its goals as one of rapid stabilisation in a residential unit. 72 Short admissions, when necessary, combined with intensive home treatment is also described in services that set out to reduce self-harming behaviour using specific psychological and medical therapies. 98 Crisis stabilisation, in hospital and over a short period, is also the goal of services in which risk reduction is a key aim,87 along with providing a level of immediate care beyond what can be achieved in the community. 70

Services with goals to immediately stabilise and manage exist in education settings. 60,69,73,77,136,171 The PEACE protocol60,69,73 is an in-school facility in which high school-aged children can be assessed by psychology services before referral on to appropriate mental health services (see Chapter 4, Educational settings). The PEACE protocol receives referrals from anyone in the school system and aims to guide interventions tailored to the level of risk. The multitiered system of support model is a comprehensive school-based programme with a tiered approach, at the top of which is a crisis intervention component to manage acute need. 77 Services for university students in the UK include initial responses from staff aiming at stabilising the crisis,171 whereas the urgent evaluation service offers a rapid response to the management of crisis in school students as an alternative to emergency department presentation. 136

To train and supervise staff

Ten services described in 14 reports61,82,83,85,103,110–112,115,119,122,125,126,132 include the goal of training and supervising of staff. More specially, this includes:

• the training of emergency department staff in the use of a triage tool115

• the training of emergency department medical officers in the use of an assessment tool132

• the education of staff in the emergency department, crisis and wider primary care, and school system in the use of a rapid response model122

• the education and training for emergency department staff to use HEARTSMAP (i.e. a tool used to inform assessments and decision-making)119

• an emergency department-based model combining a video and family therapy, which includes the goal of training emergency department, mental health and other staff as part of the overall service82,83,111

• the training of emergency department staff as part of a well-resourced emergency department service offering crisis intervention85

• training and supervision as part of the community-based SFAI approach125,126

• the home-based HBCI approach, which begins with 4 days of training in the homebuilder’s model for staff103

• increasing the clinical supervision offered to therapists, with this being provided by child psychiatrists as part of providing community-based MST112

• the training of school crisis teams to use a standardised risk assessment and the education of paediatricians about a crisis hotline (i.e. KidsLink). 110

Key implications

• A high degree of confidence existed in the synthesised evidence relating to crisis responses using telephone, text and e-mail, and in the synthesised evidence relating to direct line telephone access with round-the-clock support from trained staff.When taken together, the evidence has important implications for future service commissioning. It is suggested that in the development or review of crisis services, the inclusion of text, telephone and e-mail could be helpful as a component of a 24-hour service model.

• Several of the synthesis statements that were rated as having a moderate degree of confidence related to the barriers to and facilitators of seeking and accessing appropriate support. As CYP and families did not know how to access crisis care, better signposting and information using family-friendly language possibly co-produced with CYP and avoiding the use of jargon on how to locate the right service are important. Addressing the thresholds of eligibility that exist that make access to specialist services and professionals difficult and making crisis services easier to access for those with financial or transport issues are also priority areas for CYP and families.

• A moderate degree of confidence was found in the synthesised evidence relating to CYP feeling that peer support and involving those with lived experience of mental health crisis within services was important, or CYP feeling that services should cater specifically for them and be targeted at specific age groups. When new services are being commissioned or existing services developed, it might be helpful to include representatives from a panel of CYP to advise on aspects of service design to address age appropriateness of facilities.

• What this evidence synthesis has identified, with a moderate degree of confidence, is that, because of long wait times for specialist services, services provided by emergency departments are a central component to mental health crisis care for CYP. This is offered as a recommendation with caution, given the unique structure and function of the NHS compared with health services overseas, but an acknowledgement that there might be aspects to be drawn from the evidence that could inform operating processes in UK emergency departments where CYP present with mental health crises. We acknowledge that the quality of evidence from intervention studies was low. Therefore, caution is recommended before applying this for service development, but these are issues that might need considering in service developments and design of future research projects. It is clear is that crisis care and assessment initiated within the emergency department can result in a number of positive outcomes for CYP. To strengthen this, services need to be developmentally appropriate, staff in emergency department need a level of expertise with this client group, and the environment needs to offer privacy and a calm environment. The emergency department also needs to be networked with outpatient care, where there is transparency about eligibility and 24-hour availability. The emergency department environment itself could benefit from creating a separate area to address the concerns about the noisy and busy environment, the lack of privacy and poor staff attitudes. Admission processes could be streamlined.

• Services should consider pathways in and out of crisis, as there was evidence, with a moderate degree of confidence, of a general lack of support before crisis was reached, as well as with the assessment, management and level of follow-up care of those CYP who presented in crisis to an emergency department. Mental health support networks could be strengthened to increase the possibility of CYP being able to access early and appropriate support within their community to prevent episodes of crisis. Accessible community-based early intervention support with shorter waiting times is, therefore, important. This has relevance for the UK context, with investment in preventative and supportive services offering care in a way that might reduce the chance of a CYP experiencing a mental health crisis.

• School-, community- and home-based crisis programmes also appeared to be associated with a number of positive outcomes for CYP. However, it is important that a variety of different modes of crisis support (e.g. telephone, e-mail, text based, in person) are available so that CYP can access these in the way that is most convenient for them.

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