Background: In England, one in six children aged 5-19 have a probable diagnosable mental health disorder. Increasing numbers of children and young people (CYP) are seeking help at a point of crisis with care known to be delivered by multiple agencies using a range of approaches. Crisis care for CYP has become a national and international policy priority, with substantial funding allocated to the development of crisis services. During periods of crisis, it is vital that care is timely, effective, and based on evidence.
Methods: A mixed methods systematic review (PROSPERO-CRD42019160134) was conducted. The aim was to examine the organisation of crisis services across education, health, social care and voluntary sectors; the experiences and perceptions of young people, families, and staff; the effectiveness of current approaches to care, and the goals of crisis intervention.
All relevant English language international evidence was sought specifically relating to the provision and receipt of crisis support for CYP aged 5-25. Comprehensive searches were conducted across 17 databases from 1995 to 2021. Supplementary searching was undertaken to identify relevant UK only non-research literature. Screening, critical appraisal and data extraction was conducted by two team members following standard systematic review processes. A narrative approach to synthesis was conducted separately for each objective. Confidence in research findings was assessed using the GRADE and GRADE CERQual approaches.
Results: One hundred and thirty-eight reports (48 reports covering 42 primary research studies; 36 reports covering 39 descriptive accounts of the organisation services and 54 UK only grey literature reports) were included. We found that the organisation of crisis services has been categorised as follows: triage/assessment-only; digitally mediated support approaches; intervention approaches and models. A wide variety of different interventions have been described ranging from approaches that started in the emergency department then moved to outpatient services, inpatient care through hospitals or residential treatment centres, home-based programmes, child and adolescent mental health based services, using telepsychiatry or via a community resource such as mobile outreach through to school hospital partnerships and generic walk-in crisis services provided by voluntary organisations.
When looking at experiences of crisis care, four themes were identified: 1) barriers and facilitators to seeking and accessing appropriate support; 2) what CYP want from crisis services; 3) children’s, young people’s, and families’ experiences of crisis services; 4) service provision. Twenty-seven synthesis summary statements were generated, of which two were judged as having a high degree of confidence while the rest were moderate (n=15), low (n=3), and very low (n=7) using the CERQual approach. The statements of high confidence related to what CYP want from crisis services which centred around the need for different forms of support and pathways to services. This included support via telephone (through a direct line, with out of hours availability and staffed by trained counsellors) as well as text and email.
In determining effectiveness, the findings are summarised by type of service and were generated from single heterogenous studies so a meta-analysis could not be performed. Using the GRADE approach, outcomes across the studies were graded as moderate for randomised controlled trials, and very low for observational studies. One of the approaches that worked was crisis care in emergency departments but it is noted that this is not policy provision across all countries. We also showed that school, community, and home-based crisis programmes may also lead to positive outcomes.
The goals of a crisis service were identified.
Implications: Findings suggest that support prior to reaching crisis point is important. From this work various aspects of crisis care have been identified that can be incorporated into existing services across education, health, social care and the voluntary sector
