What do we know about the risks for young people moving into, through and out of inpatient mental health care? Findings from an evidence synthesis

In phase 2 a total of 15,662 citations were identified in the database searches (see
Fig. 4 for search results and study selection). Forty papers (reporting on 38 studies) were
included in the final review, along with a total of 20 policy and guidance documents
specifically addressing the CAMHS field, or assessed as otherwise including material
directly relevant to the aims of the study.

Fig. 4. Flow of studies in phase 2

Description of the included studies

Information on the characteristics of included studies, including assessments of quality,
is given in Table 1.

Table 1. Included studies in phase 2

The included studies were conducted in the USA (n = 22), UK (n = 12), Finland (n = 2),
Canada (n = 2), Norway (n = 1), France (n = 1). The majority of studies (n = 34) were
conducted in inpatient settings and four were conducted within residential treatment
centres in the USA. A variety of research approaches were used including experimental
design (n = 4), prospective longitudinal descriptive surveys (n = 9), retrospective
descriptive surveys (n = 4), cross-sectional surveys (n = 2), mixed methods (n = 4),
qualitative methods (n = 8), descriptions of local initiatives and practice developments
(n = 2) and clinical case reports (n = 5). Table 2 summarises the policies and guidance documents included.

Table 2. Policies included in phase 2

Description of interventions or programmes

Findings from two studies investigating interventions or programmes were extracted
into the category Dislocation: Education 14], 15]. The prospective cohort study 14] included data on high-school completion and educational attainment over a 20-year
period, whereas the single retrospective quasi-experimental multiple time series study
15] compared a (previous) self-contained classroom format with the current rotating multiclass
format for young people in a US residential training centre.

One paper by Singh et al. 16] contained findings from two studies that were extracted into the category Dislocation:
Families. These rated the family-friendliness of hospital admissions prior to, and
following, different types of training intended to enhance family-friendliness. In
study 1 the intervention was structured role-play training and in study 2 the intervention
was mindfulness training.

Methodological quality

The methodological quality of the four experimental studies (prospective cohort study
(n = 1), before-and-after studies with no control groups (n = 2), a retrospective
quasi-experimental multiple time series (n = 1) was judged against the six quality
criteria, and is summarised in Table 1 above.

In the two studies reported by Singh et al. 16] the sample sizes in study 1 were small, with only 18 participants before and 18 after
and in study 2 the number of participants was not specified. The sample in the study
by Simmerman 15] was assumed to be representative of the residential treatment centre population,
although no randomisation took place. The characteristics of the young people and
their families taking place in the observed mindfulness sessions for study 2 by Singh
et al. 16] were not described. Little raw data was presented to verify the statistical analysis,
and no ethical approval was reported for either study.

The quality of the single prospective cohort study 14] was judged to be strong, having a 20-year follow-up period. Data were first collected
between 1978 and 1981 (during a period when inpatient care was different from that
which exists today), and follow-up data collected 20 years later in 2001. The sample
in this study was from psychiatric inpatient units in one metropolitan area of north-west
USA, matched with one high school in the same area. The methodological quality of
each of the eight qualitative studies was judged against nine quality criteria, and
each was then further classified as being of high (n = 7), medium (n = 1) or low quality
(n = 0) (see Table 1). The methodological quality of each of the 15 non-experimental studies was judged
against nine quality criteria and each was then further classified as being of high
(n = 6), medium (n = 7) or low quality (n = 2) (see Table 1). For the large mixed-methods studies, the individual components were quality-assessed
based on study design and three were rated as high. However, the qualitative study
undertaken by the Mental Welfare Commission Study 17] did not detail the study methods and so the quality could not be graded. Although
the quality of research items included varied, none was excluded on quality grounds
alone.

Narrative synthesis

Dislocation: normal life

Five of the included studies 18]–22] and three of the policy and guidance documents 23]–25] addressed this area. Two subcategories were created, these being ‘Everyday life and
interactions in hospital’ and ‘Missing out on life outside and transition home’.

Everyday life and interactions in hospital

Policy recommends that children and young people in inpatient settings are enabled
to lead lives as normal as possible in the face of risks to loss of potential and
unrealised hopes 23]. Access to activities was seen as important in one study 25], and in another young people spoke of the need for normalisation within inpatient
units and the problems of boredom and staff shortages 22]. Young people reportedly valued everyday interactions with staff, with some preferring
opportunities to engage in normal chats 21]. Others felt they were discouraged from hobbies and school-work 21], describing being confined in their rooms or denied access to everyday possessions
20] or being subjected to institutional rules including being unable to engage in normal
interactions 20], 21].

Missing out on life outside and transition home

Home and community links were seen as important during periods of admission 24]. Young people identified feeling their normal lives as having been suspended 21], with normal rhythms, routines and relationships being lost 19]. ‘Normal’ activity outside hospital was seen as helpful to managing transitions home
21], with treatment regimes spurring young people towards discharge 18]. Post-discharge reintegration was described as seen as difficult 21].

Summary of dislocation: normal life

In the areas of risks to normal life, policy and guidance was sparse but did recognise
that young people undergoing treatment within inpatient settings should be able to
lead as normal a life as possible. Views and experiences were reported in rich detail
and young people and health care professionals described boredom, stringent ward rules
and routines, and a lack of opportunity for everyday interactions (CerQual—high).
Feeling separated from life outside and the subsequent difficulties experienced on
returning home were identified as pressing issues by some young people and health-care
professionals. There were no intervention studies found that focused on the testing
of actions to mitigate the risks to normal life.

Dislocation: identity

Three of the included studies report findings related to this area 19], 21], 26]. Two subcategories were created, these being ‘Mental health problems as identity-changing’
and ‘Responding to threats to identity’.

Mental health problems as identity-changing

Experience of mental health difficulties was described as identity-changing for young
people with eating disorders 21], 26] and they talked of the risks of being treated in conveyor belt fashion rather than
as individuals 26]. Inpatient care was described as having both unhelpful aspects (e.g., staff making
assumptions about young people, and care not being individualised) and helpful aspects
(e.g., being seen as unique and in need) 21].

Responding to threats to identity

Some young people talked about protecting their identities in the face of admission
and/or receiving a diagnosis by categorising other patients, but not themselves, as
‘mentally ill’, by qualifying their diagnoses or by externalising symptoms 19].

Summary of dislocation: identity

In the areas of risks to identity there was no policy and guidance information. Feeling
separated from life outside and the subsequent difficulties experienced on returning
home were identified as pressing issues by some young people and health-care professionals
(CerQual—high). Young people with eating disorders talked about mental health problems
eroding their identities (CerQual—moderate), along with the experience of not being
treated as individuals (CerQual—low). For other young people it was a struggle to
manage threats to the sense of self during admission and treatment (CerQual—low).
There were no intervention studies found that focused on the testing of actions to
mitigate the risks to identity.

Dislocation: friends

Ten of the included studies 18]–22], 26]–30], one clinical case report 31] and two policies 32], 33] report findings related to this area. Two subcategories were created, these being
‘Relationships with young people outside hospital’ and ‘Relationships with young people
in hospital’.

Relationships with young people outside hospital

Maintaining relationships with outside friends is recognised as important in policy
and guidance 32], 33]. Young people in hospital were reported as valuing relationships with friends at
home but could also find these difficult to sustain 19]. Some described becoming distant from their friends before admission, ascribed both
to the experience of illness and to peers not understanding 21]. Admission was seen as contributing to the deterioration of friendships 19], 28], 29], with others expressing discomfort that friends visiting saw them in a mental health
facility 20] or describing friendships breaking down 28]. Others talked of deliberately disconnecting from friends outside of the unit as
part of a process of recovery 19]. Whilst benefits are recognised in maintaining relationships with friends at home
obstacles to this are recognised 32], including rules on visiting and conflicting priorities for young people 19], and geographical distance 19], 22]. Time away from friends was also seen as helpful as a way of relieving pressures
22]. Young people recognised risks around reconnecting with friends post-discharge 19]–21], 28]. In one study, ‘connectedness’ with both friends and families was found to change
after being on an inpatient unit, and affected levels of depression and suicide attempts
30].

Relationships with young people in hospital

Living alongside other young people with similar difficulties was described as positive
18]–22], 26], 27], and inpatient peer support was appreciated 19], 20], 22], 26]. On the other hand living with other young people with mental health difficulties
reportedly also had negative aspects 19], 20], 22], 26], 27] including causing distress.

Summary of dislocation: friends

In the case of risks associated with friendships and peer relations, policy and guidance
are limited to making recommendations on inpatient units having space for visitors.
The evidence included in this segment of the project pointed to the difficulties (and
ambivalence) young people can experience in maintaining home friendships at a distance
(CerQual—high) and in reconnecting with their friends after discharge (CerQual—high).
In some cases, connections with friends were significantly associated with levels
of post discharge depression and suicidal ideation (CerQual—low). No intervention
studies were found investigating actions to help young people in hospital maintain
good relations with their peers at home. Evidence was found pointing to young people’s
positive views of being with others in a similar position during hospital care and
treatment, in terms of mutual support and companionship (CerQual—high). Young people
also spoke of the negative aspects of living with other young people with mental health
difficulties (CerQual—high). Some parents were found to be concerned about their children’s
sharing of living space with other vulnerable people and at least some young people
expressed ambivalence (and even fear) in their relationships with other inpatients
(CerQual—low). No intervention studies were found investigating actions to promote
positive peer relations among young people who were inpatients.

Dislocation: stigma

Six of the included studies 18]–21], 34], 35] and 11 policy and guidance documents 23], 32], 36]–44] address this area. Two sub-categories were created, these being ‘Young people’s experiences
during admission’ and ‘Young people’s experiences post-discharge’.

Young people’s experiences during admission

Young people talked about specific stigmatising experiences felt to be a result of,
or occurring during, inpatient admission 18]–21]. They perceived stigma as flowing from the ‘outside world’ 18], 21], family members 19] and staff 21] with only a small minority reporting stigma experienced in hospital 20]. Some young people contrasted the stigmatisation felt in the outside world with the
community and companionship found in hospital 18], 21].

Young people’s experiences after discharge

A number of factors that were found to significantly predict young people’s apprehension
of stigma, including sex (being female), age at first mental health treatment (being
younger at initiation of treatment) and needing greater approval from others for self-worth
35]. Six months following discharge, 70 % of young people from this study reported stigmatising
experiences surrounding their mental health difficulties 34].

Summary of dislocation: stigma

Managing the risks of stigma and discrimination is a high priority for policy-makers.
Young people felt that stigmatising experiences can occur as a result of being admitted,
as well as during their inpatient stay (CerQual—moderate) and at discharge (CerQual—low).
Being with similar young people can also lead to feelings of acceptance, in contrast
with the experience of being rejected in the community (CerQual—low). No intervention
studies were found evaluating actions to mitigate the risks of stigma or discrimination
to young people admitted to mental health hospital.

Dislocation: education

Seventeen of the included studies 14], 15], 17]–19], 21], 22], 27], 28], 45]–52], one clinical case report 53], one practice initiative 31] and 14 of the policy and guidance documents 23]–25], 32], 33], 37], 38], 41], 44], 54]–58] addressed this area. Four subcategories were created, these being ‘Education provision
and facilities’, ‘Quality of inpatient education’, ‘Academic progress’ and ‘Reintegrating
with school after discharge’. Policy and guidance documents addressing these subcategories
are included in each relevant section below, along with the single practice initiative.

Education provision and facilities

One large-scale UK study revealed that education provision for young people under
16 years of who are in mental health units is either delivered by a school integrated
into the inpatient unit, or by a school located within the hospital grounds 46]. Some UK units reportedly maintain a mainstream school ethos 18], with health professionals emphasising the importance of teachers having appropriate
expertise. Young people have described support during lessons in hospital 22], with a majority of teachers describing access to local schools 45]. School during admission was seen as normalising 22].

Policy is clear that inpatient units working in partnership with education services/systems
is important 23], 24], 32], 37], 56]–58], more specifically to maintain continuity of education provision at admission 24], 32] with a key worker/named nurse to undertake this role 24], as well as to maintain communication with the young people’s parents/carers 32]. Most inpatient units in the UK have reported good relationships with their respective
education authorities 46].

Current policy also suggests those inpatients over 16 years of age should be able
to continue with post-compulsory education while hospitalised 32] and that education and training providers should support students to remain on their
course or hold their place open for them whenever possible 41]. In the UK, however, education provision appears to be less developed for those older
than 16 years 22].

Evidence from the US includes the description of full or partial attendance at mainstream
school for young people in an RTC 52]. In one US study smaller, multi-class, specialist teaching was found to be effective
in increasing the amount of work young people were able to produce whilst in hospital
15].

Quality of inpatient education

The quality of inpatient education provided to young people in inpatient mental health
hospital compared to conventional schooling has been investigated 22], 27] along with studies exploring teaching staff 18], 22], 45], 46]. Young people have been found to appreciate the supportive aspect of education 22] with only small numbers expressing concerns about the quality of schooling 27]. Additional training for teachers in child and adolescent mental health is seen to
be beneficial 24], 33], with experienced teachers keeping up with training feeling that they understand
the needs experienced by young people 18].

Investigations have taken place into staff/student ratios and teacher shortages 22], 45], 46]. Within England and Wales the majority of units have been reported as having a 1:3
staff-student ratio although a small number of units have reported ratios between
1:4 and 1:10 45]. Some unit staff have said that they need more teachers 24]. Teachers, on the whole, have reported good working relationships with young people’s
parents 45], though parents and young people themselves have reported instances of poor liaison
22].

Academic progress

Being an inpatient can have significant effects on young people’s achievements and
long term goals 18], 19]. Service standards indicate that inpatient units should be registered as examination
centres 32], with teachers reporting that young people have the opportunity to take their examinations
45]. Hospitalised young people have been shown to have pre-existing academic-related
issues 28], 49], including below-average grades 49]. In one study 79 % on discharge reported doing the same or better in school than
they had been prior to admission 51]. In investigations where young people have been followed up a number of years after
hospital care to see what has happened to their educational attainment, it has been
reported that they have been significantly less likely than young people without inpatient
mental health experiences to complete high school, to get a bachelor’s or graduate
degree 14], less likely to take up a career after discharge 47] and more likely to be expelled from school 50]. Significant predictors of academic functioning have been shown to include exposure
to substances in the year post-treatment, and being a younger age at treatment 49].

Reintegrating with school after discharge

Re-entry and reintegration into school following discharge from hospital is reported
as a major barrier to the academic progress of hospitalised young people 21], 22], 28], 45], 48], especially when an inpatient unit is far from home 22]. It is recognised in policy and guidance that education or training providers should
support students to remain on their courses, or should hold places open, whenever
possible 41].

Re-entry and re-integration into school has been suggested as something to consider
at the point of admission 48]. There is evidence that young people enjoy the supportive aspect of education 18], 22], and a lack of education support has been associated with discharge delays 45]. Plans for re-entry into school should be made and followed through but also be flexible
28]. In studies, both health care professionals 28] and young people 21] have described school absences resulting in falling behind and young people becoming
stressed during efforts to catch up. Health care professionals have suggested that
students benefit from an identified, adult, support person in the school, and open
communication has been identified as central to school/hospital partnerships 48]. Liaison with the young person’s mainstream school has also been suggested as vital,
although some parents have described teachers not always sending homework and particular
difficulties where school and hospital are geographically distant 22]. In UK inpatient units, the majority of teachers have been found to liaise with young
people’s schools 45], and parents particularly see liaison with mainstream education as important for
wider community reintegration 22].

Different types of school-based programme to manage transitions to school been investigated
48], 59]. Specific examples include intensive support in school and care coordination for
up to 10 weeks following hospital discharge 59], and school-based re-entry and/or step-down programmes and re-entry options, with
an emphasis placed on the importance of following through on interventions and asking
students what is important 48].

Summary of dislocation: education

In policy and guidance it is clear that inpatient units should provide access to education,
including appropriate education facilities/classroom space. However, no UK studies
were found that looked at this area. Health care professionals, parents and young
people all recognise the importance of educational provision with appropriate facilities
for young people in inpatient CAMHS (CerQual—high), which is also identified as a
policy and guidance priority. Smaller class sizes utilising a multiclass format with
specialist teaching have been shown in a study involving young people in a RTC in
the USA (GRADE—low) to be effective in increasing the amount of work young people
are able to produce while in hospital. In the UK, education is provided as standard
across inpatient units, but in a majority of hospitals only core National Curriculum
subjects are taught (CerQual—high). Improving quality and maintaining good communication
and co-ordination across hospitals and schools feature prominently in policy. Within
units in the UK, varying teacher/student ratios are found in NHS and non-NHS units
(CerQual—high), and good (but not universally so) relations between parents and teachers
have been reported (CerQual—low).

Dislocation: families

Seventeen of the included studies report findings relating to the risk of dislocation
from families 16]–18], 21], 22], 26], 27], 29], 30], 45], 46], 50], 52], 60]–63], five clinical case reports 31], 53], 64]–66] and one practice initiative addressed this category 67]. Three subcategories were created, these being ‘Impact on family relationships’,
‘Family involvement’ and ‘Maintaining contact with families’. Policy and guidance
documents addressing these subcategories are included in each relevant section below,
along with the single practice initiative.

Impact on family relationships

In policy and guidance inpatient care is recognised as exerting effects on family
life 36]. Improved family relationships are described as a goal of admission 33], and parent/carer support groups are recommended 32]. There is evidence that young people who are in hospital for extended periods experience
homesickness 18], 22], 63], with others feeling a sense of rejection 26] or isolation 21], or that their families held negative attitudes towards them 29].

Perceptions of young people’s ‘connectedness’ with their families has been shown to
change after inpatient admission, along with levels of depression and ideas about
suicide 30]. Parents have expressed a need for support 18], 29], whilst in some instances family relationships have been described as breaking down
29].

Family involvement

Family involvement is recommended in policy and guidance 23], with working in partnership with families described as the way forward 33], 58]. This is seen as including during the development of care plans, and during the making
of decisions on post-discharge care 32]. Policy and guidance refers to the value of consultation with families particularly
following episodes of self-harm 43], 57]. In the case of young people with psychosis and schizophrenia, one suggestion is
that alternatives to hospital admission be considered when the inpatient unit is a
long way from home 25]. Training staff in inpatient units to be more friendly during the admission process
by utilising role plays and mindfulness has had limited benefit 16]. Creating opportunities for families to watch films together during a young people’s
hospital stay has been described as helping family engagement, and if chosen carefully,
as a way of empowering families during periods of crisis 67].

A range of obstacles to family involvement have been reported by health care professionals:
confidentiality (including young people’s wishes that the details of their treatment
to be kept from family); parents’ own varying ability to get involved; limited time;
a lack of formal structures to enable family involvement; and distance 18]. For young people whose parents are involved, benefits have been shown to include
a significantly improved chance of sustaining therapeutic gains in the community 62], using after care services 61] and of avoiding readmission 50]. In one study, rehospitalisation increased when parents felt more empowered during
a young person’s psychiatric treatment 60].

Maintaining contact with families

Inpatient units should, according to policy and guidance, have policies and procedures
on visiting 32], and flexible arrangements should be in place for family contact 24]. Recommendations include family meetings within 1 week of admission, and continuing
thereafter 33], along with the idea services should be offered as near to home as possible enabling
frequent family visits and contact 37], 58] and appropriate family interventions 58]. When asked, young people have said they would like to keep in touch with their families
17], 21], and that whilst some units offer a flexible approach to visiting and family contact
17] this was not the same for all 21].

Some young people are placed in inpatient units located at distances from their homes,
challenging regular contact with families 17], 18], 22], 27], 46]. Policy and guidance recognises that alternatives to admission should particularly
be considered when hospital is a long way from where a young person lives 25]. For some young inpatients, the telephone is an important way of staying in touch
17], 18]. One finding, however, is that some young people experience the break from their
usual environment as also beneficial 22]. Others describe the quality of inpatient care as more important than the distance
from the hospital to their family home 17], 46]. For some parents, distance did not significantly affect the level of parent engagement
or satisfaction 50].

Facilities for family visiting recommended in policy and guidance include: making
available private space for family contact to take place 32], 33]; accommodating families who have to travel a significant distance 24]; and allowing parents and others to enjoy refreshments 32]. Parents 46] and young people 17], 22], 27] have both talked about the financial costs associated with admission to inaccessible
locations. Some inpatient units have been described as having access to funds to financial
support families receiving welfare benefits to visit 17]. Some also provide overnight provision for parents visiting from longer distances
17], 45], and provide for refreshments and privacy via use of a family room 45].

Summary of dislocation: family

One of the disadvantages of inpatient care recognised in policy and guidance is the
effects of admission on family life. Training inpatient staff working with young people
and their families through the use of role plays or mindfulness did not have a significant
impact on the family-friendliness of the admission process (GRADE—low). While on an
inpatient unit, young people often feel homesickness (CerQual—high) and experience
a range of negative feelings (CerQual—moderate). Associations between family connectedness
and post-discharge depression and suicidal ideation have been reported (CerQual—low).
Some family members need additional support during their children’s admission (CerQual—low).
Partnership with families during inpatient care is strongly recommended in policy
and guidance. Young people whose parents do get involved make significant improvements
across a range of treatment and post-discharge outcomes (CerQual—low) but health professionals
report that a number of obstacles exist to enable this to take place (CerQual—low).

Whether or not families are fully involved in a young person’s care, the evidence
suggests that units should have procedures on visiting and that flexible arrangements
should be made for family contact. A particular risk of family dislocation is reported
in instances where young people are admitted to hospitals located far from home, in
terms of keeping in touch and cost (CerQual—high). For some, the quality of care at
inpatient units is considered to be more important than the distance from the hospital
to the family home (CerQual—moderate). Some young people also appreciated being away
from the home environment (CerQual—low).

Dislocation: psychological development and dislocation: social

No material was included in these two categories.

Contagion

Seven studies report findings related to the risk of contagion for young people in
inpatient mental health hospital 18], 21], 22], 26], 68]–70]. Two sub-categories were created: experiences of contagion, and evidence of contagion.

Experiences of contagion

There is evidence that health professionals and parents have concerns about young
people acquiring unhelpful, destructive, behaviours during periods of admission, particularly
in the areas of suicide and self-harm 18] or even just by picking up on others’ difficulties 22]. For some health care professionals, learning bad habits and witnessing disturbing
and distressing events are seen as treatment failures 18].

Two studies described young people with eating disorders as being quick to copy the
behaviour of those around them with the same condition 21], 26], including making comparisons with others and competing to be thin 26]. Some young people with eating disorders have described themselves as becoming more
ill, in relation to their eating but also in terms of self-harm behaviours which they
had not hitherto engaged in 26]. Others have described living in the same place as other people experiencing difficulties
as being associated with unhelpful thoughts, comparisons and competitions 21]. However, the support of other young people during admission has also been described
as positive by some (see “Dislocation: Friends”).

Evidence of contagion

In one study a decrease in self-harming behaviour was noted amongst young people who
were inpatients who had previously engaged in this behaviour 69], and in another no evidence of contagion was found amongst young people admitted
to a short-stay unit 68]. The spontaneous occurrence of self-harm amongst young inpatients not having a history
of self-harm has been suggested to be low 69].

In a study which examined motivations for contagion episodes of self-harm, relieving
anxiety and anger or feeling part of a group were all identified 70]. Self-cutting and bloodletting, for some in this study, was part of an initiation
and group cohesion process associated with the shared experience of relief through
self-harm 70].

Summary of contagion

The risks of young people in hospital learning harmful behaviours was a priority area
for phase 2 of this project, but no policy or guidance was found addressing this.
Health professionals and parents have concerns about young people acquiring unhelpful,
destructive behaviours while they are inpatients (CerQual—moderate). Young people
with eating disorders very quickly copy the behaviour of those around them with the
same condition (CerQual—moderate). There is mixed evidence of recorded contagion in
inpatient mental health facilities for young people (CerQual—low), with no fixed definition
of what constitutes ‘contagion’. No evidence was located investigating actions to
mitigate the risks of contagion in inpatient settings.

Economic analysis

None of the studies included in this project reported an economic analysis or an economic
evaluation of different ways of identifying, assessing and managing the less obvious
risks for young people in inpatient CAMHS.