Children and Young People’s Experiences of Mental Health Services in Healthcare Settings: An Integrated Review

ABSTRACT

Mental health (MH) issues can affect all children and young people (CYP), and can form a long-term negative impact on their life prospects if left unchecked. It is of utmost importance that CYP’s voices are heard and that they are involved in decision-making and care planning. CYP aged 4–17 years old have provided an invaluable insight into their experiences of mental health services within healthcare settings. This review undertaken as part of a Masters in Advanced Professional Practice explores the CYP’s views and experiences within primary, secondary, and tertiary mental health services. Consequently, the betterment of mental health services for all CYP is sought.

KEYWORDS:

• Mental health
• children and young people
• mental health services

Introduction

Healthcare professionals (HCPs) face constant challenges concerning clinical practices and services (Bettany-Saltikov, 2012), as the need for mental health (MH) care is growing rapidly. HCPs must develop alongside this to provide quality care (Kodama & Fukahor, 2017). Children and young people (CYP) from 4 to 17 years old want to be involved in decisions regarding their health and their insight can be invaluable for caregivers (Persson et al., 2017; Sorsa et al., 2006).

Throughout childhood and adolescence, socioemotional capabilities develop and it has been shown that community support during this crucial period of development enables the child or young person to evolve into a young adult with good mental wellbeing (Royal College of Psychiatrics, 2019). It is important to note that mental health issues can affect CYP as they do adults, often with long-term negative consequences if left unchecked (Brown et al., 2012).

Mental health disorders comprise a broad range of symptoms. However, the National Institute for Health and Care Excellence (NICE) states that sufferers share characteristics such as abnormal thoughts, emotions, behaviors, and relationships (National Institute for Healthcare Excellence, 2011). In 2019, it was found that approximately 10% of CYP in the United Kingdom (UK) are affected by MH problems, and 70% of these have not received timely MH care. The approximate waiting time between the first referral and first appointment is approximately 10 years in the UK (The Mental Health Foundation, 2019).

Whilst the exact causes of mental health illnesses remain unknown, research shows several common influences like biological, psychological, and environmental factors (Brown et al., 2012), whilst experiences like bereavement, abuse, stress, social disadvantage, and trauma are catalysts for poor mental health (World Health Organisation, 2019). Adverse childhood experiences (ACEs) such as domestic abuse, parental abandonment, drug, or alcohol abuse, a parent with a mental health condition, or the imprisonment of a household member can impact the CYP’s mental health status (World Health Organisation, 2019). This impact can have long-term, wide-reaching consequences for mental and physical health in adulthood. Additionally, biological factors such as genetics, neuro-development, or neurological damage can trigger mental health problems (Royal College of Psychiatrics, 2019).

Emerging evidence from the COVID-19 pandemic has revealed a variety of factors, which affect CYP’s MH such as education and play deprivation, online bullying, domestic abuse, and poverty (Fallon et al., 2020). Worryingly, these factors were evident throughout all age groups (4–17 years old). Furthermore, academic pressures and concerns about the future were noted in young people at secondary school age (The Mental Health Foundation, 2021).

According to World Health Organisation (2017), two-thirds of countries do not collect data for MH disorders or have information specific to CYP. Thereby hindering a true global interpretation of the situation (Funk et al., 2012). There is a particular lack of research in acute and pediatric settings (Funk et al., 2012), and cultural stigma concerning MH has been fueled by poor public awareness (The British Asian Trust, 2019). Many countries are subject to conflict-induced humanitarian crises, and it has been shown that CYP from such communities are twice as likely to suffer from mental health problems than others (World Health Organisation, 2019). Research suggests this is caused by an accumulation of risk factors such as age, gender, sexuality, family, school, and community systems at different socio-ecological levels (Almqvist & Brandell-Forsberg, 1997; Sack et al., 1999). The United Nations have published ‘We the Children,’ a report examining the multifaceted impact of war on child development (United Nations, 2001). Thousands of CYP are exposed to acts of terror and the deconstruction of their community and culture during war and conflict. These experiences may cause mental illnesses such as PTSD, anxiety, and depression (United Nations, 2001)

In Northern Ireland (NI) ‘The Troubles’ has caused transgenerational trauma (O’Neill, 2016). This passing of trauma from parents to children may negatively affect parent–child bonding (Fitzgerald et al., 2017) and may instigate stress-induced epigenetic changes in the child (O’Neill, 2016).

Children and young people can access several mental health support services via primary, secondary, and tertiary care services. However, there is a delay of approximately 10 years between detection and the instigation of support in line with statistics from the UK (Khan, 2017).

Review aim

To explore research presenting firsthand accounts of CYP’s experiences of mental health services. To identify to pertinent issues in these experiences and to investigate strengths and weaknesses, as well as enablers and barriers to changing mental health provision for children and young people. Consequently, the betterment of MH services for all service users is sought.

Review question

What are CYP’s views of, and experiences within primary, secondary, and tertiary Mental Health services?

Methods

Whittemore and Knalf (2005) five-stage integrative review framework was adopted – (1) problem identification (2) literature search (3) data evaluation (4) data analysis and (5) presentation. Lee et al. (2020) reported this approach facilitates the inclusion of diverse methodologies, and the potential to play a greater role in evidence-based practice along with the ability to build nursing science, inform research, practice, and policy.

Systematic searches were carried out in May 2019 in the following databases: Cumulative Index for Nursing and Allied Health Literature (CINAHL), CINAHL Plus, MEDLINE, Scopus, PubMED; EMBASE, INTERNURSE, Web of Science, PsychINFO, Cochrane, and Science Direct. Key search words/terms were ‘children’; ‘young people’; ‘experience’; ‘views’; and ‘mental health services.’ Additional keywords identified throughout multiple publications were included. Reference lists of relevant studies were screened to identify additional studies. A search limit of the English language was only applied due to translation problems. Duplicated studies were removed, and titles and abstracts of the remaining studies were screened for relevance. The full text of the remaining 33 papers were analyzed, but 24 of these did not meet the inclusion criteria (see Table 1).

Table 1. Inclusion criteria.

Inclusion Criteria
Qualitative and Quantitative Primary Research
Primary Research
Peer-reviewed empirical research articles
Full Text Available
English Language
All geographical locations (Global)
Male and Female participants
All time frames (no year/ time limits)
Children and Young People’s experiences only (0–17 years old)
All Mental Health Services within healthcare settings

A data extraction form was developed to ensure the resulting validity. Once data was extracted, the information was then placed into a table format to enable the comparison of the multiple research papers. These comparisons enabled thematic analysis, facilitating the identification of recurrent topics of interest (Whittemore & Knalf, 2005). All research papers were systematically analyzed by the primary author, and the themes were discussed and agreed with supervisors to enhance the integrity and robustness of this review. Each paper was coded to highlight keywords, and grouped together thematically. Quality assessment and key data extraction was conducted using the appropriate Joanna Briggs Institute’s (2016) Critical Appraisal Tool.

Overview of results

Seven hundred and eighty-four results were yielded from the multiple database searches. Two hundred and nine of these search results were duplicates, leaving 575 papers. These were screened at title and abstract, leading to a further 542 papers being excluded for irrelevance. The full text of the remaining 33 papers was analyzed, but 24 of these did not meet the inclusion criteria. This meant that nine research papers met all inclusion criteria (see Table 1). The reference lists of all relevant literature and yielded studies from the database search were thoroughly assessed, and further two studies were added, meaning that there were 11 studies identified for this review (see Figure 1). The current gap in research relating to CYP views and opinions could be caused by legal and ethical issues. CYP has traditionally been unmerited in research (possibly because of an endemic protectionist attitude), and recruiting adequate numbers (Fernandez, 2008).

Figure 1. Prisma flow diagram.

A search was conducted for similar reviews and two papers were found, which were called ‘Young people’s views of UK mental health services’ and ‘Children’s Voices’ (Children’s Commissioner, 2017; Plaistow et al., 2013). However, these reviews did not only collect primary data, but also secondary literature based on analysis of preexisting data. These reviews also included participants that did not fit the inclusion criteria, and they did not solely focus on CYP’s views and experiences. Therefore, this review differs in that it seeks to create relevant and current analysis that can be used to facilitate future care and policymaking for CYP mental health services. A final additional search was carried out in November 2020, which did not uncover any additional studies.

All 11 studies demonstrated congruity between the philosophical perspective and research methodology, between methodology and the research question/objective, between research methodology and the methods used to collect the data, between research methodology and the representations and analysis interpretation of results (Table 2). Data triangulation (when more than one method is used in a study) was used in three studies with the combination of focus groups and interviews (Coyne et al., 2015; Day et al., 2006; Persson et al., 2017). All studies provided narratives regarding ethical considerations, with approval granted by the relevant ethical body. The conclusions drawn by all studies were based on collected data, with four main themes and 11 sub-themes highlighted by the author and supervisors throughout the analysis (see Figure 2).

Table 2. Characteristics of included studies.

Title of research article and Purpose	Author, Year and Geographic Location	Sample studied	Study Design	Strengths and Limitations Quality Assessment Score (QA)
Paper 1 Adolescents’ perceptions of outpatient mental health services Purpose: To explore adolescent perceptions of the purpose, goals, expectations, frustrations and benefits of their mental health experiences.	Garland, A. and Besigner, B. 1996 United States of America	33 adolescents from three MH service settings 17 Male and 16 Female participants Aged 13–17 years old 36% Caucasian; 39% Hispanic; 21% African American; and 3% Asian	Qualitative Phenomenological approach Semi – Structured Interviews with Open-ended questions Taped, transcribed and coded	Strengths Representative of a diverse population within various settings Limitations Relatively small sample size – limited power to detect group differences QA Score: 20 (High)
Paper 2 Adolescents with mental health problems: what do they say about health services? Purpose: To explore health-related views and experiences of adolescent users of MH services.	Buston, K. 2002 Greater Glasgow, Forth Valley and Lanarkshire (UK)	32 young people ages 14–17 years old 21 females and 11 males All White British participants 1+ years of MH diagnosis 24 participants are attending child and adolescent services, 12 had been inpatients	Qualitative Phenomenological approach Semi-structured interviews In depth interviews that were taped, transcribed and coded following a grounded theory approach. Mean interview time = 1 hour and 30 minutes	Strengths Interview schedule piloted – increases reliability and validity Informal manner-promoting openness Various mental health illnesses Limitations One ethnic background (White). Small group and limited ages QA Score: 18 (High)
Paper 3 Children’s Key Concerns: Piloting a Qualitative Approach to Understanding Their Experience of Mental Health Care. Purpose: To systematically explore the service concerns of children who had received MH care in the community.	Day, C., Carey, M. and Surgeoner, T. 2006 Southwark, UK.	11 CAMHS service users 9–14 years old 5 males and 6 females. All white British participants	Qualitative Explorative descriptive study Stage 1: 3 semi-structured focus groups – taped and transcribed verbatim and coded Focus Group Mean Time: 52 minutes Stage 2: Validation Group – 4 participants from Stage 1 group for accuracy	Strengths Focus Group: Informal manner and icebreakers – increase honesty. Participants had various mental health illnesses Validation Group: Increases accuracy and validity of themes. Trained researchers Limitations One ethnic background (White). Small group and limited ages QA Score: 20 (High)
Paper 4 Children’s Views on Their Own Hospitalization at a Child Psychiatric Ward. Purpose: To allow children to explore and describe their own views of hospitalization at a child psychiatric ward.	Sorsa, M., Ranta, T., Hartikainen, A. and Paavilainen, E. 2006 Norway	29 participants 4–12 years old 25 males and 4 females participated. Ethnicity not specified.	Qualitative Phenomenological Approach Interviews using a structured questionnaire, including open-ended questions which were taped, recorded and transcribed verbatim	Strengths Questionnaire: Not very invasive to the children, and they felt safe when stating their point of view, improves accuracy Various mental health illnesses Limitations Small group and limited ages Ethnicities unknown QA Score: 20 (High)
Paper 5 Children’s Views Matter Too! A Pilot Project Assessing Children’s and Adolescent’s’ Experiences of Clinical Psychology Services Purpose: To explore the experiences and understanding of clinical psychology practices and services of children and adolescents attending clinical psychology outpatient appointments.	Gordon, M. and Russo, K. 2009 Northern Ireland	15 participants (Aged 7–17 years old). 9 Children, 4 Males and 5 Females (7–11 years old) 6 Adolescents, 3 Males and 3 Females (12–17 years old) Ethnicity not specified	Qualitative Explorative Interpretive Study Semi- structured interviews. 9 open-ended interview questions. Interviews taped, transcribed verbatim and coded.	Strengths Participants had various mental health illnesses Interview Style provides flexible agenda. Limitations Ethnicities unknown Small sample size QA Score: 18 (High)
Paper 6 ‘They’re not witches…’ Young children and their parents’ perceptions and experiences of Child and Adolescent Mental Health Services. Purpose: To explore children’s experiences of CAMHS with the objective of providing guidance for those wishing to improve inclusivity and empowerment.	Bone, C., O’Reilly, M., Karim, K. and Vostanis, P. 2014 England (Rural, Urban, Inner City all included)	Study included 4 CAMHS services, teams 11 participants 8–12 years old 9 Male and 2 Female Ethnicity not specified	Qualitative Explorative interpretive study Semi-structured interviews were taped and coded	Strengths Children were given the option to have an adult or present or not: makes them more comfortable and in turn, more open. Various mental health illnesses and social backgrounds Limitations Ethnicities unknown Small sample size QA Score: 20 (High)
Paper 7 Adolescents’ and parents’ views of Child and Adolescent Mental Health Services (CAMHS) in Ireland. Purpose: To explore adolescents’ experiences of CAMHS in relation to accessibility, approachability and appropriateness.	Coyne, I., McNamara, N., Gower, C. and McNicholas, F. 2015 Republic of Ireland	3 CAMHS Clinics were involved from 3 geographically distinct urban regions 15 Adolescents participated 12–17 years old 6 Male and 9 Female Ethnicity not specified	Qualitative Descriptive Qualitative Design Focus Groups (n = 9) and Semi-structured Interviews with open-ended questions (n = 10) Interviews were audio recorded, transcribed verbatim and coded	Strengths Various mental illnesses and social backgrounds Trained researchers Option of focus group or interview Limitations Unknown ethnicities Small sample size QA Score: 20 (High
Paper 8 ‘I don’t want to be here, but I feel safe’: Referral and admission to a child and adolescent psychiatric inpatient unit: The young person’s perspective. Purpose: To identify and understand the experiences of the admission process for young people referred to psychiatric inpatient units.	Salamone-Violi, G., Chur-Hansen, A. and Winefield, H. 2015 Australia	Purposeful sampling 11 Inpatients from a state psychiatric ward participated 15–17 years old 6 Males and 5 Females	Qualitative Explorative, Interpretive study Semi-structured interviews with open-ended questions – audiotaped, transcribed and thematically analyzed	Strengths Various mental illnesses and social backgrounds Purposeful sampling enabled a consideration of a range of variables. Limitations Small sample size Limited age range Ethnicities unknown QA Score: 20 (High)
Paper 9 Young offenders’ and their families’ experiences of mental health interventions. Purpose: To explore the relevance of young people’s experiences of MH interventions with CAMHS before and during their time with youth offending services.	Jack, A., Lanskey, C. and Harvey, J. 2015 UK	14 participants that were involved with Young Offender Services (YOS) and CAMHS – 19% of population in this area. All aged 14–17 years old 1 White European, 1 Chinese and 12 White British participants 5 Females and 9 Males	Qualitative Exploratory interpretative study Semi-structured interviews with open-ended questions – taped, transcribed and coded	Strengths Various mental illnesses and ethnicities Interview Style provides flexible agenda (Semi-structured interviews with open-ended questions). Limitations Small sample size and small age range QA Score: 18 (High)
Paper 10 Young voices in mental health care: Exploring children’s and adolescents’ service experiences and preferences. Purpose: To explore young service users’ views of outpatient and community health clinics.	Persson, S., Hagquist, C. and Michelson, D. 2017 Sweden	7 participants (5 Females and 2 Males). All aged between 10 and17 years old All from community and CAMHS outpatient settings	Qualitative Phenomenological approach Semi-structured focus group interviews were conducted, taped, transcribed and coded. These two sources were then combined. 4 main themes identified. Validation group to confirm themes.	Strengths Various mental illnesses The combination of data from surveys and focus groups. Informal manner of focus group-participants may be more open. Limitations Ethnicities unknown QA Score: 20 (High)
Paper 11 Vulnerable young people’s experiences of Child and Adolescent Mental Health Services. Purpose: To explore the experiences of vulnerable young people in using a local child and adolescent mental health service (CAMHS)	Davison, J., Zamperoni, V. and Stain, H. 2017 North – East England, UK.	51 CAMHS service users aged 12–17 years old (Mean age: 15 years old) 74% Female participants and 26% Male participants All White – British ethnic origin. All participants attend a multi-site Foundation Special School	Qualitative Phenomenological approach Semi-structured interviews with open -ended questions which were taped, transcribed and coded	Strengths Good validity and reliability Large sample size Limitations Comparison or involvement of children in mainstream education was not possible due to time and resource constraints: may lack generalizability QA Score: 20 (High)

Figure 2. Themes and sub-themes.

Key themes and sub-themes

Theme one: user involvement

This theme highlights the idea that CYP wants help in resolving conflicts, freedom of choice, and possible decision-making.

Sub-theme: session expectation

The research participants expressed that they wanted help have better control of their condition and behavior (Garland & Besinger, 1996; Gordon & Russo, 2009; Jack et al., 2015; Persson et al., 2017). Persson et al. (2017) highlighted that individuals prefer effective and instructive advice, not something always offered. Furthermore, they emphasized the importance of focused treatment throughout as some interventions lacked individualization. Jack et al. (2015) found that many participants were anxious about their sessions as little information was provided.

Sub-theme: session content

Throughout each included research paper, session content was highlighted as the most important factor to influence staff – patient relationships and positive outcomes. However, there was consensus that the sessions and appointments went on for too long (n = 11). Despite this, in extended session times several participants explained that they were given medication without any information, which left them feeling anxious (Buston, 2002).

Day et al. (2006), Jack et al. (2015), Coyne et al. (2015), and Persson et al. (2017) found that some participants were reluctant to discuss certain matters in front of their parents, thus hindering care and patient progression.

Sub-theme: value of action

All CYP expressed a preference for achievable goals throughout the process. They also wanted clinicians to be involved in their facilitation and planning (Bone et al., 2014; Persson et al., 2017). In particular, Bone et al. (2014) and Persson et al. (2017) found that rewards such as stickers or certificates promote CYP’s empowerment, increasing the motivation for treatment compliance, especially in younger children (4–11 years old).

Theme two: stigma

Stigma appears to be the main barrier to CYP seeking help (Davison et al., 2017). Throughout the studies, it became evident that CYP are sensitive to the stigma attached to MH illnesses, causing reluctance to seek help (n = 11).

Sub-theme: health care professionals

All 11 studies showed that CYP felt that their HCPS held misconceptions and prejudgments about them.

Sub-theme: feelings

Many research papers have found that CYP fears talking about their feelings and diagnosis. Jack et al. (2015) found that participants felt frightened and disempowered when discussing MH issues because of attached stigmas. Gordon and Russo (2009) and Salamone-Violi et al. (2015) found that participants had initial feelings of powerlessness, but ultimately, many had a positive experience, believing the intervention effective. However, many felt feelings of guilt and shame once diagnosed (Garland & Besinger, 1996). Young people, particularly between 14 and 17 years old, highlighted that they believed professionals fail to recognize that there is a suffering life behind the diagnosis, and it is not just a way of seeking out attention. Furthermore, they felt that a lot of skepticism greeted their report of symptoms (Buston, 2002; Gordon & Russo, 2009).

Sub-theme: education

CYP appeared to have limited awareness and understanding of mental health, including the variation of MH difficulties, available services, and management of symptoms (Day et al., 2006). They also tended to be unfamiliar with support networks, and how to access them (Buston, 2002). Therefore, many CYP suffering from MH issues delayed accessing necessary support (Davison et al., 2017). Furthermore, many CYP felt that HCPs lacked education and were unable to manage their illnesses (Buston, 2002; Jack et al., 2015).

Theme 3: relationships

Relationships form the core of service users’ experiences. The staff – patient relationship, and relationships built with other children are discussed throughout this theme. Familiarity and consistency throughout care will also be explored.

Sub-theme: staff – patient

Staff must build a therapeutic relationship with patients to provide quality care (Davison et al., 2017; Garland & Besinger, 1996). Participants in each of the papers (n = 11) emphasized the importance of being heard. The CYP felt that their feelings should be respected in a non-judgmental manner (Gordon & Russo, 2009; Salamone-Violi et al., 2015). Jack et al. (2015) explained that being understood is pivotal to developing relationships, as otherwise CYP may feel distressed, causing negative effects such as a lack of openness and honesty.

Positive interactions encourage openness and honesty, and promote the adoption of healthy behaviors (Buston, 2002; Sorsa et al., 2006). Many participants had a positive experience with staff members, which promoted wellness and honesty (Sorsa et al., 2006).

Sub-theme: other children

Several CYP described their stay in a CAMHS inpatient unit as lonely. Many participants felt that the stay caused disruption to their everyday routine, impacting on education, playing games, and socializing (Sorsa et al., 2006). However, young people (12–17 years old) describe positive interactions with other inpatients, heightening their level of satisfaction (Persson et al., 2017)

Theme 4: access

Accessibility often leaves CYP feeling frustrated. Many said that the acceptance criteria were too rigid, waiting lists were too long, services failed to recognize their needs, and there was limited flexibility (n = 11). Coyne et al. (2015) found that many participants and families were unsure where to access help, and often accessed private services when told of the waiting list time.

Sub-theme: environment

This sub-theme included the participants’ perceptions of the physical environments of healthcare settings and their appropriateness. Privacy was frequently highlighted. Furthermore, CYP expressed the poor meal quality (Buston, 2002). Garland and Besinger (1996) and Salamone-Voli et al. (2015) found that participants commented negatively about the inaccessibility of outdoor areas. Alternatively, some participants recognized the environment as having a level of safety (Salamone-Violi et al., 2015). Day et al. (2006) and Persson et al. (2017) discussed session disruption due to the presence of younger siblings or interruption by other HCPs. These disturbances left CYP feeling shocked, making them doubt confidentiality and feeling disrespected.

Sub-theme: location

Many participants were concerned about the geographical location of the MH inpatient units and community CAMHS (Day et al., 2006; Garland & Besinger, 1996). CYP explained that they are too far away (Bone et al., 2014; Buston, 2002; Davison et al., 2017), making it difficult to attend appointments because of the distance involved. They stressed they had a negative inpatient experience as it was too distant for family and friends to visit. Additionally, some children were having to miss school due to the lengthy travel (Davison et al., 2017).

Sub-theme: waiting lists

Throughout all the papers, there was a consensus that waiting lists were too long (n = 11). Participants felt that they waited too long for an appointment or hear back from the service. Furthermore, the inconvenience of set appointment times was highlighted (Jack et al., 2015). CYP expressed that they felt rushed by HCPs, making them feel undervalued. Each of these factors can be counterproductive in the therapeutic process (Bone et al., 2014).

Discussion

Implications for practice

All included papers (n = 11) emphasized that mental health services should embrace a child-centered approach, this allows care to be tailored to the child’s age and stage of development. Additionally, recognition of the child’s developmental stage is important, and care should be tailored around this. HCPs require further training to strengthen their understanding of working alongside CYP with mental health problems (Buston, 2002; Garland & Besinger, 1996; Sorsa et al., 2006). In particular, in emotional intelligence and communication skills (Sorsa et al., 2006). Salamone-Violi et al. (2015) and Jack et al., (2015) suggested that HCPs should be approachable, friendly, and non-judgmental.

In 2015, Coyne et al. found that adolescents should be given the choice of having a parent or carer present during consultations as some participants stated they would prefer to be alone throughout as it allows them to be more open and honest (Coyne et al., 2015). Salamone-Violi et al., (2015) suggested the implementation of fun-based activities such as art and music. CYP expressed the issue of high staff turnover as they were regularly re-assigned a keyworker and this had a negative effect on the patient–staff relationship (Salamone-Violi et al., 2015). Rising levels of burnout and poor wellbeing in staff are an international concern for healthcare services. Multiple studies included in a review by Hall et al. (2016) have highlighted the importance of designing interventions that target staff burnout within healthcare settings.

Implications for services

Jack et al. (2015) believed that a singularly dedicated inpatient unit might not have the capacity to meet everyone’s needs, as illnesses vary enormously. Within most inpatient wards, there will be a mixture of voluntary patients and patients who are sectioned under the Mental Health Act. Wards should be individualized according to patient needs as some may require to be locked and have a secure outdoor space. If a child or young person has been voluntarily admitted this may make them feel unnecessarily restricted which could have a negative impact on their progress and care (Jack et al., 2015). This may also breach requirements under the Human Rights Act 1998 or other legislation (HM Government, 2019). Davison et al. (2017) recommended that a supportive, pleasant environment be created for all. They also encouraged regular consultations with CYP as they found this was vital to securing and maintaining engagement. Furthermore, outreach services could be developed to improve service accessibility. Persson et al. (2017) and Davison et al. (2017) also suggested flexible appointment times and locations.

All 11 papers found that an improvement is needed in crisis management, so CYP can be treated in a timely manner and as close to home as possible. Unfortunately, many emergency departments do not have an environment, which can ensure the privacy and safety of CYP. Most departments in the UK do not have barricaded doors meaning that HCPs may need to restrain the child or young person if they are putting themselves or others at risk. Any period of restraint can be dangerous for both the patient and HCPs. HCPs must abide by the Mental Health Units (Use of Force) Act 2018 and reduce the use of physical, mechanical, or chemical restraint and not intentionally cause pain to CYP in an attempt to force compliance (HM Government, 2019).

Additionally, CYP expressed the need for comfortable furniture and more welcoming waiting areas (Bone et al., 2014). Participants from all age groups suggested the use of toys, games, and refreshments to create a therapeutic environment. These suggestions, while they appear to be trivial, are critical to forming links between services and outcomes (Bone et al., 2014). Therefore, a commitment to funding, time, and additional staffing is required, which may prove difficult within the current context of practice.

Davison et al. (2017) suggested that HCPs should implement MH awareness sessions in schools to challenge stigma and promote services. HCPs should aim to improve our understanding of MH, so there is less stigma around this topic. Persson et al. (2017) and Davison et al. (2017) suggested providing parental access to evidence-based programs of intervention, and support to strengthen parent and child bonding, avoid early trauma, build resilience, and improve overall behaviors.

Implications for research

Buston (2002) recommended that more research be carried out based on representative samples of CYP` with MH problems to address methodological constraints such as sampling and recruitment (Buston, 2002). Davison et al. (2017) suggested that HCPs should gain regular service-user feedback, rather than just at discharge. Northern Ireland, for example, one of The United Kingdom’s (UK) four countries has the highest incidence of mental health problems in the UK. An up-to-date prevalence survey, which captured the mental health of children by Bunting et al. (2020) advises ‘children and young people today live in a world that is vastly different to the one in which many of us grew up in. The influence of social media and the internet, cyber bullying alongside school pressures, particularly regarding exams, have all contributed in no small part to rising levels of anxiety and stress amongst our children and young people.’ When all factors were analyzed simultaneously, only six remained significantly associated: two of interest were: (1) Adverse Childhood Experiences: these increased the rate of any mood or anxiety disorder by a ratio of eight. (2) Age: young people aged 16–19 year olds were almost five times more likely to have any mood or anxiety disorder than the youngest age group.

Limitations of this review

A limitation of this search strategy was that only English language papers were reviewed. The inclusion of other languages and unpublished papers may have revealed additional information. A more comprehensive search strategy that included gray literature may have further contributed to the findings. Furthermore, all included studies involved CYP known to mental health services, meaning CYP with little or limited access to services are under-represented.

Conclusion

In this literature review, we have developed an innovative and systematic method for exploring CYP’s experiences of MH care. This is a reminder for all HCPs that high quality, patient-centered care is vital to ensure positive outcomes. Each study included in this review articulated complex and intricate ideas that reflect the main concerns in relation to CYP MH services within healthcare settings. There is consensus that improvement is needed both globally and locally. It is essential that changes are made and that these are inspired by the views of CYP receiving the service.

It is important to note that this review was undertaken prior to the COVID-19 pandemic. Whilst largely spared from the direct health effects of COVID-19, children, and young people have been profoundly affected by the indirect effects of social distancing and lockdown measures and will potentially be exposed to many more adverse childhood experiences than ever before. Moreover, mental health services are being forced to function in new and different ways due to social distancing regulations. The findings of this review are therefore even more important to inform practice and support the development of new working practices, ensuring the voices of children and young people are heard.

Acknowledgments

The first author (RK) wishes to acknowledge the financial assistance and support given by the Royal College of Nursing – Rae Bequest Bursary for Advanced Professional Practice M.Sc. Secondly, she would like to express her sincere gratitude to her supervisors, Dr. Sonya Clarke and Mrs. Julie Brown, her partner, parents, and wider family for their support.

Disclosure statement

We wish to acknowledge that no financial interests or benefits have arisen from undertaking this literature review.

Additional information

Funding

This work was supported by the Royal College of Nursing.