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Abstract
Objective To systematically review the literature describing children and young people (CYP) admissions to paediatric general wards because of primary mental health (MH) reasons, particularly in MH crisis.
Design PubMed, Embase, PsycINFO, Web of Science and Google Scholar were searched, with no restriction on country or language. We addressed five search questions to inform: trends and/or the number of admissions, the risk factors for adverse care, the experiences of CYP, families/carers and healthcare professionals (HCPs) and the evidence of interventions aimed at improving the care during admissions.
Two reviewers independently assessed the relevance of abstracts identified, extracted data and undertook quality assessment. This review was registered with PROSPERO (CRD42022350655).
Results Thirty-two studies met the inclusion criteria. Eighteen addressed trends and/or numbers/proportions of admissions, 12 provided data about the views/experiences of HCPs, two provided data about CYP’s experiences and four explored improving care. We were unable to identify studies examining risk factors for harm during admissions, but studies did report the length of stay in general paediatric/adult settings while waiting for specialised care, which could be considered a risk factor while caring for this group.
Conclusions MH admissions to children’s wards are a long-standing issue and are increasing. CYP will continue to need to be admitted in crisis, with paediatric wards a common location while waiting for assessment. For services to be delivered effectively and for CYP and their families/carers to feel supported and HCPs to feel confident, we need to facilitate more integrated physical and MH pathways of care.
PROSPERO registration number CRD42022350655.
- Child Psychiatry
- Mental health
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Anecdotally, there is evidence that both the number of pediatric admissions and mental health (MH) crisis severity in children and young people (CYP) have increased.
Such admissions can present specific challenges for both service users and providers.
There is no published systematic review on this topic.
WHAT THIS STUDY ADDS
This is the first systematic review on CYP admissions to paediatric wards with a primary MH indication.
Evidence suggested increased numbers of admissions over time and healthcare professionals reported concerns about skill sets to manage CYP with MH presentations.
There is limited evidence on CYP experiences. A main finding was a need for clear communication and compassionate clinicians caring for them.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The data provided by the review will be used to produce recommendations and transformation plans to share with policymakers, commissioners, service leads and professionals.
Introduction
Mental health (MH) disorders represent a significant burden on the health of children and young people (CYP)1 with some CYP admitted to hospital because of a deterioration in their MH.2 In an emergency, such admissions tend to be to medical children’s wards3 which may serve as an acute place for safety/assessment4 or provide interventions such as treatment for overdose5 or nutritional rehabilitation.6 Paediatric wards can also be a place of admission while waiting for a specialist MH admission, sometimes called ‘psychiatric boarding/psychiatric boarders (PBs)’.7 8 Although CYP with acute MH presentations have always formed part of the case load of paediatric medical wards,3 clinicians are reporting that these admissions are becoming more common and more complex since the SARS-CoV-2 pandemic.7 9 10 MH admissions to paediatric wards present challenges for service users and providers alike. Paediatric wards may not be safely prepared for the numbers or specialist care needed.3
A number of systematic reviews have also found limited efficacy for interventions to reduce admissions of CYP with an MH crisis,2 11 and there is evidence that CYP admitted with an MH diagnosis are more likely to require readmission.12 Therefore, such admissions are not just considerations for providing care in paediatric medical wards in the here and now but are likely to remain so for the foreseeable future. This calls for a focus on the quality and safety of care for such admissions for CYP, families/carers and the teams caring for them13 to which an up-to-date synthesis of the published literature can contribute. While several systematic reviews have focused on the care of CYP presenting to emergency departments (ED) with MH disorders,14–16 at the time of writing we were unable to find any systematic reviews on admissions to paediatric wards. Our broad systematic review of the literature on acute MH admissions to paediatric medical wards was carried out using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We asked five questions: (1) To inform the size of the problem, what is the evidence for trends in the number of admissions and/or the number/proportions of CYP admitted to paediatric or adult wards because of a primary MH diagnosis? (2) To inform factors that can impact care, what are the risk factors for poor care for CYP and families/carers during admissions to paediatric wards (or adult general wards) because of a primary MH diagnosis? (3) To examine the context of care, what are the reported experiences of healthcare professionals (HCPs) on paediatric wards (or adult general wards) during the admissions of CYP because of a primary MH diagnosis? (4) To understand CYP and families/carers' experiences as part of the context of care, what are the reported experiences of CYP and their families/carers during admissions to paediatric wards (or adult general wards) because of a primary MH diagnosis? (5) To inform about support during MH admissions, is there evidence of interventions or quality improvement projects aimed at improving the care of CYP and families/carers during admissions to paediatric wards (or adult wards) because of a primary MH diagnosis?
Methods
Protocol and registration
Our review protocol was registered with PROSPERO registry of systematic reviews (CRD42022350655) (online supplemental appendix 1).
Supplemental material
Eligibility criteria
We included full-text publications since 1990 with no language restrictions and including observational studies, qualitative studies, reports by professional bodies, systematic reviews and randomised controlled trials reporting on admissions of CYP (≤18 years) to any paediatric ward or adult general ward with a primary MH diagnosis. We included studies involving CYP with any mental disorder or MH presentation, so long as it was the primary reason for admission. In studies where only average age was reported, studies were eligible if the average age of participants was ≤18 years. We excluded studies which exclusively reported on CYP presenting to the ED and those that reported admissions solely of participants aged >18 years.
Search method for identification of studies
We searched PubMed, Embase, PsycINFO and Web of Science (1990 to April 2023). An additional search of Google Scholar was performed to identify reports which might contain unpublished data/additional studies. Search terms developed in conjunction with a clinical librarian were: (admission* OR admitted OR admittance OR hospitalized OR hospitalised OR treated OR inpatient* OR in patient* OR boarding OR boarders OR psychiatric boarders) and (paediatric ward* OR children* ward* OR pediatric ward*) and (mental health* OR psychiatric or psychological). Specific search terms for each database are shown in online supplemental appendix 2. Reference lists of selected articles were reviewed to identify additional studies.
Supplemental material
Study selection process
After duplicates were removed, two researchers (AV-V, AS) independently reviewed titles and abstracts for inclusion. Differences were resolved by discussion with a third reviewer (LDH). The same reviewers independently extracted information from selected studies to address the five review questions above.
Quality assessment
The reviewers independently assessed included studies for quality. For qualitative studies, the Critical Appraisal Skills Programme (CASP) tool was used. This consists of 10 questions (scored as ‘yes’, ‘can’t tell’ or ‘no’) that address the rigour of the research methodology and the findings’ credibility. We then followed Fullen et al’s17 proposal that if two-thirds scored ‘yes’, it was rated ‘high’, between four and six ‘yes’ was rated as ‘moderate’, and if over two-thirds was rated ‘no’, it was scored as ‘poor’ quality. For quantitative studies, the Appraisal tool for Cross-Sectional Studies (AXIS) was used. The AXIS tool aims to aid systematic interpretation of a study and to inform decisions about the quality of the study.
Analysis
We found insufficient studies to perform meta-analysis and so present our findings in narrative format for each of our five questions.
Results
Description of included studies
Thirty-two studies met the inclusion criteria (figure 1). The most common reasons for exclusion were full text unavailable, ED admissions only and irrelevance to our questions. Ten were US studies, seven were from the UK, six were from Australia, and the remaining were from Paraguay (n=1), Chile (n=1), France (n=1), Taiwan (n=2), Canada (n=1), Ireland (n=2) and Germany (n=1). Detailed findings of the included studies are collated in tables 1–4. Eighteen studies addressed trends and/or numbers/proportions of admissions,3 4 6–8 18–30 12 provided data about HCP views/experiences,4 31–41 two provided data about CYP views/experiences37 42 and four aimed at improving the care during admissions.6 40 43 44
Flow chart for review.
What is the trend in the number of admissions and the number/proportions of CYP admitted to paediatric wards or adult wards because of an MH diagnosis?
What are the reported experiences of clinical staff on paediatric wards (or adult general wards) during the admissions of CYP because of a primary MH diagnosis?
What are the reported experiences of CYP and their families during admissions to paediatric wards (or adult general wards) because of a primary MH diagnosis?
Is there evidence of interventions or quality improvement projects aimed at improving the care of CYP and families during admissions to paediatric wards (or adult wards) because of a primary MH diagnosis?
The review included CYP ≤18 years, with a range from 4 years to 18 years, with only 15 studies providing a sex description.6–8 18–24 26 27 29 37 42 In most of the studies, females made up 51–97% of the sample; only one study included gender-minority participants.42 CYP were admitted to paediatric wards with various MH diagnoses such as anxiety disorders, depression, obsessive-compulsive disorder, eating disorders, suicide attempts (SA) and suicidal ideation (SI). Finally, the review also included HCPs with a variety of roles, such as generalist HCPs, paediatricians, dieticians, paediatric nurses and paediatric residents.
Quality assessment
We assessed nine studies using the CASP tool (online supplemental appendix 3, table S1). Six studies were rated high quality,31 35 36 39 41 42 which represents 67% of the total studies assessed (n=9), two33 37 moderate quality (22%) and only one40 low quality (11%). We assessed 15 studies using the AXIS scale (online supplemental appendix 3, table S2). In 11 studies (73%), it was unclear what methods were used to determine the sample size.7 8 18 21–25 28 29 32 Only one study (7%) provided clear information about the measurements undertaken to address non-response,22 and none reported clear information about concerns around non-response bias. Five studies (33%) did not provide clear methods to determine statistical significance or precision estimates8 18 21 24 28 and 10 (67%) did not disclose if funding sources or conflicts of interest might affect authors’ interpretation of the results.19–24 26 28 32
Supplemental material
We were unable to assess two mixed methods because of the lack of a clear mixed-method question/objectives38 and insufficient information on the qualitative methods to address the data collection34 (see screening questions of the Mixed Methods Appraisal Tool 2018, http://mixedmethodsappraisaltoolpublic.pbworks.com/). One cross-sectional study was not assessed due to insufficient information on the methodology.3 Moreover, we did not find an appropriate tool that allowed us to assess studies that focused on describing the implementation/description of workshops, teaching weeks, working models/programmes and clinical audits.4 6 30 43 44
Trends/number/proportions of admissions of CYP
We found 18 studies reporting numbers and proportions of primary MH admissions of CYP ≤18 years to paediatric settings (table 1). Nine used a retrospective chart review design for reporting admissions to single hospitals.7 8 18 21–23 26 28 29 Ibeziako et al 7 reported 3799 paediatric MH admissions to the ED and inpatient units at a paediatric hospital from March 2019 to February 2021. Duarte and Zelaya26 reported 180 admissions of patients with psychiatric diagnoses (January to August 2015); 74.4% required admission to the paediatric ward or hospital interconsultation because of psychiatric pathology or primary psychiatric disorders. Wallis et al 28 reported 111 emergency admissions (83 patients) of CYP with MH needs to the paediatric ward between August 2017 and July 2017. Gallagher et al 8 reported 437 PB admissions to inpatient paediatric units between January and December 2013. Santillanes et al 29 reported 308 visits (265 patients on involuntary psychiatric hold) from April 2013 to April 2015; 1% of visits resulted in admissions to the paediatric ward. Claudius et al 18 reported 1108 patients on an involuntary psychiatric hold between July 2009 and December 2010; 50.1% were admitted to the general paediatric medical unit. Smith et al 21 reported that yearly admissions to the paediatric unit of patients with a psychiatric diagnosis ranged from 25 per year to 45 per year over the 5 years studied (1998 to 2003). Mansbach et al 22 reported 315 paediatric admissions to inpatient and ED units from July 1999 to June 2000; 33% were boarded on the medical/service floor. Valdivia et al 23 reported 46 patients admitted for SA to a paediatric ward between October 1995 and September 1999.
Four studies analysed large databases that included the reporting of MH admissions and discharges.19 20 25 27 Using the Paediatric Health Information database, Plemmons et al 27 identified, between 2008 and 2015, a total of 115 856 SA and SI encounters across 31 hospitals of which 67 588 resulted in an inpatient hospitalisation in a children’s hospital. Using the representative Kids’ Inpatient Database for 2000, Levine et al 20 reported that care for SA patients (n=32 655) was provided in adult hospitals (83.3%), children’s units (10.2%) and children’s hospitals (4.4%). Using the Nationwide Inpatient Sample, Case et al 19 analysed data between 1900 and 2000 (n≈1000 hospitals) reporting non-significant changes in CYP MH disorder discharges from community hospitals (per 1000 children: 1.9 vs 2.0 (95% CI −0.4 to 0.6), respectively). However, CYP discharges aged 6–13 years rose significantly (26.7% (5727/21 450) in 1990 vs 34.4% (10 179/29 590) in 2000; p<0.001). Finally, Kölch et al 25 analysed data for MH admissions in CYP from Germany, comparing the first 6 months of 2019 (prepandemic) and 2021 (during the pandemic). They found no change in the number of admissions to specialist MH inpatient care for CYP with anxiety disorders or obsessive-compulsive disorders between time points. However, there was an increase in patients with anorexia nervosa (AN) to both general paediatric wards and specialist MH inpatient setting, with a higher burden of cases reported in paediatric wards—2019: 611 vs 2021: 1057.
Three studies reported data from surveys. Hudson et al 4 surveyed paediatricians working in acute paediatric services in England and received responses from 22% of all acute wards in England; they found that 88% of respondents reported increases in MH admissions between January and March 2021 compared with the same period in 2020.4 Gasquet and Choquet24 reported 430/11 242 SA records between December 1988 and March 1990 among 164 hospitals; 174/430 patients were admitted to the paediatric wards.24 Royal College of Paediatrics and Child Health surveyed all general paediatric services in the UK in 2019 and found that across sites 6% of the general paediatric inpatient beds in the UK were occupied by CYP with a primary MH disorder.3 Finally, two studies that describe the development/implementation of programmes for patients with eating disorders reported, as part of this description, the number of admissions. Street et al 6 reported that from August 2012 to August 2015, thirty-one patients with eating disorders were admitted to the general paediatric ward in Exeter. Compared with admissions between 2008 and 2010 (seven admissions), admissions increased. Suetani et al 30 reported an increase in the number of patients admitted to the paediatric inpatient unit for treatment of eating disorders at the Flinders Medical Centre in Australia from over 20 per year in 2007/2008 to 80 in 2012/2013.
HCPs’ experiences
Twelve papers reported experiences of HCPs (table 2). Six were qualitative (semistructured or in-depth interviews and focus groups)31 33 35–37 39 and two mixed method.38 41 These studies used a range of epistemological perspectives (grounded theory, content analysis, thematic analysis and phenomenology) for data analysis. Four other observational studies used a questionnaire to survey HCPs caring for CYP during admissions,4 32 40 with one applying thematic content analysis using data derived from open-ended questions.34 Eight studies provided evidence suggesting that a concern of HCPs was lack of skills/knowledge and confidence to care for CYP admitted to acute paediatric wards.4 31 32 34 36 39–41 Four studies also reported HCPs’ concerns about the appropriateness of paediatric ward environments for the treatment of this group of patients. Commonly, HCPs reported difficulty in focusing on patients with MH problems in the acute ward due to the busy and complex make-up of patients across wards, and stressed the need for separate units/rooms to treat this group.32 35 38 39 Other reported experiences were a lack of support from MH professionals,4 40 feeling frustrated because of the lack of knowledge/time/resources while caring for this group33 40 41 and the difficulty of establishing therapeutic relationships.31 35 41 HCPs, however, reported their desire for more knowledge about MH resources and how to safely allocate and plan care for them,36 and also positive impacts of training applied to experience caring for CYP with MH problems to enhance competence/confidence.32 34
CYP’s experiences
We found two qualitative studies examining CYP experiences during admissions37 42 (table 3). Worsley et al 42 explored the experiences of adolescents during boarding hospitalisation following SI or SA (n=27). Participants expressed appreciation for compassionate clinicians and for information about what to expect during their hospital stay. Ramjan and Gill37 interviewed 10 adolescents with anorexia admitted to the acute care paediatric setting within an inpatient behavioural programme. One participant described her first admission as a ‘terrible, traumatic’ experience. Others recalled emotions, including fear, anger, depression and confusion.
Improving the care of CYP and their families/carers during admissions
We found four studies aimed at improving the care of CYP during admissions6 40 43 44 (table 4). Todd et al 43 carried out an MH teaching week with HCPs to improve the quality of care/confidence when working with this group. Overall, after the teaching session, 89% reported improvement in their confidence in managing MH presentations in paediatrics. However, there were no sustained improvements in the care of MH patients when comparing the audit from March 2021 (preteaching week) with the post-teaching week audit (January 2022). Bolland et al 44 carried out an interactive workshop to promote HCPs’ communication skills with CYP with MH needs. Participants (n=34) completed an evaluation of the session and reported that the workshop provided them with tools/strategies to try in practice. Six weeks after the workshop, there was evidence of improved communication skills and participants felt more confident when communicating with CYP. Street et al 9 developed a joint working model with Child and Adolescent Mental Health Services (CAMHS) to avoid specialist CAMHS-Eating Disorders inpatient unit admissions. They reported positive impacts provided by communication and joint working between professionals, in particular between physical health and MH professionals. Watson et al 40 reported on a project to improve paediatric nursing liaison with CAMHS nurses providing support/advice to paediatric nurses. A 2-day programme was carried out which aimed to enable nurses to become better informed on the holistic aspects of MH care. Feedback indicated that nurses felt able to contact CAMHS colleagues for advice/guidance. Nurses were more confident in challenging approaches/attitudes of paediatricians/other disciplines as they established new working practices/methods for care.
Discussion
To our knowledge, this is the first systematic review on CYP admissions to paediatric wards with a primary MH indication. We found a range of studies reporting on numbers of such admissions indicating that these admissions are common across a range of countries, however, only a small number of studies addressed trends over time. Those that did suggested increased numbers over time, especially since the pandemic. Reasons cited for increased admissions in those papers included lack of joint working between paediatric medical and MH services,6 unavailability of inpatient psychiatric placements,7 8 22 shortage of paediatric liaison psychiatry services28 and the increasing prevalence of MH conditions in CYP such as SI or attempt and depressive disorders.19 27 We also found evidence of HCPs working on paediatric wards of concerns about skill sets to manage CYP with MH presentations, and from some questioning the appropriateness of the acute ward for this care. Specific concerns included a lack of guidelines or standards for delivering care in this acute setting,28 lack of knowledge about what MH resources exist and how to allocate them,36 little knowledge of CAMHS provision,40 lack of separate units in the ward to care/treat this group32 35 38 39 and not being able to offer specific skills, such as competency in communicating with this group41 and restraint practices.4 Available evidence of CYP experiences was very limited and we found no studies on families/carers’ experiences. A main finding from CYP experience was a need for clear communication and compassionate clinicians caring for them. We found no studies addressing the impact of CYP admitted to wards with an MH indication on other patients or vice versa. Finally, we found a limited number of studies reporting efforts to improve the care of CYP during admission. These were all service evaluation papers rather than trials, limiting the quality of evidence provided, but they highlighted the importance of coworking and training to improve competencies and confidence, although with a need for repetition of training over time to maintain these. We found no published evidence of specific risk factors for adverse care for CYP and families/carers during admissions.
Our review therefore provides important information for care of CYP admitted to general paediatric wards as well as key areas of need for further research. Better training and support for staff and clear communication with CYP through their admission are important. Training opportunities may need to be repeated to ensure sustained impact. Joint working, between professionals with physical health and MH expertise, also appears important, fraught as this is with availability and calls for joint training across professions for this domain. While several papers have reported absolute numbers, there is a clear need for bigger studies using nationally available data on trends of admissions to better inform and plan care and workforce needs at both a local and national level. The number of studies examining CYP and carer experience and needs is lacking and requires more studies, as does the potential bidirectional impact of CYP admitted with MH problems to wards and other CYP admitted for other reasons. Lastly, there is a clear need for the development of interventions to improve the experience and quality of care for CYP admitted to paediatric wards, and where possible these interventions should be tested and reported with better quality methodology such as trials. Given CYP’s experiences, such studies should use the input of CYP and carers in codesign.
Strengths and limitations
We conducted a broad search across a range of important questions on this topic using five databases, and with independent screening of study eligibility. That said, despite finding sufficient suggestive evidence for clinical and research recommendations, we found few relevant studies, generally with small sample sizes and of limited quality in relation to the questions we were asking. Although we carried out a Google Scholar search to identify unpublished data and snowballed references, we know that paediatric centres frequently have unpublished audits and service evaluations which we will have missed.
In summary, for services to be delivered effectively, for CYP and their families/carers to feel supported and HCPs to feel confident, we need to strengthen the evidence base, but meanwhile to facilitate more robustly evaluated integrated physical and MH pathways of care, better (and regular) training and communication to CYP. These admissions are common and appropriate and safe care requires a significant increase in the amount and quality of research to provide this.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Acknowledgments
We thank Heather Chesters, Deputy Librarian at UCL Great Ormond Street Institute of Child Health Library, for supporting this work.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @gabriellealphon, @_joe_ward, @DashaNicholls, @damian_roland
Contributors LDH, FG and RMV conceived the study. LDH and AV-V designed the search strategy. AV-V and AS carried out the literature searches. AV-V and AS screened the titles, abstracts and full texts and carried out the data extraction and quality assessment. AV-V wrote the first draft and LDH and HR were involved in the interpretation of data and provided valuable contribution towards reviewing, editing and completion of the final draft. All authors had access to all the data in the study and the responsibility for the decision to submit for publication. AV-V and LDH are responsible for the overall content as guarantors.
Funding The review was undertaken as part of a wider project (MAPS: Mental Health Admissions to Paediatric Wards Study) that has been funded by the National Institute for Health and Care Research (NIHR135036).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.