key: cord-0730033-tj330mpv
authors: Clisu, Denisa A; Layther, Imogen; Dover, Deborah; Viner, Russell M; Read, Tina; Cheesman, David; Hodges, Sally; Hudson, Lee D
title: Alternatives to mental health admissions for children and adolescents experiencing mental health crises: A systematic review of the literature
date: 2021-11-26
journal: Clin Child Psychol Psychiatry
DOI: 10.1177/13591045211044743
sha: dec2eda4a81ef40b08528dd0c460364df47b5f63
doc_id: 730033
cord_uid: tj330mpv

Background: Many children and young people (CYP) presenting with mental health crises are admitted to hospital due to concerns around illness severity and risk. Whilst inpatient admissions have an important role for such children, there are a number of burdens associated with them, and safe avoidance of admissions is favourable. We systematically reviewed the literature for studies of interventions reported as alternatives to a hospital admission in CYP presenting with mental health crises, in any inpatient setting. Methods: Three databases (PsychInfo, PubMed and Web of Science) were searched for peer-reviewed papers in October 2020, with an updated search in May 2021. Results: We identified 19 papers of interventions delivered in the emergency department, the home, outside of home but outside of clinics and in hospital clinics. The quality of most included studies was low, with less than half being randomised controlled trials and only half of these at low risk of bias. The best quality studies and greatest evidence for efficacy came from in-home interventions, in particular multisystemic therapy, which improved psychological outcomes, and though a large number of CYP still ended up being admitted, there appeared to be decreased length of stay. Conclusions: Overall, we could not recommend a particular intervention as an alternative to inpatient admission; however, our review describes benefits across a range of types of interventions that might be considered in multi-modal treatments. We also provide recommendations for future research, in particular the evaluation of new interventions as they emerge.

Mental health disorders are a substantial burden for children and young people's (CYP) health globally (Polanczyk et al., 2015) , with suicide a leading cause of death (Wasserman et al., 2005) . In the UK, recent data have shown that 16% of CYP have a mental health disorder, with over half of older adolescents with a disorder having self-harmed or attempted suicide (Vizard et al., 2020) . Similar prevalence rates have been reported in Europe and the United States (Kovess-Masfety et al., 2016; Merikangas et al., 2010) . Though these are longstanding issues, the recent COVID-19 pandemic appears to have worsened the mental health for some children (Ford et al., 2021) . Many CYP with mental health disorders will present to health care providers with an acute (sometimes called psychiatric) crisis due to their mental health. Such crises can be defined as subjective experiences where a change in mental wellbeing occurs, and the person becomes unstable or at risk to themselves or others (Jennings & Child, 2017) . In high income countries, numbers of such presentations for CYP seemed to have increased, both to secondary and primary care (Mahajan et al., 2009; Morgan et al., 2017; Newton et al., 2009; Pittsenbarger & Mannix, 2014) . Severity of illness, concern about risk (especially in relation to suicide) (Hawton et al., 2012) , available community services (Lancet, 2020) and social circumstances (Paranjothy et al., 2018) may mean that such presentations result in an inpatient admission. Whilst hospitalisation rates for most paediatric conditions in high income countries have decreased in recent years, admissions because of mental health have increased (Torio et al., 2015) .

Inpatient mental health admissions can provide important and vital services for significantly unwell CYP (Green et al., 2007) , for example more intensive levels of care and the opportunity for longer, good quality, therapeutic relationships with inpatient staff (Sergent, 2009 ). However, they can also carry substantial burden. Mental health admissions can be lengthy, in locations away from a usual place of residence, leading to disconnection from friends and family and separation from education or employment. These burdens are especially amplified for CYP experiencing repeated admissions (Miller et al., 2020) . Inpatient mental health admissions are also more costly for health care systems (Green et al., 2007) versus outpatient care. Demand can also outstrip capacity (O'Herlihy et al., 2003) , resulting in admissions of CYP in adult psychiatric wards or non-mental health inpatient settings such as paediatric medical wards (Worrall et al., 2004) . Safe and effective interventions acting as alternatives to inpatient admissions for CYP presenting in crisis are therefore highly favourable. Policy makers have turned attention on to this issue, for example in the UK there are strategies in place to improve community services (Alderwick & Dixon, 2019) .

Developing and implementing alternatives to inpatient mental health admissions for CYP presenting in crisis requires an up-to-date synthesis of the literature. Previous systematic reviews on this topic (Kwok et al., 2016; Shepperd et al., 2009 ) are now outdated (with the latest literature search performed in 2014) and also included papers of interventions with an admission component (such as short-term hospitalisations) which could be a confounder for the effects of proposed alternatives. We therefore systematically reviewed the literature for studies of interventions reported as alternatives to a mental health admission in CYP presenting with a significant mental health crisis, in any inpatient setting. We specifically examined for:

1. effectiveness at avoiding admission or any impact on reducing the length of an inpatient stay if one followed. Clinical Child Psychology and Psychiatry 27 (1) 2. Improvements in psychological parameters for CYP secondary to such interventions.

We searched three databases: PsychInfo, PubMed and Web of Science in October 2020, with an updated search in May 2021. We used search terms to encompass 'children and young people', 'mental health crisis' and 'potential locations of care' (Supplementary Appendix A). Searches were conducted individually by two researchers (DC and IL) who selected abstracts for inclusion or exclusion. Papers were then downloaded and considered independently, with LH providing adjudication. Reference lists within studies were also screened. We included studies reporting outcomes of interventions specifically as alternatives to a mental health admission for CYP presenting with a mental health crisis. We defined admission as any hospitalisation in any inpatient setting (including general medical settings). We excluded (1) studies where some or all participants were >18 years; (2) studies not published in English; (3) reviews; (4) papers which did not provide any outcome measures or insufficient outcome measures, or only described interventions; (4) studies where the intervention included an admission.

Independent bias assessments were conducted by DC and IL using the Cochrane Review tools for assessing risk of bias in randomised trials (RCTs) (Sterne et al., 2019) and non-RCT (Sterne et al., 2016) . Discrepancies were discussed for agreement with final adjudication by LH.

We found 782 papers in initial searches of databases and were left with 640 unique studies after duplicate removal. Seventy-one papers were retrieved, with 60 excluded based on full text assessment. We found an additional 8 studies from screening reference lists. We included a total of 19 studies. A summary of the search with numbers is shown in Figure 1 .

Eight studies were RCTs, 4 studies were service evaluations, 4 studies used an uncontrolled prepost-treatment investigation, 2 papers used pre-intervention historical/retrospective control groups and 1 paper used a matched control group. Fourteen studies were conducted in the USA, 2 were conducted in Germany, 2 in Canada and 1 in the UK. Two studies reported on interventions specifically for CYP with suicidal risk, 1 for psychosis and 1 for disruptive behaviour/externalising crisis presentations and 15 were for mixed types of crisis mental health presentations. For RCTs, we found 4 papers at low risk of bias, 2 raising some concerns and 2 at high risk of bias, and for non-RCTs, we found 1 paper at low risk of bias, 2 papers at moderate risk, 6 papers at serious risk of bias and 2 papers at critical risk. Detailed summaries of included studies, including bias assessment are shown in Table 1 . Detailed rationale for classifying final bias category for each study is shown in Supplementary Appendix B.

Included papers did not allow sufficiently robust information to perform meta-analysis, and so, we present findings here narratively, with interventions grouped by: (1) Single-session interventions for emergency department crisis presentations and (2) Community-based crisis interventions (as (i) exclusively in-home interventions, (ii) interventions outside of the home but outside clinics and (iii) exclusively clinic-based outpatient interventions, including intensive day treatment).

We found three papers which evaluated the effectiveness of single-session urgent response consultations in emergency departments. Two papers were service evaluations (Gillig, 2004; Parker et al., 2003) , and one paper used a pre-intervention historical/retrospective control group (Wharff et al., 2012) . One paper was at critical risk of bias (Gillig, 2004) , one at serious risk of bias (Parker et al., 2003) and one at low risk of bias (Wharff et al., 2012) . Gillig (2004) investigated the effects of offering an emergency evaluation interview and a brief therapeutic intervention at a maximum of 24 hours after CYP presentation, using a supportive, reality-based and present-focused therapeutic approach. They reported that only 10% (n = 5) of the patients seen by the emergency consultation team were hospitalised right after the input was received, no patients were hospitalised in the month following the input and 4.2% (n = 2) patients were hospitalised 6 months later. Parker et al. (2003) analysed a Rapid Response Model (RRM) which offered consultations to CYP in acute mental health crises within 48 hours of their presentation to the ED, focussing on the crisis and risk. They Family and behavioural therapy strategies used to intervene in the key social systems Hospitalisation (n = 56) Both groups reported pre-to post-treatment improvements in GSI-BSI (child and caregiverreported), CBCL internalising (caregiver-reported) and CBCL-social functioning (caregiver-reported), and a deterioration in FACES-III family adaptability (caregiver) (p < .05). MST was reported to be superior to hospitalisation in improving externalising symptoms in both caregiver and teacher-reports: F(1,102) = 6.55, p < . Group differences for these measures were not significant. Patients in the MST condition reported a steeper decrease in child-reported suicide attempts from pre-treatment (31%) to follow-up (4%) than hospitalised CYP (from 19% to 4%): t = 3.60, p <.001.

This effect was not reported for the caregiver-rated attempted suicide where results did not reach statistical significance (p > .05). Different trajectories were reported in the two groups for FFS caregiver-rated parental control (t = 2.08, p < .05), with MST parents reporting an initial increase in control at post-treatment After treatment, n = 34 (68%) scored ≤9, n = 14 (28%) scored 10-19 and n = 2 (4%) scored ≥20. This difference between pre-and post-treatment reached statistical significance (p < .001). Significant pre-to posttreatment differences were reported in the child-rated psychosocial functioning as well (p < .001), with n = 27 (54%) and n = 23 (46%) scoring 5 and 4 respectively, while post-treatment n = 2 (4%) scored 4, n = 20 (40%) scored 5, n = 17 (34%) scored 6, n = 9 (18%) scored 7,

The 

Overall risk of bias n = 1 (2%) scored 8 and n = 1 (2%) scored 9. In comparison to pre-treatment, significantly more participants achieved higher scores in parent-rated psychosocial functioning at post-treatment in the following sub-domains: family (p = .001), peers (p = .02), interests (p = .001) and autonomy (p = .02), while school performance did not reach statistical significance (p = .22) and school discipline and social behaviour had no data. In comparison to pre-treatment, significantly more participants achieved higher scores in all the therapist-rated sub-domains: family (p = .001), peers (p = .002), interests (p = .001), autonomy (p = .001), school performance (p = .004), school discipline (p = .002) and school social behaviour (p = .003)

Mosier et al. Both groups achieved significant positive pre-treatment to follow-up changes in the total MEI symptom score (p < .001). Hospitalisation was superior in improving the total symptom score and achieving higher behaviour changes. For home-treatment patients, the MEI symptoms scores decreased from M = 12.0 (SD = 5.2) at pre-treatment to M = 8.0 (SD = 5.2) at posttreatment, while for CYP admitted, the scores decreased from M = 14.8 (SD = 5.4) at pre-treatment to M = 6.2 (SD = 3.7) at post-treatment p < .001.

Receiving the home-treatment was associated with significant improvements from intake to follow-up in 4 of the 5 functioning subscales (family, peers, interests and autonomy) while for hospitalisation, change from pre-treatment to follow-up was only significant in 3 subscales (family, interests, autonomy). When comparing the degree of change from pre-treatment to follow-up between the two treatment groups, no significant differences were reported for the child-and parent-rated behaviour changes at post-treatment, patients in the home-treatment group scored significantly lower (M = 4.1; SD = 0.9/M = 4.2; SD = 0.7) than patients in the hospitalisation group (M = 4.6; SD = 0.6/M = 4.5; SD = 0.6): child (p = .02), parent (p = .03). These changes were not significant (p = .05) when comparing the therapist ratings for the two treatment groups. When investigating the blind examiners' rating of each treatment's effectiveness, hospitalisation proved to be superior in every measure: symptoms CYP admitted had higher significant improvements reported in the total symptoms score (p < Author ( Although both treatments improved externalising and behavioural problems and social competence, the family programme was superior in improving internalising symptoms in comparison to the residential treatment, which was reported to worsen the problems Some concerns

Outside of the home but outside of hospital clinics Darwish et al. No counselling with or without medication Most of the patients were maintained in the community and no significant differences were reported between the 4 groups in regard to the number of patients hospitalised (p > .05). The number of patients who successfully avoided hospitalisation in each group were as follows: parental counselling + medication group -n = 11 (N = 12, 91.7%); parental counselling + placebo -n = 11 (N = 12, 91.7%); no counselling + medication -n = 14 (N = 14, 100%); no counselling + placebo -n = 10 (N = 10, 100%). No significant group differences occurred for amount of patients who did not provoke hospitalisation requests, did not get into police difficulties and remained in their regular classroom: parental counselling + medication (n = 11, n = 9, n = 8 out of N = 12), parental counselling + placebo (n = 11, n = 10, n = 9 out of N = 12), no counselling + medication (n = 13, n= 14, n = 11 out of N = 14), no counselling + placebo (n = 10, n = 10, n = 8 out of N =

The majority of the patients in the trial were maintained in the community, did not provoke hospitalisation requests, did not get into police difficulties and remained in their regular classroom. adolescents is a good quality friend (from 65% to 88%, χ 2 = 6.45, df = 1, p < .05), incarcerated (from 4.7% to 6.3%, χ 2 = 19.6, df = 1, p < .01), trouble with police (from 13.4% to 16.4%, χ 2 = 11.6, df = 1, p < .01). The following parent-rated child functioning dimensions did not reach statistical significance from intake to followup: school (grade C or above, students failing, conduct: satisfactory or excellent); peer relations (well-adjusted/ somewhat adjusted socially, many friends); community integration (on probation while for the eligible for work/holding jobs, no statistical test was conducted).

For the parent-rated FAD, treatment was associated with a significant change from intake to follow-up in the following subscales: roles ( plementation, post-RRM termination and during RRM re-implementation as four time periods) and another over 2 years (pre-RRM and post-RRM as two time periods). Findings were mixed. For the first site, no change was reported in the number of admissions over the four time periods but RRM stage had a significant effect on the monthly average length of inpatient stay: F(1, 42) = 3.1, p < .05). For the second site, there was a reported decrease in the percentage of admissions, with a reduction from 22% at pre-RRM to 2% at post-RRM (χ 2 = 31.6, N = 340, d.f. = 1, p < .001). Wharff et al. (2012) investigated a single-session family-based crisis intervention (FBCI) for suicidal adolescents, delivered in a paediatric ED and focussing on constructing a safety plan and encouraging family communication. They reported a reduction in numbers admitted during the implementation of FBCI (55%-35%, p < .0001).

We found fourteen papers investigating the effectiveness of community-based treatments for CYP presenting in crisis. Nine were of home interventions, three were community interventions outside of the home but outside clinics and two were exclusively clinic-based outpatient interventions, including day treatment.

Exclusively in-home interventions. We found nine papers studying in-home interventions -five studying multisystemic therapy (MST) and four papers of other family-based interventions in the home.

Five papers investigated the effectiveness of multisystemic therapy (MST) delivered at home and which combined a range of therapeutic approaches. All five papers were RCTs, although four were in effect different outcomes from one single trial (Henggeler et al., 1999 (Henggeler et al., , 2003 Huey et al., 2004; Schoenwald et al., 2000) . The risk of bias assessment revealed that four papers were at low risk of bias (Henggeler et al., 1999 (Henggeler et al., , 2003 Huey et al., 2004; Rowland et al., 2005; Schoenwald et al., 2000) while one raised some concerns (Rowland et al., 2005) .

The effects of MST on admission rates and length of stay were investigated by two papers in two separate trials (Rowland et al., 2005; Schoenwald et al., 2000) . In one RCT, in a sample of CYP in mental health crisis assessed to require an admission, MST was compared to hospitalisation (Schoenwald et al., 2000) . At the end of treatment, 44% of those assigned to the MST group (approximately 4 months post-referral) were admitted to hospital and mean length of stay was lower than the hospitalised control group (mean days 2.39 vs. 8.82, t = 3.91, p = .001). In a second RCT, CYP at risk of out-of-home placement (e.g. inpatient hospitalisation, group homes and foster care) were randomly assigned to receive either MST or usual care (Rowland et al., 2005) . The study did not report on the number of patients hospitalised following the intervention in either group. However, number of days spent in out-of-home placement per month were lower in the intervention group (mean days 3.75 vs. 11.83, F = 5.68, p = .025).

Potential psychological benefits of MST were investigated in four papers, three reporting outcomes from a single trial comparing MST to inpatients, and one from another trial comparing MST to usual care. Compared to hospitalisation (Henggeler et al., 1999; Huey et al., 2004) , MST was reported to have superiority in improving a number of psychological measures. Postintervention changes were superior compared to admission controls for the caregiver-rated externalising symptoms (F(1,102) = 6.55, p < .011), teacher rated externalising symptoms (F(1, 45) = 4.10, p < .048), youth-reported family adaptability (F(2, 220) = 3.28, p = .039), caregiver-rated family cohesion (F(2, 206) = 6.56, p < .001) and youth-reported suicide attempts (t = 3.60, p < .001).

However, a further paper of 12-16 month follow-up revealed that generally superiority was not sustained (Henggeler et al., 2003) . Change in self-esteem was initially superior in the hospitalised group (F(1, 109) = 7.72, p = .006); however, again this was not sustained at 12-16-month follow-up. For MST compared to treatment as usual (Rowland et al., 2005) , there was superior change in youthrated externalising symptoms (F(1, 25) = 4.62, p = .041) and internalising symptoms (F(1,28) = 6.05, p = .021) for the MST group.

We found four papers of other family-based interventions delivered at home which reported on psychological outcomes. One was an RCT (Wilmshurst, 2002) , one was a study using a matched sample control group (Schmidt et al., 2006) and two were uncontrolled studies investigating pre-to post-treatment changes (Lay et al., 2001; Mosier et al., 2001) . Bias assessment revealed that two papers were at serious risk of bias (Lay et al., 2001; Mosier et al., 2001) , one paper was at moderate risk (Schmidt et al., 2006) while the other paper raised some concerns (Wilmshurst, 2002) . Neither paper described proportions of CYP receiving the alternative interventions who required admission. In the RCT, Wilmshurst (2002) reported that the in-home treatment was superior to a 5-day residential programme in improving internalising symptoms at follow-up (F (2,62) = 3.92 and p = .025). Comparing the intervention to a matched control group receiving hospitalisation, Schmidt et al. (2006) reported that by the end of treatment, hospitalisation was superior at improving psychological symptoms related to major DSM-IV diagnoses (p < .001), child-rated behaviour (p = .02), parent-rated behaviour (p = .03) and increased functioning in more domains (family, peers, interests and autonomy) than the in-home treatment (family, interests and autonomy). Lay et al. (2001) compared pre-and post-treatment outcomes in a sample of CYP requiring an intervention as an alternative to admission presenting with high risk externalising behaviours. Improvements were reported in the total symptoms related to major DSM-IV diagnoses (p < .001) and child-rated psychosocial functioning (p < .001). Mosier et al. (2001) also compared pre-and post-treatment outcomes of an in-home famility therapy for CYP requiring restrictive and intensive mental health treatment. In comparison to pre-treatment, post-treatment improvements were reported in clinical symptoms for a number of CYP, with some being reported to have recovered. No statistical tests were conducted for this comparison. The end of treatment mean clinical symptoms of the group was compared to the normative scores of patients receiving inpatient/outpatient treatment, but no significant differences were reported.

Interventions outside of the home but outside of hospital clinics. We found three papers which evaluated the effectiveness of community interventions outside of the home but away from clinic settings. The stated aim of these interventions was to stabilize the patients by offering an array of services, delivered flexibly in the community depending on need (e.g. schools). One paper was an RCT (Winsberg et al., 1980) and two papers were service evaluations (Darwish et al., 2006; Vanderploeg et al., 2016) . The risk of bias assessment revealed that one paper was at high risk of bias (Winsberg et al., 1980) , one was at critical risk (Vanderploeg et al., 2016) and one was at serious risk (Darwish et al., 2006) . Only one of these papers, Darwish et al. (2006) , reported on admission outcomes for their intervention, reporting that their community intensive therapy decreased admissions compared to a pre-intervention historical group (decreasing to one person per year over 5 years versus six people per year at pre-implementation, no statistics presented). Two papers reported on psychological outcomes. Winsberg et al. (1980) reported pre-and post-intervention scales and hospitalisation on a group of CYP in crisis, on a range of psychological parameters. Post-intervention, the community treatment improved symptoms of aggression (t = 2.58, p < .05), inattentiveness (t = 3.53, p < .01), hyperactivity (t = 4.27, p < .01), school behaviour (t = 2.58, p < .05), and overall child behaviour (t = 2.22, p < .05). In comparison, hospitalisation improved only inattentiveness (t = 2.32 p < .05). There was however no comparison of differences between the interventions and hospitalised groups. Vanderploeg et al. (2016) studied changes in a sample of CYP receiving emergency mobile psychiatric services however they did not compare their outcomes to a control group. They reported that improvements were achieved in parent-rated problem severity (t = À8.53, p < .001), clinician-rated problem severity (t = À21.24, p < .001) parent-rated child functioning (t = 4.70, p < .001) and clinician-rated child functioning (t = 14.96, p < .001).

Exclusively clinic-based interventions, including intensive day treatment. We found four papers which evaluated the effects of interventions in clinic-based settings (one including intensive day treatment) in CYP presenting in crisis as alternatives to hospitalisation. One paper was an RCT (Silberstein et al., 1968) , one paper used a matched sample control group (Greenfield et al., 1995) and two papers were uncontrolled pre-post-intervention studies (Asarnow et al., 2015; Kiser et al., 1996) . The risk of bias assessment revealed that one paper was at moderate risk of bias (Asarnow et al., 2015) , one at high risk of bias (Silberstein et al., 1968) , one at serious risk of bias (Greenfield et al., 1995) and one at critical risk (Kiser et al., 1996) . Silberstein et al. (1968) compared 4 separate groups of CYP presenting with psychosis receiving: (1) parental counselling with or (2) without medication; (3) no counselling plus medication; and (4) no counselling plus placebo. There were no differences in rates of admissions between groups. Greenfield et al. (1995) investigated the outcomes of implementing an emergency room follow-up team and reported that in comparison to a period before its implementation, the admission rate of CYP presenting to the emergency room in psychiatric crisis decreased by 16% (p < .001). No statistical difference was reported between the two groups in the number of hospitalisations occurring per patient after a second emergency room visit. Kiser et al. (1996) reported on psychological outcomes of an outpatient day program for CYP in mental health crisis as an alternative to admission. Post-intervention, improvements were reported in being withdrawn (parent report: t = 5.25, p < .001; CYP report: t = 2.91, p = .005), somatic complaints (parent report: t = 3.11, p = .003; CYP report: t = 2.76, p = .008), anxious/depressed (parent report: t = 3.95, p < .001; CYP report: t = 3.95, p < .001), social problems (parent report: t = 2.70, p = .008; CYP report: t = 2.38, p = .021), thought problems (parent report: t = 5.66, p < .001; CYP report: t = 3.28, p = .002), attention problems (parent report: t = 4.28, p < .001; CYP report: t = 2.89, p = .06), delinquent behaviour (parent report: t = 32.49, p = .015; CYP report: t = 3.77, p < .001), aggressive behaviour (parent report: t = 4.49, p < .001; CYP report t = 3.59, p < .001); sex problems (significant for CYP report only: t = 4.66, p < .001), total problems (parent report: t = 6.24, p < .001; CYP report t = 5.58, p < .001), internalising (parent report: t = 4.90, p < .001; CYP report: t = 4.94, p < .001) and externalising (parent report: t = 4.84, p < .001; CYP report t = 4.90, p < .001). Both parents and CYP also reported that at follow-up, family functioning was improved in the following domains: roles (parent report only: t = 2.68, p = .009), affective involvement (CYP report only: t = 2.24, p = .03) and behaviour control (parent report: t = 3.41, p = .001; CYP report: t = 3.48, p = .001). Follow-up improvements were also reported in rates of school suspensions (from 39% to 36%, χ 2 = 8.78, df = 1, p < .01) and CYP being a good quality friend (from 65% to 88%, χ 2 = 6.45, df =1, p < .05), while a deterioration occurred in the CYP's legal status, with increased incarceration rates (from 4.7% to 6.3%, χ 2 = 19.6, df = 1, p < .01) and more trouble with the police at follow-up (from 13.4% to 16.4%, χ 2 = 11.6, df = 1, p < .01). Asarnow et al. (2015) reported on psychological outcomes of an outpatient intervention (the SAFETY program) delivered to adolescent suicide attempters. They reported pre-to post-treatment improvements in all outcomes measured: suicide attempts (t = 2.42, p = .019, d = .64), active suicide behaviour and ideation (t = 2.63, p = .019, d = .59), passive suicide ideation (t = 2.56, p = .016, d = .39), total suicidality score (t = 2.70, p = .011, d = .46), CYP reported youth depression symptoms (t = 4.53, p < .001, d = .91), parent-reported parental depression symptoms (t = 3.47, p = .002, d = .71), hopelessness (t = 5.58, p < .001, d = 1.01), social adjustment total score (t = 6.13, p < .001, d = 1.27), social adjustment at school (t = 3.53, p = .002, d = .90), social adjustment with peers (t = 5.36, p < .001, d = 1.11), social adjustment with the family (t = 2.79, p = .009, d = .66) and social adjustment in the spare time (t = 2.76, p = .01, d = .52).

In this systematic review of studies of alternatives to inpatient admissions for CYP presenting with a mental health crisis, we found a range of published studies on interventions in different settings. We found studies describing interventions in emergency departments, the home, other community settings and hospital-based clinics. In general, the level of evidence was poor with less than half of included studies RCTs, of which only half were considered of low risk of bias in bias assessments. Studies also varied with regard to consistency of reporting on measures on preventing admissions and psychological outcomes. This meant that robust data for meta-analysis was insufficient. The greatest level of evidence came from home-treatments, in particular MST. The studies we found for MST offered treatment for 3-6 months and used family and behavioural therapy techniques to address the strengths and weaknesses of the CYP and their environment (i.e. family, peers and school) in a highly individualised treatment plan. MST was reported as improving a range of psychological parameters associated with risk for CYP (such as suicide attempts) and benefits for families (adaptation and cohesion though not maintained at 4 months); and though a large proportion of CYP appeared to still ultimately be admitted (in one study 44%), there was evidence that length of stay from these admissions was reduced compared to admission alone. We found some evidence suggesting that brief emergency department-based interventions could have a beneficial impact on admission rates. These interventions consisted of either a single treatment session or support over a short period of time (i.e. 24 hours), and used either brief interviews to understand the crisis and risk, or cognitive-behavioural and family therapy techniques for psychoeducation, therapeutic readiness and safety planning. However, none of these studies were RCTs, and there was no information on impact upon psychological parameters in any paper. Evidence for other community interventions, and clinic-based interventions were scarce, and generally of low quality. However, we found some evidence for reduction in admission rates and improvements in postintervention symptom severity, child and family functioning, although these were not compared to outcomes of control groups.

Our review did not find sufficient amount of quality data to recommend a specific type of intervention for CYP presenting in crisis, a similar conclusion to the two other systematic reviews on this topic which included searches from over 6 years ago (Kwok et al., 2016; Shepperd et al., 2009) . However, the evidence we have presented provides useful information for the development of new and existing services, including the potential for mix-models of care, or 'menus' of care for individual patients' needs by understanding variable benefits of different models. Given the challenges associated with the complexity of such CYP presenting in crisis, especially with regard to risk, the limited availability of good quality data is perhaps understandable. However, with such presentations increasing, and pressure on inpatient units rising (Children's Commissioner, 2020), this is clearly an area which needs to see an increase in research as a priority. With new emphasis on improvement for CYP with mental health disorders, especially those presenting in crisis (Ougrin et al., 2018) , it is likely that new models will develop. It is important that as they do so, they are robustly evaluated, in particular with comparison to controls (including for example pre-intervention controls), with consistent measurement and reporting of success at reducing absolute numbers of admissions, duration of admissions and also psychological impacts for CYP and families. Studies should also report detail on change between groups of intervention and control, for a large proportion of studies we found in our review presented only pre and post values for intervention and control separately, and this impedes the opportunity for an appropriate pooling of studies in meta-analysis (Higgins et al., 2017) .

Beyond the limitations which we have highlighted above, our review has a number of strengths. We used an a priori search strategy of multiple databases, with defined inclusion and exclusion criteria for the studies and two independent researchers performed searches. We also investigated on a large range of intervention types by also including non-RCTs, in comparison to previous reviews that looked at RCTs only. We reported on all outcomes described and had two independent researchers to conduct thorough bias assessments, with a third providing final adjudication.

In conclusion, although we found a range of interventions in different settings, the quality of studies was insufficient to allow for an overall recommendation. Interventions using multisystemic therapy at home had the best quality, with evidence suggesting benefits around avoiding admissions, length of admission and psychological outcomes. However, these interventions generally failed to show long-term effects. New models of care should be robustly evaluated using consistent outcomes.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article is supported by Great Ormond Street Hospital Charity.

Denisa A Clisu  https://orcid.org/0000-0002-7636-616X Lee D Hudson  https://orcid.org/0000-0003-0883-8791

Supplemental material for this article is available online. Table B1 . Results of risk of bias assessment for randomised-controlled trials using the ROB2 tool.

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The SAFETY program: A treatmentdevelopment trial of a cognitive-behavioral family treatment for adolescent suicide attempters

Who are they? Where are they? 2020. Children in Tier 4 Mental Health Units

The community intensive therapy team: Development and philosophy of a new service

Mental health of children and young people during pandemic

Child & adolescent psychiatry: An adolescent crisis service in a rural area

Short-term efficacy of interventions by a youth crisis team

Inpatient treatment in child and adolescent psychiatry-a prospective study of health gain and costs

Repetition of self-harm and suicide following self-harm in children and adolescents: Findings from the multicentre study of selfharm in England

One-year follow-up of multisystemic therapy as an alternative to the hospitalisation of youths in psychiatric crisis

Home-based multisystemic therapy as an alternative to the hospitalisation of youths in psychiatric crisis: Clinical outcomes

Cochrane handbook for systematic reviews of interventions version 5.2.0. Cochrane

Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies

Healthy London partnership-children and young people programme: Improving care for children and young people in mental health crisis in London: Recommendations for transformation of services

Results of treatment one year later: Child and adolescent partial hospitalisation

Comparing the prevalence of mental health problems in children 6-11 across

Review: Alternatives to inpatient care for children and adolescents with mental health disorders

Effectiveness of home treatment in children and adolescents with externalising psychiatric disorders

Epidemiology of psychiatric-related visits to emergency departments in a multicentre collaborative research pediatric network

Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National comorbidity survey replication-adolescent supplement (NCS-A)

Longitudinal examination of youth readmission to mental health inpatient units

Incidence, clinical management, and mortality risk following self harm among children and adolescents: Cohort study in primary care

In-Home, family-centered psychiatric treatment for high-risk children and youth

A 4-year review of pediatric mental health emergencies in Alberta

Distribution and characteristics of in-patient child and adolescent mental health services in England and Wales

Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: A randomised controlled trial

Risk of emergency hospital admission in children associated with mental disorders and alcohol misuse in the household: An electronic birth cohort study

Urgent adolescent psychiatric consultation: From the accident and emergency department to inpatient adolescent psychiatry

Trends in pediatric visits to the emergency department for psychiatric illnesses

Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents

A randomized trial of multisystemic therapy with Hawaii's Felix class youths

Home treatment for children and adolescents with psychiatric disorders

Multisystemic therapy versus hospitalisation for crisis stabilisation of youth: Placement outcomes 4 months postreferral

National Workforce Programme Child and Adolescent Mental Health National CAMHS Mental Health. Working Within Child and Adolescent Mental Health

Alternatives to inpatient mental health care for children and young people

Avoiding institutionalisation of psychotic children

ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions

RoB 2: A revised tool for assessing risk of bias in randomised trials

Annual report on health care for children and youth in the United States: National estimates of cost, utilisation and expenditures for children with mental health conditions

Mobile crisis services for children and families: Advancing a community-based model in connecticut

Mental health of children and young people in England, 2020: Wave 1 follow up to the 2017 survey

Global suicide rates among young people aged 15-19

Family-based crisis intervention with suicidal adolescents in the emergency room: A pilot study

Treatment programs for youth with emotional and behavioural disorders: An outcome study of two alternate approaches

Home vs hospital care of children with behavior disorders

Inappropriate admission of young people with mental disorder to adult psychiatric wards and paediatric wards: Cross sectional study of six months' activity

Search terms used for all databases: [(children and adolescents OR children OR adolescents OR youth) AND mental health AND (crisis OR crises)] AND [emergency department OR a&e OR 'alternatives to hospital admission' OR 'home treatment' OR 'community based crisis' OR 'alternative care' OR 'short stay hospital' OR 'acute day hospital' OR 'acute ward' OR 'crisis houses' OR 'family based treatment' OR 'multisystemic therapy' OR 'crash pad*' NOT (homeless OR homelessness)].

Author ( Lee Hudson is a clincial associate professor at the GOS UCL Institute of Child Health and an honorary consultant paediatrician at Great Ormond Street Hospital.