Making children and young people’s mental health care evidence-based

Children and young people’s (CYP) mental health is a priority for the NHS, with recent data indicating that 18% of children aged 7-16 have a probable mental disorder (NHS Digital, 2022). To address this increasing demand on CYP mental health services, researchers have developed and tested a range of evidence-based practices (EBP). These are service practices (e.g., referral, assessment, outcome monitoring, treatment and case management) that are based on scientific evidence (Hoagwood et al., 2017).

Research trials have found encouraging results for EBPs, with many interventions demonstrating beneficial outcomes when compared with control groups (Weisz et al., 2017). However, despite this progress, research often fails to translate into practice (Bear et al., 2020), meaning that the most effective interventions are often not being implemented in the most effective way for CYP. An explanation for this is the implementation process itself, which on average takes 17 years (Bauer et al., 2015).

One potential solution to improve the uptake of these EBP’s is to utilise implementation science to understand the implementation process, identifying the barriers and facilitators to implementation (Finley et al, 2018). The current study by Peters-Corbett et al. (2023) therefore aimed to use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to identify and synthesise the barriers and facilitators to implementing EBP in CYP mental health care and provide recommendations for clinicians/researchers.

Rates of children and young people with a probable mental health disorder have been increasing steadily over recent years, resulting in increased demand for support. Despite promising research, there is a gap in implementing findings within practice.

Methods

The authors conducted a systematic review across four databases to identify relevant research, editorial and opinion papers between 2011 and September 2021. Titles and abstracts were screened for relevance, before full-text eligibility was assessed by two independent reviewers. Disagreements were resolved by a third researcher.

Included studies had to relate directly to the barriers and facilitators of implementation of EBPs in CYP mental health, although school implementation studies were excluded.

Barriers and facilitators were then extracted by the same two reviewers across two levels: organisational and individual/clinical factors, in line with the i-PARIHS framework. Quality assessments were conducted using the CASP quality checklist and CASP (qualitative/economic evaluation and randomised controlled trial) checklists.

Results

Of the 26 papers included in the review, 17 were primary research papers, five were non-empirical, three were case studies, and one was an economic evaluation. The majority of these studies were conducted in the USA (n = 20), followed by Canada (n = 3) and the UK (n = 2). Intervention type varied, with 10 studies looked at psychological interventions, eight at EBPs, four at organisational interventions, two on screening/assessment programmes and one each on implementation of national guidelines and clinician training/professional development.

In total, 14 papers were assessed as moderate quality, and one as low quality.

Identified barriers and facilitators for implementation were organised into 4 categories:

Organisational barriers

• Lack of resources, including lack of access to funding
• High service demands and lack of clinical capacity
• Culture of service, including lack of readiness for change or innovation
• Lack of engagement or support from senior management
• Lack of knowledge around EBPs and their benefits
• Organisational structure, including lack of infrastructure, strategy, adaptability and measurable objectives
• Lack of access to other organisational data.

Clinician/individual barriers

• Clinician attitudes/perceptions towards EBPs, including perceptions that manuals are too rigid/have poor usability, and clinician resistance to change
• Competing priorities for clinicians with heavy caseloads
• Competing demands preventing innovation to be given time during the workflow
• Disparity between research trials and actual service setting
• Lack of knowledge or access to information about EBPs and why they were being implemented
• Lack of accountability and responsibility
• Lack of infrastructure and support for clinicians delivering EBP’s, including a lack of continuous training
• High staff turnover.

Organisational facilitators

• Access to resources such as funding and clinician time
• A shared sense of innovation as a high priority within the work-flow relative to competing demands
• Leadership that inspires, supports, motivates and provides a strong commitment to change/innovation
• Having designated and accountable leadership on the innovation/project
• Integration of facilitation strategies and activities
• Regular supervision
• System-wide training
• Effective communication that reflects adaptability and flexibility
• Perceived fit of EBP within the organisation ethos/mission
• Presence of regulatory mandate for the innovation.

Clinician/individual facilitators

• Clinician perceptions of EBPs including openness to change, having a “yes” mentality
• Clinician skill, competence, and motivation
• Regular supervision
• Working with stakeholders to create a sense of ownership and understanding
• Individual characteristics, including a positive relationship between clinician knowledge and EBP, and previous experience of self-efficacy
• Training/education, including ongoing training for new and existing staff, and opportunities for achievement-based reward and training based on experience-level
• Simplification of process to fit clinician and service user’s needs
• Observation of other agencies effectively adopting the innovation.

Several competing barriers and facilitators were identified across both organisational level and clinician/individual level. For example, high service demands were identified as a barrier, as well as prioritising innovation being identified as a facilitator.

Conclusions

As the authors of this paper state,

offering timely access to evidence-based practices is crucial to address the research-practice gap and provide evidence-based care to children and young people.

This review summarises the key barriers and facilitators to help achieve this. It also highlights some of the conflicting priorities that CYP mental health services currently face between these identified facilitators and barriers (e.g., high service demands and prioritising innovation).

Additionally, this review emphasises the need to learn and use implementation strategies within CYP mental health settings in order to test and trial these methods and understand the effects within local and individual contexts.

Funding was one of the main barriers and facilitators to implementation of evidence-based practices in children and young people’s mental health services, identified as “the most important but least changeable barrier”.

Strengths and limitations

This was a good quality review which presented important findings, as well as practical recommendations to support the implementation of EBPs in CYP mental health services. Multiple common barriers and facilitators at both organisational and clinician level were identified – however, the authors do note that the current literature does appear to lack any specific consideration about how those barriers and facilitators could be adapted in practice to support implementation into CYP services. This highlights the importance of researchers, clinicians, commissioners, policymakers, and wider stakeholders coming together to understand this further.

The studies included in this review were all of moderate or high methodological quality and did cover a wide range of intervention types and origin countries, which provided a range of evidence from differing systems and cultures worldwide and subsequently increased the reliability of this review. However, this variety of origin country could also be considered a limitation given the differences that exist between countries in how CYP mental health care systems run (Sadeniemi et al, 2018) and in key identified barriers/facilitators such as clinician perceptions of EBPs and how funding is accessed.

Finally, this review did not include studies from the grey literature or in languages other than English which may have led to publication bias and some relevant papers being excluded. Furthermore, this review excluded all school-based implementation studies, on the grounds that intervention delivery was specific to an education setting rather than a specific mental health setting. Although this rational is justified, it could be argued that information from implementing those interventions in community settings could also be relevant to implementation of similar interventions in clinical mental health settings.

Exclusion of literature focused on implementing evidence-based practices within educational settings is one potential weakness of this review, missing an opportunity for cross-sectoral learning.

Implications for practice

This review identified a number of clinical implications that are worth consideration by clinicians, managers, service leads, academics, policy makers and those that commission CYP mental health services:

Research

• Academics, those that commission services and policy makers should prioritise the implementation process beyond the end of research trials, so that EBPs are not ‘lost’ or forgotten about. They should also be encouraged to increase their adoption of implementation research designs so that implementation outcomes are prioritised alongside effectiveness outcomes.
• Case studies of implementation in CYP mental health care should be collected and the knowledge shared to increase awareness and uptake of the successful use of EBP.

Policy

• Funding should be ring-fenced within services for implementation in CYP mental health, and prioritised within budgets. Funding could support the employment of well-placed roles such as psychology graduates/assistant psychologists and/or health-care librarians.
• Clinical and operational models, service specifications and policies that support the development and delivery of CYP mental health services should explicitly include the importance of implementing the latest EBPs and recognise its potential impact on improved outcomes.

Practical considerations

• Clinical institutions should prioritise training and upskilling of all staff to recognise the importance of integrating EBP into the care and ethos of the service.
• The opportunity to use implementation strategies should be job-planned into specifically identified staff roles. This should include the ‘de-implementation’ of practices that might not be as effective.
• Education around the implementation of EBPs should be routinely incorporated into clinical training for all staff.
• Clinical institutions should appoint enthusiastic and knowledgeable implementation leaders and champions within their services to uphold the expectations and provide supervision around using EBP.
• The co-production and use of service users and parents/carers should be prioritised when services are considering how best to implement new EBPs and adapt to their contexts.

Training and upskilling of new and current staff is a key recommendation from this review.

Statement of interests

The author of this blog was previously supervised by one of the authors on the paper, but had no involvement with the current study.

Links

Primary paper

Peters‐Corbett, A., Parke, S., Bear, H., & Clarke, T. (2023). Barriers and facilitators of implementation of evidence‐based interventions in children and young people’s mental health care–a systematic review. Child and Adolescent Mental Health.

Other references

Bauer, M.S., Damschroder, L., Hagedorn, H., Smith, J., & Kilbourne, A.M. (2015). An introduction to implementation science for the non-specialist. BMC Psychology, 3, 1–12.

Bear, H.A., Edbrooke-Childs, J., Norton, S., Krause, K.R., & Wolpert, M. (2020). Systematic review and meta-analysis: Outcomes of routine specialist mental health care for young people with depression and/or anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 59, 810– 841.

Finley, E.P., Huynh, A.K., Farmer, M.M., Bean-Mayberry, B., Moin, T., Oishi, S.M., … & Hamilton, A.B. (2018). Periodic reflections: A method of guided discussions for documenting implementation phenomena. BMC Medical Research Methodology, 18, 1–15

Hoagwood, K., Burns, B. J., Kiser, L., Ringeisen, H., & Schoenwald, S. K. (2001). Evidence-based practice in child and adolescent mental health services. Psychiatric Services, 52(9), 1179-1189.

Sadeniemi, M., Almeda, N., Salinas-Pérez, J. A., Gutiérrez-Colosía, M. R., García-Alonso, C., Ala-Nikkola, T., … & Salvador-Carulla, L. (2018). A comparison of mental health care systems in Northern and Southern Europe: a service mapping study. International Journal of Environmental Research and Public Health, 15(6), 1133.

Weisz, J.R., Kuppens, S., Ng, M.Y., Eckshtain, D., Ugueto, A.M., Vaughn-Coaxum, R., … & Fordwood, S.R. (2017). What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. American Psychologist, 72, 79–117

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