Rationale:
Mental health difficulties are common among children and young people (CYP). In 2020, one in six 5–16 year-olds (16%) in England had a probable diagnosable disorder [1]. This pattern is similar worldwide, with 10–20% of children and adolescents experiencing mental ill health [2]. Looking at incidence across the lifespan, half of all psychiatric conditions start before the age of 14 [2, 3]. Mental health difficulties are associated with multiple salient individual and societal outcomes. Longitudinal studies have found associations between poor mental health in childhood and adolescence, and lower quality of life and loneliness [4], higher criminal behaviour [5], and poorer health, both mental and physical, in adulthood [4, 6]. In terms of financial burden, mental ill health is estimated to cost over £100 billion in England per year [7] when the detrimental impact on economic productivity is considered alongside higher service utilisation [8]. These statistics clearly suggest that early intervention is vital if poor mental health among CYP is to be ameliorated.
Mental health professionals, such as psychologists, psychiatrists, and mental health nurses immediately come to mind when we consider those who provide relevant care and support for CYP. High quality training, whether basic or specialist, should be offered actively and regularly to these professionals, to improve and update their skills and knowledge [9]. However, CYP also encounter a wide variety of non-mental health trained professionals in their everyday lives, including teachers, police, and general healthcare providers. These allied professionals also need to be well placed to support the needs of the CYP they encounter, irrespective of whether or not they have been referred to specialist mental health services.
A climate of austerity and budget cuts to Child and Adolescent Mental Health Services (CAMHS) in the UK means that these alternative, non-specialised services are increasingly being relied upon to provide mental health support. In 2014/2015, only 25% of CYP with a psychiatric disorder had made contact with mental health services [10], compared to 38% in 2005/2006 [11]. A funding cut of 5.4% to CAMHS within this period is perhaps responsible for this severely reduced rate of service contact [12]. Additionally, an increase in average waiting times for access to CAMHS [13], along with a substantial likelihood of referral rejection [14], means that many CYP cannot benefit from specialist support, particularly when the cross-sector communication needed to signpost to alternative sources of support is notoriously poor [15]. Indeed, a recent systematic review found that over 25% of CYP with diagnoses or elevated symptoms were not utilising any form of mental health support, specialist or otherwise [16], suggesting that even alternative support is inaccessible to many.
Bearing these issues in mind, teachers were found to be the most common allied service contact that CYP and/or their parents utilised regarding emotional, behavioural, or concentration difficulties [17]. Teachers perceive themselves as being the “front line” for help-seeking for several reasons, including the close bonds forged throughout the school year, and the mental health stigma held by some parents [18]. However, because mental health support is not the primary role of school staff, they do not have the time and resources needed to effectively provide it, nor do they feel adequately trained to do so [18]. Even primary medical professionals such as general practitioners feel under-equipped to recognise issues and provide appropriate support for CYP, with the criteria for CAMHS referral poorly understood [19]. Reduced government funding for mental healthcare means that patients of all ages are more likely to turn to Accident and Emergency (A&E) departments at times of crisis [20]. For CYP specifically, between 2010 and 2015, the number of psychiatric A&E attendances doubled [21]. A&E staff perceive their own knowledge and effectiveness for dealing with CYP psychiatric admissions as low [22], with the A&E environment decidedly unsuitable to care for such patients [20].
Clearly, CYP are clearly “falling between the gaps” in terms of accessing the support they need. Recent efforts have consequently been made to ensure that CYP mental health is “everybody’s business”. Initiatives such as i-THRIVE [23], introduced in 70 areas in England, emphasise the value of providing support through a diverse range of access points, not only health services (e.g. the UK’s National Health Service). i-THRIVE represents a shift from a mind-set where mental health is solely the purview of health professionals, to one where schools, social care, and even the arts sector, can be informed advisors - providing support, and signposting effectively and confidently [23]. For this vision to become a reality, training a diverse range of allied professionals should be a priority. They should be equipped with the skills required to provide appropriate support, be this individualised or community-based care. The latter, for example school-based mental health promotion [24] can benefit even healthy populations of CYP, helping them to deal with the inevitable “ups and downs” of life [23].
What should training look like? In broad terms, mental health training should improve the mental health literacy of its trainees. Mental health literacy refers to the understanding of mental health problems, how to improve mental health, and confidence in knowing when, where, and how, to provide or signpost to assistance [25]. Additionally, an increase in literacy and awareness should result in a reduction of negative stigma [26]. In terms of content, training programmes often vary in specificity, depending on the type of professionals being trained. Basic level programmes such as Youth Mental Health First Aider training [27], or basic psychotherapeutic skills [28], may be suitable for allied professionals. However, mental health professionals should be offered more focussed training that reflects their level of background knowledge [27]. Training is also one of the most widely used implementation strategies when disseminating new evidence-based practices in CYP mental health [29].
Objectives and research questions:
Given the primacy of training in the CYP mental health support system, it is vital to understand the factors that maximise its potential gains and facilitate uptake, for example, a training programme being of appropriate complexity for those completing it [28]. To date, a number of qualitative studies have explored these barriers and facilitators, by speaking to those receiving and delivering training. However, a systematic review that aggregates research across the field, where both mental health and allied professionals are participants, has not yet been conducted.
Considering this, the current review located and explored relevant qualitative research evidence, to identify the barriers and facilitators underpinning successful delivery and implementation of training that focusses on the mental health of CYP. These barriers and facilitators were established by collating the experiences and views of mental health trained professionals, along with any allied professionals who might, in their daily roles, encounter CYP who require mental health support. The review built upon the findings of a similar qualitative review by Scantlebury et al. (2018) [30]. Their qualitative synthesis identified several delivery and organisational factors, reported by allied professionals, as predictive of whether or not training was well implemented. By simultaneously narrowing the reach of the systematic search to only include studies of training pertaining to CYP, and broadening it to include the views of mental health professionals, the current review sought to provide further insights into how training delivery, and its subsequent implementation in practice, could be improved for all professionals. Given that such a wide range of professionals are currently so closely involved with supporting CYP, even those with diagnosed psychiatric disorders, it may be the case that their experiences do not vary as much as one would immediately imagine. As such, the current review was able to explore whether, and if so, how, the reported barriers and facilitators differed by professional group.
The review sought to answer the following questions:
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What are the barriers and facilitators that a) mental health professionals, and b) allied professionals, perceive as influencing the training delivery process?
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What are the barriers and facilitators that a) mental health professionals, and b) allied professionals, perceive as influencing the implementation of training in the workplace?
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Based on the above, what evidence-based recommendations can be made in order to improve training delivery and implementation?