Experiences of Care for Adolescents With Mental Health Difficulties in Acute Paediatric Services: A Systematic Review

ABSTRACT

Background

Adolescents with mental health difficulties often attend acute paediatric services. There is a need to establish how well these services address their difficulties. No systematic review of this issue for adolescents aged 12–17 has been published.

Aim

To explore perspectives of healthcare professionals, adolescents and families on the provision of care for adolescents with mental health difficulties in acute paediatric services.

Design

Mixed methods systematic review.

Methods

Authors screened published studies using Covidence for eligibility and extracted data. Findings were synthesised using qualitative convergent synthesis. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT).

Data Sources

Five databases were searched: MEDLINE, PsycINFO, CINAHL, Embase and Web of Science Core Collection from June 2003 to July 2023.

Results

Sixteen studies were included. Eleven studies were good quality, three were low quality and two were fair quality. Healthcare professionals' perspectives consisted of two themes: barriers and facilitators of care. Adolescents' perspectives consisted of two themes: perceptions of care and supportive and unsupportive interpersonal interactions. One study explored families' experiences of care.

Conclusion

Perspectives of care were similar across various countries and suggest that acute paediatric services do not adequately address mental health difficulties. There is a need for more support and education for healthcare professionals, targeted interventions and further research.

Reporting Method

The SWiM guideline was used to ensure a transparent and systematic literature review.

No patient or public contribution.

Trial Registration

PROSPERO: CRD42023443336 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=443336)

Summary.

• What does this paper contribute to the wider global clinical community?

  • ○
    There are institutional and personal barriers to caring for adolescents with mental health difficulties in acute paediatric services.
  • ○
    Although adolescents and families had some positive encounters, most were dissatisfied with the mental health support provided.
  • ○
    More research on views of adolescents with mental health difficulties and families is needed.

1. Introduction

Adolescents are particularly vulnerable to mental health problems, and the global prevalence of these difficulties among this age group is increasing (Laporte et al. 2021; Racine et al. 2021). Approximately one in seven 10–19‐year‐old experience problems with their mental health, which amounts to 166 million adolescents globally (UNICEF 2021; WHO 2021). Mental health difficulties currently account for 13% of the global burden of disease in the adolescent age group (UNICEF 2021). Anxiety and depression are cited as the most common mental health difficulties, and the prevalence among adolescents has increased more than 2‐fold since the onset of the COVID‐19 pandemic (Racine et al. 2021; UNICEF 2021).

The rise in mental health difficulties among adolescents is a multifaceted issue and may be driven by various factors, such as social media and technology, the Covid‐19 pandemic and exposure to trauma and adversity (Woods and Scott 2016; Marques de Miranda et al. 2020; Knipschild et al. 2024). Half of all mental health conditions start by 14 years of age, but most cases are undetected and untreated (UNICEF and WHO 2022). This is concerning as adolescents with mental health difficulties face many challenges such as social exclusion, prejudice and stigma, reduced quality of life in adulthood and an increased risk of morbidity and mortality (Schlack et al. 2021). Moreover, without timely intervention and adequate support for young people with mental health difficulties, long‐term physical and mental health issues may continue into adulthood (WHO 2021).

Globally, specialist mental healthcare services for adolescents are underfunded, underdeveloped and fail to meet the needs of this vulnerable population (Alderman et al. 2019; UNICEF and WHO 2022). In the absence of specialist mental health services and care pathways, acute paediatric services are often the first point of contact for adolescents in crisis with their mental health (Kuehn 2021; UNICEF 2021). There is evidence to suggest that the number of adolescents with mental health difficulties presenting at acute paediatric services is rising worldwide, placing additional strain on an already overwhelmed system (Fitzgerald et al. 2020; Yeasmin et al. 2020; Clavenna et al. 2022; Ferro et al. 2023; So et al. 2023; Villas‐Boas et al. 2023). Acute paediatric services often lack the specialised training, resources, and infrastructure required to adequately address mental health needs (Williams and Walker 2022).

Mental health has emerged as a key priority in adolescent‐focused research, policy, and healthcare (WHO 2020). Most research in this field focuses on specialist mental health services (Anderson et al. 2017; Bear et al. 2020; Leahy and McNicholas 2021). However, two recent systematic reviews focused on mental health difficulties in children and young adults from 5 up to 25 years old in paediatric or adult wards and in emergency departments (Cadorna et al. 2023; Vázquez‐Vázquez et al. 2024). These systematic reviews suggest that children and young people with mental health difficulties feel dissatisfied with the care they receive, and healthcare professionals face challenges in delivering optimal care to them in acute care settings.

Although these are valuable findings, to date, no systematic reviews have reported specifically on adolescents aged 12–17 years with mental health difficulties in acute paediatric services. This systematic review is intended to fill this knowledge gap. The WHO (2016) has highlighted that to achieve a full understanding of these issues, all key stakeholders' experiences and expectations of care need to be included. This review is therefore focused specifically on integrating and synthesising findings of studies addressing the perspectives of healthcare professionals', as well as adolescents', and families. This review includes a critical examination of the empirical literature using different methodologies and provides a synthesis of findings to generate specific recommendations that could lead to better care for adolescents with mental health difficulties and their families in acute paediatric settings.

2. Research Aims and Objectives

The aims of this systematic review were:

1. To explore the provision of care for adolescents with mental health difficulties in acute paediatric services from the perspective of healthcare professionals, as well as adolescents and families.

2. To identify facilitators and barriers of care experienced across the three groups.

3. Methods

3.1. Design

The protocol for this review was prospectively registered with the database PROSPERO (Pieper and Rombey 2022). A mixed methods systematic review was undertaken to synthesise findings from primary quantitative, qualitative, and mixed methods studies (Pluye and Hong 2014). This choice was made because the topic area is unlikely to have inspired validated measures and therefore various qualitative studies may have been conducted. Furthermore, adolescents, their families and healthcare professionals each bring distinct experiences and perspectives to the context of mental health care, and including either quantitative or qualitative methods alone would most likely not do justice to the complexities involved (Stern, Lizarondo, Rieger, et al. 2020; Stern, Lizarondo, Carrier, et al. 2020; Viksveen et al. 2021). Given the diversity of study designs, contexts, and outcome measures among the included studies, a meta‐analysis was not feasible. Instead, the SWiM (Synthesis Without Meta‐analysis) reporting guideline was applied to guide a clear, systematic, and transparent review of the literature (Campbell et al. 2020). See Table S1 Synthesis Without Meta‐analysis (SWiM) reporting items for more detail.

3.2. Search Strategy

Subject headings and keywords such as experiences, adolescents, mental health difficulties and acute care setting were used to systematically search five databases MEDLINE, PsycINFO, CINAHL, Embase and Web of Science Core Collection for studies published between June 2003 and July 2023. An example of a search string used is provided in Table S2. Reference lists of related studies and reviews were hand searched to identify studies that were not located during database searches.

3.3. Selection Criteria

Studies were included if they: (1) reported the experiences of care for adolescents with mental health difficulties from the perspective of healthcare professionals, adolescents and families; (2) reported experiences during admission to an emergency department or after transfer to acute paediatric services including high dependency; and (3) reported primary research (see Table S3).

3.4. Search Outcome and Study Selection

All relevant studies were collated into the online review management tool Covidence. After removal of duplicate citations, two of the authors/reviewers independently screened citations by title and abstract and screened full texts of potentially eligible articles to identify the final studies for review. Each reviewer was blinded to the other's decisions during the screening process. Any disagreements were discussed with an independent clinical academic (IC) until consensus was achieved.

3.5. Data Extraction

Data were extracted from the studies by the first reviewer in Covidence using a modified version of the JBI Mixed Methods Data Extraction Tool (Lizarando et al. 2019). The first reviewer extracted characteristics such as the population, phenomena of interest, methodology, outcomes, or findings relevant to the review question. Data extraction tables were cross‐checked by the second reviewer in Covidence for consistency and accuracy (Waffenschmidt et al. 2019). Any disagreements were discussed with an independent clinical academic until consensus was achieved.

3.6. Quality Appraisal

The quality of included studies was independently assessed by the first author (L.K.) using the Mixed Methods Appraisal Tool (MMAT) (Pluye 2012; Hong et al. 2018). Each study was appraised on methodology, study design, data collection methods, sample size, analysis and risk of bias. Studies were given a methodological rating of low (0%–49%), fair (50%–74%) and good (75%–100%) using the MMAT (Hong et al. 2020). Each critical appraisal score was cross‐checked by one of the other authors (E.A.) for quality assurance (Waffenschmidt et al. 2019). Any disagreements were discussed with the team until consensus was achieved. All eligible studies were included in the review regardless of their methodological quality to avoid publication bias (Boutron et al. 2024).

3.7. Data Synthesis

Data extracted from each study were imported into NVivo v.12 software to facilitate data synthesis. A qualitative convergent integrated synthesis was used to synthesise findings from the studies as the review question can be addressed by research using quantitative and qualitative designs (Hong et al. 2017; Stern, Lizarondo, Carrier, et al. 2020). Quantitative findings were converted into narrative summaries to integrate them with qualitative data during the synthesis. The first author allocated descriptive codes to findings from each study and grouped coded findings into hierarchies of categories and subcategories based on similarities. The categories were cross‐compared to develop themes and subthemes that represent the synthesised findings in the context of the review question (Hong et al. 2017; Thomas and Harden 2008). Discussions between the authors were held to achieve consensus on the developed codes, categories and themes. Only one eligible study explored families' experiences, so this study was reported narratively rather than included in the main synthesis (Hong et al. 2017).

4. Results

4.1. Identification of the Studies

As detailed in Figure 1, the search retrieved 10,181 articles, of which 90 were included for full‐text review. After application of the inclusion and exclusion criteria, 16 studies were included in the review.

FIGURE 1.

PRISMA flow chart of study selection process, including reasons for exclusion. [Colour figure can be viewed at wileyonlinelibrary.com]

4.2. Characteristics of the Studies

As detailed in Table 1, the studies were conducted in six countries: United States of America (Harken et al. 2017; Worsley et al. 2019; Foster et al. 2021), Australia (Ramjan 2004; Micevski and McCann 2005; Reid‐Searl et al. 2009; Happell et al. 2009), United Kingdom (Anderson et al. 2003; Latif et al. 2017; MacDonald et al. 2020), Canada (Carter et al. 2012; Vallières‐Noël et al. 2016; Lategan et al. 2023), Taiwan (Chang et al. 2023; Wu and Chen 2021), and Ireland (Buckley 2010). There were 14 qualitative, one quantitative and one mixed methods study. The studies used semi‐structured interviews (n = 11), focus groups (n = 4), surveys (n = 2) and storyboards (n = 1). Fourteen studies explored the experiences of care from the perspectives of healthcare professionals, mainly nurses and doctors. Three studies explored experiences of care from the perspective of adolescents, and one from families' perspective.

TABLE 1.

Summary characteristics of studies.

Author (date), country	Design	Data collection methods	Sampling and recruitment	Key findings	Quality appraisal (MMAT)
Anderson et al. (2003), UK.	Qualitative (Grounded Theory)	Semi‐structured interview.	Purposive sampling of nurses (n = 28) and doctors (n = 17) recruited from paediatric clinical areas.	Healthcare professionals experiences many barriers to caring for adolescents who engage in suicidal behaviour such as stigma and the physical environment. Facilitators of care include more training for staff.	Good (75%–100%)
Buckley (2010), Ireland.	Quantitative (cross‐sectional)	Survey	Convenience sampling of nurses (n = 70) recruited from a paediatric ward.	66.6% of nurses are dissatisfied with caring for young people with mental health problems on paediatric wards. 81% of nurses had inadequate educational preparation to care for these patients. 75.7% of nurses want more in‐house training on caring for these patients. 86.6% of nurses want these patients cared for by mental health nurses in separate adolescent units.	Low (0%–49%)
Carter et al. (2012), Canada.	Qualitative (descriptive)	Semi‐structured interviews and focus groups.	Sample of nurses (n = 13) and healthcare professionals (n = 10), such as doctors, social workers, a registered dietician, psychologists and a child life specialist were recruited from a paediatric unit.	Nurses experience many challenges such as prioritising care for these patients. Nurses need more training in caring for these patients. Specialist nurse roles in this area can enhance care for these patients.	Good (75%–100%)
Chang et al. (2023), Taiwan.	Qualitative (descriptive)	Semi‐structured interviews.	Purposive sample of nurses (n = 10), dietitians (n = 3), and doctors (n = 3) recruited from a paediatric ward.	Healthcare professionals focus on the physical needs rather than addressing the psychological needs of these patients. More training for healthcare professionals in caring for these patients is needed.	Good (75%–100%)
Foster et al. (2021), USA.	Qualitative (phenomenology)	Semi‐structured interviews.	Purposive sample of senior nurses and doctors (n = 19) and other healthcare professionals (n = 5) in a paediatric emergency department (ED).	Healthcare professionals face barriers to providing optimal care to young people with mental health conditions in the ED. Caring for these patients can cause moral distress among staff and can impact the quality of patient care. Facilitators of care include specialised care pathways and training for staff.	Good (75%–100%)
Happell et al. (2009), Australia.	Qualitative (participatory action)	Focus Group.	Convenience sampling of nurses (n = 20) in a paediatric unit.	Nurses face many barriers to caring for young people with mental health difficulties such as the unsuitability of the environment. More training for nurses caring for these patients and care pathways are needed.	Good (75%–100%)
Harken et al. (2017), USA.	Qualitative (descriptive study)	Semi‐structured interviews.	Convenience sampling of nurses (n = 9), doctors (n = 7) and care assistants (n = 4) from paediatric units at two hospitals.	Healthcare professions experience challenges and positive aspects to caring for young people with eating disorders. More training for nurses caring for these patients and care pathways are needed.	Good (75%–100%)
Lategan et al. (2023), Canada.	Quantitative, (cross‐sectional)	Survey.	Convenience sampling of adolescents (n = 40) and their parents/caregivers (n = 606) from two paediatric emergency departments.	Parents/caregivers were least satisfied with how ED services helped reduce their child's symptoms or problems (mean 3.0, SD 1.2) and how ED services helped their child get well and stay well (mean 3.1, SD 1.2). Adolescents were least satisfied with how ED services helped reduce their symptoms/problems (mean 3.0, SD 1.0). The more help a young person got from healthcare professionals, the more satisfied they were with care (r = 0.85, 95% CI 0.83–0.87), they received an evaluation by a mental health team member (OR = 15.39, 95% CI 5.40–43.90, p = 0.004) or consultation from a psychiatrist (OR = 8.97, 95% CI 3.15–25.58, p = 0.05). Young people were less satisfied with care the longer they had to wait for care (r = 0.31, 95% CI 0.23–0.38)	Fair (50%–74%)
Latif et al. (2017), UK.	Qualitative (adapted Delphi Study)	Focus group and Story Boards.	Purposive sampling of nurses (n = 7) from a children's hospital and young people (n = 4) from a specialist mental health service.	Nurses face barriers to caring for this patient group such as a lack of confidence in their caring abilities, lack of time to provide care and the unsuitability of the acute care setting for providing care. More training and guidelines for nurses caring for these patients such as making risk assessments and how to support families. Young people reported negative attitudes from staff towards them making them feel that their needs were neglected. Young people wanted more involvement in their care, access to recreational activity and more emotional support from staff.	Low (0%–49%)
MacDonald et al. (2020), UK.	Qualitative (case study)	Semi‐Structured Interviews	Snowball sampling of nurses (n = 6) and doctors (n = 7) from paediatric units.	Healthcare professionals experience challenges to caring for young people with self‐harm such as safely managing risks in the acute care setting. More training is needed for healthcare professional on caring for this patient group. Some facilitators of care were identified, such as addressing the psychosocial needs of these patients.	Good (75%–100%)
Micevski and McCann (2005), Australia.	Qualitative (Grounded Theory)	Semi‐Structured Interviews.	Convenience and theoretical sampling of nurses (n = 10) from a children's ward.	Nurses experience many barriers to developing therapeutic relationships with adolescents with anorexia nervosa such as strict unit protocols. More training is needed for nurses on caring for this patient group.	Good (75%–100%)
Ramjan (2004), Australia.	Qualitative (naturalistic inquiry)	Semi‐structured Interviews.	Unknown sampling method of nurses (n = 10) from two paediatric units.	Nurses experience many barriers to developing therapeutic relationships with adolescents with anorexia nervosa such as a lack of understanding about the illness. More training is needed for nurses on caring for this patient group. Caring for these patients on separate units with specialist trained staff may be beneficial.	Fair (50%–74%)
Reid‐Searl et al. (2009), Australia.	Qualitative (participatory action)	Focus groups.	Convenience and purposive sampling of nurses (n = 20) from a paediatric unit.	Nurses experience barriers to caring for young people with mental health difficulties in acute paediatric services such as the unsuitability of the environment and lack of time. More training and care pathways are needed for nurses on caring for this patient group. Better collaboration and involvement are needed from specialist mental health services in the care of these patients.	Good (75%–100%)
Vallières‐Noël et al. (2016), Canada.	Qualitative (descriptive)	Semi‐structured Interviews.	Purposive sampling of nurses (n = 17) from two paediatric units.	Nurses experience barriers to caring for young people with mental health difficulties, such as the lack of specialist mental health resources. More training and individualised care pathways are needed for nurses when caring for this patient group. Better collaboration and involvement are needed from specialist mental health services in the care of these patients.	Good (75%–100%)
Worsley et al. (2019), USA.	Unspecified qualitative methodology	Semi‐structured Interviews.	Convenience sampling of adolescents (n = 27) with suicidal ideation from paediatric emergency department.	Adolescents reported positive interpersonal interactions with healthcare professionals and felt safe in the clinical environment. Adolescents want to be informed about their care and have access to comforts in the acute care environment.	Good (75%–100%)
Wu and Chen (2021), Taiwan.	Qualitative (exploratory)	Semi‐structured Interviews.	Purposive sampling of nurses (n = 10) from a paediatric ward.	Nurses need support to develop therapeutic relationships with adolescents with anorexia nervosa. Family‐centred care and providing familial support optimises the care for these patients. More training is needed for nurses on caring for this patient group.	Low (0%–49%)

Six studies explored experiences of care in the emergency department and 10 explored experiences of care on paediatric units. The studies explored experiences of care for adolescents with various mental health difficulties ranging from suicidal ideation and self‐harm (Anderson et al. 2003; Latif et al. 2017; Worsley et al. 2019; MacDonald et al. 2020), eating disorders (Ramjan 2004; Micevski and McCann 2005; Carter et al. 2012; Harken et al. 2017; Wu and Chen 2021; Chang et al. 2023) to a mix of mental health difficulties including anxiety, depression and behavioural disorders (Happell et al. 2009; Reid‐Searl et al. 2009; Buckley 2010; Vallières‐Noël et al. 2016; Foster et al. 2021; Lategan et al. 2023).

4.3. Quality Assessment

The quality appraisal using MMAT revealed that 11 studies were of good quality, three studies of low quality, and two studies of fair quality. Two out of three studies from adolescents' and families' perspectives were of low quality. Studies failed to achieve optimal methodological quality due to inadequate description of data collection methods (n = 6), unclear how findings were derived from the data (n = 3) or insufficient interpretation of data (n = 3).

4.4. Review Findings

This review explored the experiences of care for adolescents with mental health difficulties in acute paediatric services from the perspective of healthcare professionals, adolescents and families.

4.4.1. Healthcare Professionals' Experiences

The studies included the experiences of nurses (n = 14), doctors (n = 6), healthcare assistants (n = 1) and other healthcare professionals such as dietitians, psychologists and child life specialists (each n = 1). The findings could be integrated into two themes: barriers to care and facilitators of care.

4.4.1.1. Barriers to Care

Fourteen of the studies in this review described the personal and institutional barriers they face when caring for adolescents with mental health difficulties (Anderson et al. 2003; Buckley 2010; Carter et al. 2012; Chang et al. 2023; Foster et al. 2021; Happell et al. 2009; Harken et al. 2017; Latif et al. 2017; MacDonald et al. 2020; Micevski and McCann 2005; Ramjan 2004; Reid‐Searl et al. 2009; Vallières‐Noël et al. 2016; Wu and Chen 2021).

4.4.1.2. Personal Barriers

Personal barriers to care were identified as individual factors or limitations that healthcare professionals faced and which hindered their ability to deliver optimal care to adolescents with mental health difficulties in acute settings. Negative attitudes such as stigma were cited as barriers to providing compassionate care (Anderson et al. 2003; Ramjan 2004; MacDonald et al. 2020). A qualitative study in the UK explored nurses and doctors' perceptions of young people who engage in suicidal behaviour and identified stigmatising attitudes towards this group (Anderson et al. 2003). Typically, healthcare professionals saw mental health issues as self‐inflicted problems that adolescents should resolve independently. A comparable qualitative study conducted in Canada revealed that some healthcare professionals did not prioritise the care of adolescents with mental health difficulties as much as they did for patients with acute medical conditions (Carter et al. 2012). Other studies showed that some healthcare professionals see adolescents with mental health difficulties as having less urgent needs and less deserving of care than those with physical illnesses. (Ramjan 2004; Reid‐Searl et al. 2009; Carter et al. 2012; Vallières‐Noël et al. 2016; MacDonald et al. 2020; Wu and Chen 2021).

This came with difficult emotions such as frustration and powerlessness as healthcare staff recognised their personal barriers. In Foster et al.'s (2021) study, emergency department staff reported feelings of moral distress when caring for adolescents with mental health difficulties, and this caused them burnout and job dissatisfaction. Healthcare professionals in other studies also reported symptoms of moral distress, frustration, fear, being out of control or overwhelmed (Ramjan 2004; Carter et al. 2012; Vallières‐Noël et al. 2016; Harken et al. 2017; Foster et al. 2021; MacDonald et al. 2020). Healthcare professionals often noted that it brings less gratification and recognition compared to caring for other paediatric patients (Anderson et al. 2003; Happell et al. 2009; Carter et al. 2012; Vallières‐Noël et al. 2016; Harken et al. 2017; Foster et al. 2021; MacDonald et al. 2020). Healthcare professionals also indicated that adolescents with mental health difficulties may not readily accept the help and care offered to them, which exacerbated their frustration (Anderson et al. 2003; Carter et al. 2012; Wu and Chen 2021; Chang et al. 2023). Poor behaviour and hostility from adolescents with mental health difficulties led to feelings of failure and a propensity to avoid treating these patients (Ramjan 2004; MacDonald et al. 2020).

In 13 studies, healthcare professionals identified deficits in their knowledge as a personal barrier to caring for adolescents in acute paediatric services (Anderson et al. 2003; Ramjan 2004; Micevski and McCann 2005; Happell et al. 2009; Reid‐Searl et al. 2009; Buckley 2010; Carter et al. 2012; Vallières‐Noël et al. 2016; Latif et al. 2017; Wu and Chen 2021; Foster et al. 2021; MacDonald et al. 2020; Chang et al. 2023). Specifically, knowledge deficits may be experienced as a personal responsibility but tend to have an institutional cause. The need for more opportunities to build specialised skills and knowledge in mental healthcare was reported in several studies. Happell et al. (2009) explored mental health practices in a rural general paediatric unit in Australia through participatory action research. Nurses in this study attributed their lack of knowledge in adolescent mental healthcare to inadequate training, education and exposure to the care of these patients. Nurses in other studies also identified that deficits in knowledge and skills had a negative impact on the mental health side of care (Anderson et al. 2003; Ramjan 2004; Micevski and McCann 2005; Happell et al. 2009; Buckley 2010; Carter et al. 2012; Vallières‐Noël et al. 2016; Latif et al. 2017; Wu and Chen 2021; Chang et al. 2023). It is not surprising that healthcare professionals requested more training on caring for adolescents with mental health difficulty who are in crisis (Carter et al. 2012; Vallières‐Noël et al. 2016; Foster et al. 2021), require physical restraint (Carter et al. 2012; Foster et al. 2021) or who need direct supervision (Harken et al. 2017).

4.4.1.3. Institutional Barriers

As we have seen in the last paragraph, personal and institutional barriers may overlap. However, several studies isolated work‐related factors, organisational structures, policies, and practices that hindered effective care provision for adolescents with mental health difficulties. Interestingly, ambiguity in responsibilities was also considered a barrier to caring for adolescents with mental health difficulties (Happell et al. 2009; Carter et al. 2012; Harken et al. 2017; Latif et al. 2017; MacDonald et al. 2020; Chang et al. 2023). A qualitative study in the USA exploring perceptions of caring for adolescents with eating disorders on a general paediatric ward identified that doctors were unclear about boundaries in their role and sources of support available for these patients (Harken et al. 2017). Similarly, nurses from various acute settings also reported uncertainty and a lack of confidence in their role when caring for adolescents with mental health difficulties (Happell et al. 2009; Harken et al. 2017; Reid‐Searl et al. 2009; Vallières‐Noël et al. 2016; Carter et al. 2012; Chang et al. 2023). Nurses in three studies reported challenges in maintaining professional boundaries while negotiating care with adolescents with eating disorders (Micevski and McCann 2005; Ramjan 2004; Wu and Chen 2021).

Healthcare professionals recognised the benefits of building therapeutic relationships with adolescents with mental health difficulties but needed more guidance on how to do so effectively (Reid‐Searl et al. 2009; Latif et al. 2017; MacDonald et al. 2020; Wu and Chen 2021). More generally, a lack of guidance and support in the care for adolescents with mental health difficulties was identified (Reid‐Searl et al. 2009; Micevski and McCann 2005; Happell et al. 2009; Carter et al. 2012; Vallières‐Noël et al. 2016; Latif et al. 2017; Foster et al. 2021). Many healthcare professionals reported that mental healthcare pathways were unclear and poorly developed, which led to inconsistencies in the care given (Reid‐Searl et al. 2009; Micevski and McCann 2005; Happell et al. 2009; Carter et al. 2012; Vallières‐Noël et al. 2016; Latif et al. 2017; Foster et al. 2021). Also reported were a lack of communication and collaboration between staff in acute paediatric services and the specialist mental healthcare team (Reid‐Searl et al. 2009; Vallières‐Noël et al. 2016; MacDonald et al. 2020).

Healthcare professionals across most included studies identified the environment as a barrier to providing optimal care to adolescents with mental health difficulties in acute paediatric services (Anderson et al. 2003; Happell et al. 2009; Buckley 2010; Carter et al. 2012; Latif et al. 2017; Foster et al. 2021; MacDonald et al. 2020). Nurses in an Irish study by Buckley (2010) reported difficulty and concern about the impact of caring for adolescents with mental health difficulties alongside children with medical conditions in a ward setting. Some nurses felt that the ward environment was not safe or supportive of the needs of adolescents with mental health difficulties, a concern also raised by healthcare professionals in other settings (Happell et al. 2009; Reid‐Searl et al. 2009; Foster et al. 2021). In several studies, healthcare professionals identified a lack of privacy and safety in the acute care environment (Anderson et al. 2003; Happell et al. 2009; Reid‐Searl et al. 2009; MacDonald et al. 2020). Insufficient time was also mentioned (Anderson et al. 2003; Happell et al. 2009; Vallières‐Noël et al. 2016; MacDonald et al. 2020; Foster et al. 2021; Chang et al. 2023). In some studies, nurses found it challenging to balance their care priorities for other patients with those of adolescents experiencing mental health difficulties (Ramjan 2004; Micevski and McCann 2005; Carter et al. 2012; Vallières‐Noël et al. 2016; Foster et al. 2021; MacDonald et al. 2020; Wu and Chen 2021).

4.4.1.4. Facilitators of Care

Healthcare professionals across fourteen studies identified several facilitators of care for adolescents with mental health difficulties, including protocols, practices or resources that help overcome barriers and enhance the delivery, accessibility and quality of care (Anderson et al. 2003; Buckley 2010; Carter et al. 2012; Chang et al. 2023; Foster et al. 2021; Happell et al. 2009; Harken et al. 2017; Latif et al. 2017; MacDonald et al. 2020; Micevski and McCann 2005; Ramjan 2004; Reid‐Searl et al. 2009; Vallières‐Noël et al. 2016; Wu and Chen 2021).

To overcome personal barriers to care such as negative attitudes and difficult emotions, healthcare professionals identified the need for de‐briefing and support from their peers to support their own mental well‐being (Harken et al. 2017; Foster et al. 2021; MacDonald et al. 2020). Healthcare professionals highlighted the need to enhance understanding and awareness of mental illness to help reduce stigmatising attitudes towards adolescents with mental health difficulties (Anderson et al. 2003; Ramjan 2004; MacDonald et al. 2020). More education and training for healthcare professionals were frequently cited as a means to overcome barriers to care (Anderson et al. 2003; Ramjan 2004; Micevski and McCann 2005; Happell et al. 2009; Reid‐Searl et al. 2009; Buckley 2010; Carter et al. 2012; Vallières‐Noël et al. 2016; Latif et al. 2017; Wu and Chen 2021; Foster et al. 2021; MacDonald et al. 2020; Chang et al. 2023). Healthcare professionals requested further training and education in relation to therapeutic communication skills (Anderson et al. 2003; Buckley 2010; Chang et al. 2023; Micevski and McCann 2005; Reid‐Searl et al. 2009), fostering patient and family‐centred care (Micevski and McCann 2005; Reid‐Searl et al. 2009; Carter et al. 2012), making risk assessments (Vallières‐Noël et al. 2016; Latif et al. 2017), managing crisis situations (Carter et al. 2012; Vallières‐Noël et al. 2016; Foster et al. 2021) and the administration of psychiatric medication (Foster et al. 2021). Nurses from two studies requested that education and training be provided by mental health specialists (Harken et al. 2017; Chang et al. 2023).

To overcome institutional barriers to care, healthcare professionals suggested more policies and specialised care pathways that support optimal care for adolescents with mental health difficulties in acute paediatric services (Micevski and McCann 2005; Buckley 2010; Vallières‐Noël et al. 2016; Foster et al. 2021). Care plans and pathways should be individualised and involve adolescents with mental health difficulties and their families (Carter et al. 2012; Harken et al. 2017; Vallières‐Noël et al. 2016; Foster et al. 2021). Healthcare professionals identified that specialised care pathways need better involvement from specialist mental healthcare professionals and multidisciplinary collaboration (Anderson et al. 2003; Buckley 2010; Happell et al. 2009; Harken et al. 2017; Carter et al. 2012; Latif et al. 2017; Vallières‐Noël et al. 2016; Reid‐Searl et al. 2009; MacDonald et al. 2020). To overcome institutional barriers to care, healthcare professionals reported that specialist mental health settings would be a more appropriate place to care for adolescents with mental health difficulties involving staff who have the expertise to implement specialist mental healthcare (Anderson et al. 2003; Ramjan 2004; Buckley 2010; Carter et al. 2012; Harken et al. 2017).

4.4.2. Patients Experiences

Only three studies explored the experiences of care in acute paediatric services from the perspective of adolescents with mental health difficulties (Lategan et al. 2023; Latif et al. 2017; Worsley et al. 2019). Two themes emerged from these studies: Perceptions of care and the care environment, Supportive and unsupportive interpersonal interactions.

4.4.2.1. Perceptions of Care and the Care Environment

Two studies explored adolescents' perceptions of care delivery and the care environment in paediatric emergency departments (Lategan et al. 2023; Worsley et al. 2019). In both studies, adolescents reported both positive and negative perceptions of care delivery and the care environment.

Adolescents' satisfaction with care in two Canadian paediatric emergency departments was measured by Lategan et al. (2023). In this quantitative study, adolescents' overall satisfaction with mental healthcare delivery in the emergency department was briefly measured using the Service Satisfaction Scale. Adolescents (n = 40) reported that the more help they got from healthcare professionals, the more satisfied they were with care (r = 0.85, 95% CI 0.83–0.87). Young people were more satisfied with care if they received an evaluation by a mental health team member (OR = 15.39, 95% CI 5.40–43.90, p = 0.004) or consultation from a psychiatrist (OR = 8.97, 95% CI 3.15–25.58, p = 0.05). Young people were less satisfied with care the longer they had to wait for care (r = 0.31, 95% CI 0.23–0.38) or did not have access to specialist mental health services. Adolescents were least satisfied with how care in the emergency department helped reduce symptoms of their mental health difficulty. Some positive experiences of care were captured in open‐ended questions such as that adolescents with mental health difficulties were satisfied with healthcare professionals' interpersonal skills, the timeliness of care provided and that specialist mental healthcare professionals participated in their care. Overall, this study brought to light that accessible and timely specialist mental healthcare for adolescents with mental health difficulties was preferable and may improve outcomes for them.

In the United States, Worsley et al. (2019) interviewed adolescents (n = 27) with suicidal ideation in a paediatric emergency department while awaiting transfer to an inpatient psychiatric unit. Adolescents reported both negative and positive encounters with the clinical environment and staff who provided care to them. Some adolescents described the hospital environment as familiar and a comfortable place, whereas others were concerned about their physical safety and their privacy and dignity in the emergency department. Other adolescents reported feelings of boredom and distress as they did not have access to activities and resources such as crafts, video games, television, a smart phone and play specialists.

4.4.2.2. Supportive and Unsupportive Interpersonal Interactions

Three studies explored adolescents' experiences of interpersonal interactions with healthcare professionals in acute paediatric services (Lategan et al. 2023; Latif et al. 2017; Worsley et al. 2019).

In a study by Lategan et al. (2023), adolescents with mental health difficulties were more satisfied with the care that they received in the paediatric emergency department when healthcare professionals demonstrated a positive attitude and good interpersonal skills. Similarly, adolescents in the study by Worsley et al. (2019) reported positive interpersonal interactions and communication with healthcare professionals who were approachable and easy to talk to. Adolescents felt more comfortable and safer when healthcare professionals showed compassion towards them, were interested in their well‐being, and received reassurance from them.

In contrast, many adolescents in the study by Latif et al. (2017) reported negative interpersonal interactions and communication with healthcare professionals. This study explored the experiences and needs of children and young people with self‐harm when cared for in a paediatric hospital as part of the co‐production of a digital education programme in this area. Adolescents reported that some nurses displayed stigmatising attitudes towards them and made them feel neglected, unimportant, misunderstood, and isolated. Furthermore, adolescents reported that their care was overly clinical, and their emotional state was overlooked as they were asked generic questions about their health and well‐being. A similar finding was identified in the study by Worsley et al. (2019) where adolescents reported negative interpersonal interactions with healthcare professionals when there were repeated inquiries about their medical history and rationale for being in hospital.

Adolescents in Worsley et al. (2019) and Latif et al. (2017) studies made similar suggestions on how interpersonal interactions with healthcare professionals in acute paediatric services could be improved. Adolescents appreciated when healthcare professionals involved them in discussions about their care, when there was transparency about their care, and they were kept informed of all aspects of their care such as healthcare professionals involved in their care, visitation policies, their prognosis, and recreational activities. Adolescents appreciated healthcare professionals who were open to conversations, asked more direct questions about their mental health difficulty, and received training on communication techniques to improve interpersonal interactions with them.

4.4.3. Families' Experiences

Only one study was found that briefly explored families' experiences of adolescents with mental health difficulties receiving care in an Emergency Department (ED) (Lategan et al. 2023). This study was reported narratively rather than included in the main synthesis due to limited reporting of relevant data in this article. As aforementioned, this study used a validated tool called the Service Satisfaction Scale (SSS‐10) to identify aspects of ED care that family members (n = 606) were satisfied or dissatisfied with for their child with a mental health difficulty. The findings revealed that families were mostly dissatisfied with the mental health care received by their child. Families were satisfied that confidentiality and respect for their child was upheld (mean 4.2–4.3, SD 0.8–0.9) but they were least satisfied with the treatment and management of their child's mental health difficulty (mean 3.0–3.1, SD 1.2). Families were more satisfied with the mental health care received by their child in the ED if there was input from specialist mental healthcare professionals.

5. Discussion

The studies in this review explored the experiences of care for adolescents with a range of mental health difficulties such as self‐harm, suicidal ideation, eating disorders, anxiety, depression, and behavioural disorders. Studies were conducted in six different countries, but the findings were similar across all studies and settings. Healthcare professionals reported that they faced many personal and institutional barriers to providing optimal care to adolescents with mental health difficulties in acute paediatric services. Although adolescents had some positive encounters, most perceived that their care needs were inadequately met, and families were also dissatisfied with care provision in acute paediatric services.

5.1. The Impact of Stigma

In studies of adults with mental health problems, the role of stigma is pervasive and influences the quality of care, access to services and the well‐being of both patients and healthcare professionals (Perry et al. 2020; Smith et al. 2024). Our review suggests that the same conclusion applies to adolescents. Healthcare professionals in the reviewed studies reported their negative attitudes towards adolescents with mental health difficulties. Adolescents and their families highlighted negative interpersonal experiences with healthcare professionals in acute paediatric services, attributing these to stigmatising attitudes. They expressed a desire for more compassionate treatment.

This stigma can prevent adolescents from seeking professional help for mental health problems (Nearchou et al. 2018; Villatoro et al. 2022; Ferrie et al. 2020). The expectation of being labelled, stereotyped, separated and discriminated against can be a profound deterrent to help‐seeking. A study by Coyne et al. (2015) identified that stigma led to feelings of being a burden or undeserving of treatment in child and adolescent specialist mental healthcare settings. Evidently, stigmatising attitudes from healthcare professionals put the health and well‐being of adolescents with mental health difficulties at risk as they may be less likely to access care or receive optimal care in acute paediatric services as a result. It is possible that our review may not have fathomed the full burden of stigma, because its' expectation may have led to avoidance of paediatric acute care centres by some adolescents.

5.2. Lack of Education on Mental Healthcare

Most studies in this review consistently highlighted a lack of education, training, and support for healthcare professionals in delivering optimal care to adolescents with mental health difficulties in acute paediatric settings. Healthcare professionals identified the need for additional training in therapeutic communication, family‐centred care, risk assessment, crisis intervention, and the administration of psychiatric medication (Anderson et al. 2003; Buckley 2010; Chang et al. 2023; Micevski and McCann 2005; Reid‐Searl et al. 2009; Carter et al. 2012; Vallières‐Noël et al. 2016; Latif et al. 2017; Foster et al. 2021). International studies have similarly identified the need for enhanced training for healthcare professionals in child and adolescent mental health, in areas like the management of psychological conditions, developmentally appropriate communication, and legal and ethical issues (Oshodi et al. 2013; Thomas 2017; Sawyer et al. 2018; McMillan et al. 2019; Banwell et al. 2021; Onileimo et al. 2021). In 2018, the World Health Organisation (WHO) Mental Health Gap Action Programme (mhGAP) identified the importance of educating staff in non‐specialised health settings to address mental health issues in patients effectively. One systematic review published after this initiative by the WHO showed that mental health training for generalised healthcare professionals improves knowledge, attitudes, skills, and confidence, leading to better care and outcomes for mental health patients in non‐specialised health settings (Caulfield et al. 2019). In the United Kingdom, educational initiatives for healthcare professionals who care for adolescents with mental health difficulties in acute paediatric services have been beneficial for enhancing knowledge and skills among healthcare professionals (Manning et al. 2017, 2022; Singh‐Weldon et al. 2022). However, the findings from this review show that deficits remain common.

5.3. Unsuitability of the Acute Paediatric Environment

The unsuitability of the acute paediatric environment for adequately meeting the care needs of adolescents with mental health difficulties was cited as a key institutional barrier in many studies, as has been reported previously (Cadorna et al. 2023; Vázquez‐Vázquez et al. 2024). Adolescents with mental health difficulties identified that the acute paediatric environment can be uncomfortable for them and that more needs to be done to adapt acute paediatric services to accommodate their needs. This is not an isolated finding. Reports worldwide continue to highlight the deficit of specialist inpatient child and adolescent mental health facilities and the lack of preventative community services for adolescents with mental health difficulties (UNICEF 2021; UNICEF and WHO 2022). Healthcare professionals in our review advocated for a standardised approach to caring for adolescents with mental health difficulties and suggested they be treated in a separate unit staffed by specialists skilled in managing this patient group. Other related studies have evaluated paediatric liaison mental health services which provide broader access to support for adolescents with mental health difficulties within acute paediatric services (Sheridan et al. 2016; Doherty et al. 2021; Hines et al. 2023). These studies show that while specialist mental health services in acute paediatric services offer some benefits, such as a baseline level of mental healthcare, they often remain underdeveloped and may not fully address the diverse and complex needs of those seeking support.

5.4. Implications for Practice

In our discussion of the findings, three implications were highlighted: the impact of stigma, lack of education among healthcare professionals on mental healthcare in adolescents, and the basic suitability of the acute paediatric services to address mental health problems. Each of these factors includes individual and institutional elements that make them difficult to change.

Reducing stigma in society is a slow process and a matter of changing attitudes. As with most change in society, education plays an important role. Evidently, healthcare education should and could include segments to specifically address ways to reduce prejudice and stereotyping. Specialised training should be offered to those involved in acute paediatric care. Reducing stigma is not enough; healthcare workers in paediatric services need to know more about what they can do differently. This would require more effort to address knowledge of mental distress and what to do about it among healthcare professionals. Moreover, it is essential that this is not limited to theory but includes training in how to use psychosocial interventions that are appropriate and feasible in acute healthcare settings. This means also catering to individual needs, preferences, and cultural backgrounds (Meldahl et al. 2022).

Although acute paediatric services strive to meet the needs of adolescents with mental health difficulties, they may lack the optimal infrastructure and resources to provide comprehensive care. Although the shift towards community‐based care for adolescents with mental health difficulties is a positive step, progress remains slow (UNICEF and WHO 2022). Due to the underdeveloped and fragmented nature of specialist mental health services for adolescents, many will continue to receive care within acute paediatric services (World Economic Forum 2020). Although this situation is unsatisfactory, more could be done to address the barriers of care identified in this review such as staff treating adolescents with empathy and eliciting support or advice from specialist mental health staff on the best way to care for this vulnerable group. Minor adjustments to the acute care environment could make a difference such as providing recreational activities and giving access to private spaces.

Studies included in this review offer valuable insights into the facilitators of care for adolescents with mental health difficulties in acute paediatric services from the perspective of all stakeholders, such as well‐being support for staff, specialist care pathways, better multidisciplinary collaboration, supportive interpersonal interactions, individualised care, and input from specialist mental health teams.

5.5. Implications for Research

This review explored the care provision for adolescents with mental health difficulties in acute paediatric services from the perspective of healthcare professionals, adolescents and families. However, most studies focused on healthcare professionals' experiences. Only three studies were conducted with adolescents, and one study was from families' perspectives, and these studies were of low quality. The deficit of good quality evidence on how adolescents' experience care in acute paediatric services is concerning. The few studies found indicate that adolescents have generally negative experiences. Increasing numbers of adolescents experiencing mental health difficulties worldwide means that the number of those admitted to acute paediatric services will increase concomitantly. Therefore, more research is needed to elicit the views and experiences of adolescents with mental health difficulties and their families as this is key to understanding how services can be more responsive to their care needs (Meldahl et al. 2022). Only one Irish study and three UK studies explored experiences of care for adolescents with mental health difficulties in acute paediatric services. Conducting more research from a European lens would enrich the diversity of perspectives and would inform policy and practices that address region‐specific issues in this field.

There is an indication from this review as to the facilitators of care for adolescents with mental health difficulties in acute paediatric services, and further research is needed to identify the efficacy and impact of interventions to support care in this area. Future intervention studies should be co‐designed with adolescents with mental health difficulties and their families to ensure the relevance, effectiveness and practicality of these interventions for meeting their care needs in acute paediatric services (McCabe et al. 2022). As more training and education for staff were identified as a priority across all studies, future research could focus on the development and implementation of an educational initiative for healthcare professionals who care for adolescents with mental health difficulties in acute paediatric services.

5.6. Strengths and Limitations

The strength of the review was rooted in the methodical approach throughout. The selection of studies (PRISMA), data analysis (JBI Mixed Methods Data Extraction Tool), and quality appraisal (MMAT) were all performed using standardised guidelines. In addition, regular consensus meetings were held, and an independent clinical academic ensured the transparency and accuracy of data interpretations. The limitations of the review were that the small number of relevant studies, small sample sizes and diverse settings may have limited the context and depth of the findings (Stern, Lizarondo, Rieger, et al. 2020). Not all studies in this review provided sufficient methodological detail, which made it difficult to fully assess quality and limited the integration of findings.

6. Conclusion

As the numbers of adolescents with mental health difficulties being admitted to acute paediatric services increases, there is a need to focus on the quality of care that is provided to this vulnerable group (Kuehn 2021). A limited number of studies have directly involved adolescents and their families, underscoring a critical gap in the evidence base concerning their distinct perspectives and experiences. This systematic review is the first to focus specifically on the care experiences of adolescents aged 12–17 years in acute paediatric services, synthesising insights from healthcare professionals, adolescents, and their families. Findings suggest that acute paediatric services fall short in meeting the care needs of adolescents with mental health difficulties and their families. New insights were provided on the barriers that healthcare professionals face to providing optimal care for adolescents with mental health difficulties, such as difficult emotions, a lack of training and institutional support. This review highlighted the importance of reducing stigma among healthcare professionals, promoting more compassionate care for adolescents and their families, providing additional education and support for healthcare professionals and addressing the challenges inherent in the acute care setting. More evidence is needed on the optimal care pathway for adolescents with mental health difficulties in acute paediatric services. Through targeted interventions and continued research, it is possible to enhance the quality of care for adolescents with mental health difficulties.

Author Contributions

All authors have read and agreed to the published version of the manuscript. Conceptualization: L.K., I.C., J.D.; methodology: L.K., I.C.; data curation: L.K., E.A., G.S.; writing – original draft preparation: L.K.; writing – review and editing: L.K., I.C., J.D.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1

Appendix S1

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.