Health care services instead of admission to hospital for young people or children with mental health problems

Many countries place emphasis on providing mental health services in the least restrictive setting, recognizing that some children will need to be admitted to hospital.  As a result there are a range of mental health services to manage young people with serious mental health problems in community or outpatient settings who are at risk of being admitted to hospital.

This review found seven studies which evaluated whether these other services helped children and young people with mental health problems.  This review did not find any studies about intensive day treatment (where children attend treatment programmes during the day for a short period of time), intensive case management (health care professionals coordinate services and support for the children), therapeutic foster care (children live with specially trained foster parents) or residential care with inpatient care (children live in a residence, but not a hospital, which provides mental health care services).

The studies evaluated four different types of services.  In Multisystemic therapy (MST) at home, therapists provide therapy to the child and the family together in their home.  Some behaviours in the children, improved with MST.  They also spent fewer days out of school and in hospital. Intensive home treatment provides children with therapy in their home to solve problems with the way they interact with other people in the home and to improve their psychological symptoms.  Children who received this type of service did not improve any more than children who did not.  Intensive home based crisis intervention (Homebuilders model for crisis intervention), focuses on the child and family to learn skills in relationship building, reframing problems, anger management, communication, and cognitive behavioural therapy.  Children with this service had small improvements. Specialist outpatient services are provided by a range of health care professionals in clinics.  Children who received this service did not improve any more than children who did not.

The quality of some of the studies was not high and most did not have enough people to evaluate the true effect of the services.  The evidence we now have provides very little guidance for the development of these types of services.

Authors' conclusions: 

The quality of the evidence base currently provides very little guidance for the development of services. If randomised controlled trials are not feasible then consideration should be given to alternative study designs, such as prospective systems of audit conducted across several centres, as this has the potential to improve the current level of evidence. These studies should include baseline measurement at admission along with demographic data, and outcomes measured using a few standardised robust instruments.

Read the full abstract...

Current policy in the UK and elsewhere places emphasis on the provision of mental health services in the least restrictive setting, whilst also recognising that some children will require inpatient care. As a result, there are a range of mental health services to manage young people with serious mental health problems who are at risk of being admitted to an inpatient unit in community or outpatient settings.


1. To assess the effectiveness, acceptability and cost of mental health services that provide an alternative to inpatient care for children and young people.
2. To identify the range and prevalence of different models of service that seek to avoid inpatient care for children and young people.

Search strategy: 

Our search included the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 4), MEDLINE (1966 to 2007), EMBASE (1982 to 2006), the British Nursing Index (1994 to 2006), RCN database (1985 to 1996), CINAHL (1982 to 2006) and PsycInfo (1972 to 2007).

Selection criteria: 

Randomised controlled trials of mental health services providing specialist care, beyond the scope of generic outpatient provision, as an alternative to inpatient mental health care, for children or adolescents aged from five to 18 years who have a serious mental health condition requiring specialist services beyond the capacity of generic outpatient provision. The control group received mental health services in an inpatient or equivalent setting.

Data collection and analysis: 

Two authors independently extracted data and assessed study quality. We grouped studies according to the intervention type but did not pool data because of differences in the interventions and measures of outcome. Where data were available we calculated confidence intervals (CIs) for differences between groups at follow up. We also calculated standardised mean differences (SMDs) and 95% CIs for each outcome in terms of mean change from baseline to follow up using the follow-up SDs. We calculated SMDs (taking into account the direction of change and the scoring of each instrument) so that negative SMDs indicate results that favour treatment and positive SMDs favour the control group.

Main results: 

We included seven randomised controlled trials (recruiting a total of 799 participants) evaluating four distinct models of care: multi-systemic therapy (MST) at home, specialist outpatient service, intensive home treatment and intensive home-based crisis intervention ('Homebuilders' model for crisis intervention). Young people receiving home-based MST experienced some improved functioning in terms of externalising symptoms and they spent fewer days out of school and out-of-home placement. At short term follow up the control group had a greater improvement in terms of adaptability and cohesion; this was not sustained at four months follow up. There were small, significant patient improvements reported in both groups in the trial evaluating the intensive home-based crisis intervention using the 'Homebuilders' model. No differences at follow up were reported in the two trials evaluating intensive home treatment, or in the trials evaluating specialist outpatient services.