Title: Disparities in detention: An investigation into relationships between sociodemographic status and compulsory psychiatric care among children and adolescents
Funder: Department of Health and Social Care

Abstract: Background The number of people, including children and adolescents, being detained in psychiatric units under the Mental Health Act 1983 (MHA) is growing. This has become a high-profile issue as compulsory care contradicts the ethos of modern medical ethics, can be associated with poor long-term mental health outcomes, and diverts significant funds from community services. It has been identified as a priority for urgent change by the Care Quality Commission (CQC), and there is an imperative to reduce the rate of detentions through early community intervention, targeted at those groups most at risk of detention. While inequalities in use of the MHA are well documented in adults, we know very little about the factors that may increase the risk of detention among children and adolescents. Understanding the disparities in risk and experiences of compulsory admission among children and adolescents is needed in order to identify modifiable causes and highlight where preventative interventions should be targeted.Aim To undertake a linked quantitative and qualitative investigation of disparities in risk and experiences of compulsory psychiatric care among children and adolescents, in order to identify modifiable causes and expose potential targets for preventative intervention.Plan of investigation This study is a two-phase mixed-methods sequential explanatory design.Phase 1: Quantitative The world's largest database of child and adolescent mental health service (CAMHS) records that can be used for research purposes, the Clinical Record Interactive Search system (CRIS) established by Kings College London and South London and the Maudsley NHS Trust (SLaM) has recently been linked to the National Pupil database (NPD). This highly novel UK linked dataset will be exploited to identify young people aged 10-17 detained under the MHA over an 8 year period from the population of four boroughs in South London (over 155,000 young people). The in-depth clinical information within CRIS linked with the census data within the NPD will enable modelling of the associations between individual-level sociodemographic factors (eg. ethnicity and looked-after-child status), clinical factors (eg. diagnosis, previous treatment) and risk of a compulsory admission.Phase 2: Qualitative Building on the findings from phase 1, the views and experiences of key stakeholders will be sought to explore factors underlying the reasons for their detention. Semi-structured interviews will be carried out with 20 adolescents who have been detained and ten of their parents/guardians. Purposive sampling will be used to ensure to offer demographic and phenomenal variation, led by the findings of Phase 1, and interviews will be flexible but cover perceptions of the detention, circumstances leading to it, experience of the MHA assessment and inpatient care. The interviews will be analysed using thematic analysis. The views of healthcare professionals involved in decisions to detain children and adolescents will be sought through two focus groups.Summary of potential benefits to patients and the NHS This research will identify any disparities in the use of the MHA in young people, which could be contributing to life-long inequalities of access to mental health services, and repeated compulsory admissions among certain groups. It will be the UK's first large scale investigation into the compulsory care of minors, and the first time that the combined narratives of young people who have been detained, their parents/guardians and healthcare professionals will have been heard and used to explore experiences of detention and pathways to care. Improving our understanding of young people's risks and experiences of detention will provide an evidence-base to inform service improvement, address staff training and support needs, and guide the implementation of targeted community support to reduce the need for coercive inpatient care. This will offer obvious benefits to the NHS, including significant economic savings.

Lay abstract: The aim of my research is to understand more about the children and young people admitted to psychiatric hospitals against their will. This is important as we need to know which young people are most at risk of having this happen and why, in order to start to work out what we can do to reduce these admissions.In England, someone of any age can be legally admitted to hospital against their will if they have a severe mental illness and are thought to be a risk to themselves or someone else. This law, known as the Mental Health Act (MHA), is designed to protect people with severe mental health problems. Professionals have to follow strict rules if they use this law. Taking away someone's choice should always be a last resort. There is also some evidence that an admission to hospital under the MHA can lead to frustration with psychiatric services and increased social and mental health difficulties in future.It is worrying that the number of people, including children and adolescents, who are being admitted against their will (we call this detained') is growing. No-one really knows why this is. The Care Quality Commission (CQC), the agency responsible for monitoring the use of the MHA in England, has called for urgent change and a reduction in the number of detentions over the next five years. They suggest that this can be done through addressing problems early and in the community, and should focus on people most at risk of detention. Despite the strict rules about how and when to use the MHA, some people including those from Black and minority ethnic groups and those from poorer areas are more likely to be detained than others. As almost all of the research into compulsory admission is about adults, we know very little about the children and adolescents who are detained, or what might increase their risk of a detention. Without this information, we do not know where to start to change things. There has been a lot of investment in adult mental health services over the last ten years to try to address inequalities in the use of the MHA, but so far, they do not seem to be working. It could be because the investments need to happen earlier.This study is the first large scale investigation into the compulsory admission of children and adolescents. It will be carried out in two phases. In the first phase I will use the largest database of its kind which links NHS child and adolescent mental health service (CAMHS) records to census data. These records are anonymous, so no one's privacy is invaded. Looking at these records will enable me to understand the links between the characteristics of children and young people and the likelihood of them being compulsorily detained.In the second phase, I will build on what I find out in the first. I will talk to adolescents who have been detained, their parents/guardians and people who work in the NHS. I will find out what they think about compulsory care, their experiences, and their understanding of why they were detained.After this study is finished I would like to find out more about what happens in a country where fewer young people are admitted to hospital against their will. I have spoken to two groups of young people about my research plans; a group of inpatients who had been detained, and the Young People's Mental Health Advisory Group (YPMHAG), a group of people aged 16 to 24 with experience of mental health problems who provide advice and support to researchers. Sometimes, people wonder whether research makes any difference, but when we talked about this work, they felt that this research was really needed if things are going to improve. The YPMHAG have offered to meet with me regularly throughout the fellowship and support where needed. Young people have helped write this summary, and we will work on it again, including an easy read version for children and young people with learning disabilities, who are sometimes detained.I will talk about my work and what I find at conferences, and invite young people who have experienced detention and/or their carers to talk with me. I will write about what I find for medical journals, and for other kinds of publications which more people read. In collaboration with young people I will use social media to reach more people, and will also work with organisations such as Young Minds.

Research activity codes: 4.3 INFLUENCES AND IMPACT
Health categories: MENTAL HEALTH