Facilitators and Barriers to Person-centred Care in Child and Young People Mental Health Services: A Systematic Review

Implementation of person-centred care has beenwidely advocated across various health settings and patient populations, including recent policy for child and family services. Nonetheless, evidence suggests that service users are rarely involved in decision-making, whilst their preferences and goals may be often unheard. The aim of the present research was to systematically review factors influencing personcentred care in mental health services for children, young people and families examining perspectives from professionals, service users and carers. This was conducted according to best practice guidelines, and seven academic databases were searched. Overall, 23 qualitative studies were included. Findings from the narrative synthesis of the facilitators and barriers are discussed in light of a recently published systematic review examining person-centred care in mental health services for adults. Facilitators and barriers were broadly similar across both settings. Training professionals in person-centred care, supporting them to use it flexibly to meet the unique needs of service users whilst also being responsive to times when it may be less appropriate and improving both the quantity and quality of information for service users and carers are key recommendations to facilitate person-centred care in mental health services with children, young people and families. Copyright © 2016 John Wiley & Sons, Ltd.

manage our own health and care, and delivers care with respect for our individual abilities, preferences, lifestyles and goals' (Harding, Wait, & Scrutton, 2015;p. 131). PCC is a multidimensional concept surrounded by an ambiguity regarding its definition; nonetheless, there is a consensus that its focus on the person, as opposed to the condition or illness, is at the heart of PCC and that it promotes dignity, respect and compassion (Harding et al., 2015;Leplege et al., 2007;Mead & Bower, 2000). Because of a wide use of the PCC terminology, there are numerous other interlinked terms, such as 'shared decision-making' and 'patient engagement' that reflect fundamental principles of PCC care and serve as a theoretical guide for this review (Harding et al., 2015).
Implementation of PCC has been widely advocated across various health settings and patient populations, including recent policy for services for children and families, such as Child and Adolescent Mental Health Services (Chief Medical Officer, 2013;Chief Medical Officer, 2014;Department of Health, 2015;Wolpert et al., 2012). Nonetheless, evidence suggests that service users are rarely involved in decision-making regarding their care or treatment and their preferences and goals may be often unheard (Coyne, Hayes, Gallagher, & Regan, 2006;Wolpert et al., 2012). This can make them feel lonely, ignored and betrayed (Coyne et al., 2006), which may lead to disengagement from services and treatment. Using an approach grounded in PCC may ameliorate these issues (Simmons, Hetrick, & Jorm, 2011). Implementation of PCC in child services appears to be more problematic than other healthcare domains as it 'raises particular challenges in terms of complex conversations with vulnerable and often highly stressed or disturbed young children, involving on-going and complex relationships over time (rather than in a single decision point) and balancing multiple perspectives (e.g., child and parent)' (Wolpert et al., 2012;p. 4). Evidence suggests that service users, their carers and professionals may differ in perceptions of presenting problems and reasons for attending therapy (Bloemsma et al., 2013;Hawley & Weisz, 2005;Jepsen, Gray, & Taffe, 2012;Yeh & Weisz, 2001), adding to the complexity of implementing PCC. Professionals also raise concerns regarding capacity of service users to be involved in decision-making, because of age and severity of symptoms (Fonagy, Steele, Moran, & Higgitt, 1991;Ruhe, Wangmo, Badarau, Elger, & Niggli, 2015). Moreover, involvement of service users in child and young people mental health services may introduce potential safeguarding issues (Abrines-Jaume et al., 2014).
Some of the qualitative studies show that service users perceive involvement in treatment decision-making as important, emphasizing that they want to be consulted and well informed about their illness, to be more engaged in the treatment and to build a strong therapeutic relationship based on effective communication (Bury, Raval, & Lyon, 2007;Coyne, Hayes, Gallagher, & Regan, 2006;Freake, Barley, & Kent, 2007;Kelsey, Abelson-Mitchell, & Skirton, 2007). Despite this, studies suggest that service users are often not well informed or involved (Gyamfi, Keens-Douglas, & Medin, 2007;Simmons, Hetrick, & Jorm, 2011;Wisdom, Clarke, & Green, 2006).
In order to effectively implement PCC, it is necessary to understand the factors that influence it from the perspective of multiple stakeholders. Thus far, there has been only one attempt to systematically review the literature regarding PCC in mental health settings that was conducted in adult services, reporting on factors from the perspective of service users, carers and healthcare professionals (e.g., psychiatrists, occupational therapists and case managers; Bee, Price, Baker, & Lovell, 2015). The review included 117 studies conducted across a variety of settings such as community, inpatient and outpatient mental health services. Factors influencing PCC were distinguished at three levels: relational (i.e., related to the relationship between professionals and service users), individual service users (i.e., capacities and competencies of service users) and organizational (i.e., characteristics of organizational context). In particular, professionals most commonly reported a lack of service users' or carers' interest in and capacity for involvement, administrative burden, a lack of resources and PCC training and experience (Bee et al., 2015). Conversely, service users and carers most commonly reported professionals' emotional support, respect for service users' autonomy, service-level communication failure and information that was limited in quantity and quality. In addition, power imbalance with professionals was commonly reported. Carers also reported confidentiality as a factor potentially hindering PCC, as it was used by professionals as a reason not to share information leaving carers feeling marginalized (Askey, Holmshaw, Gamblec, & Grayd, 2009;Bee et al., 2015). Importantly, the above review was limited to adults in mental health settings. The aim of the present research was to systematically review factors influencing PCC in mental health services for children and young people reported by professionals, service users and carers.

METHODS
The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (Moher, Liberati, Tetzlaff, & Altman, 2009) and best practice guidelines (Centre for Reviews and Dissemination, 2008;Higgins, Green, & Cochrane Collaboration, 2008). A protocol was developed based on initial scoping of the literature, in which the search strategy was developed by scanning keywords of known papers (e.g., Abrines-Jaume et al., 2014) and search terms of previous related reviews (e.g., Bee, Price, Baker, & Lovell, 2015). In addition, the search was refined several times after reviewing initial search results.
The search included four concepts: the population (e.g., child), setting (e.g., mental health), intervention (e.g., PCC) and study design (e.g., qualitative; see Table S1 for search terms). As the definition and interpretation of PCC varies extensively (Leplege et al., 2007), a range of terms was used to capture the core elements of PCC as a process and a concept; for instance, shared/collaborative decisionmaking, information sharing or patient participation.
Search terms for each concept were combined using the Boolean operator 'OR', and concepts were combined using the operator 'AND'. The search strategy combined free-text words and medical subject headings.
The search was conducted in Ovid MEDLINE, PsycExtra, PsycINFO, Embase, PsycInfo, Web of Science and the Cumulative Index to Nursing and Allied Health Literature until 6 November 2015. In addition, reference lists of included publications and other systematic reviews were screened in order to identify any other publications meeting the inclusion criteria. Finally, sources of grey literature (Google Scholar, Open Grey and GreyNet International) were searched.

Inclusion Criteria
Studies were eligible for inclusion based on the criteria shown in Table 1.

Search Flow (See Figure 1 for Details)
The initial search resulted in 8818 hits (phase 1: identification). After excluding duplicates, 7676 were identified for the screening of titles/abstracts (phase 2: screening). Given the wide variability in definitions of PCC, a 'low threshold' strategy for the phase 2 screening was employed. Here, full texts were retrieved if the study examined any aspect of service users' utilization of mental health services (e.g., consent, assessment and treatment) and if any of the reviewers identified the paper as potentially relevant. Given the volume of titles and abstracts, three reviewers carried out filtering in parallel. For phase 2, one researcher (L. C.) screened 80% (n = 6140) titles and abstracts of all publications, whereas the second reviewer (F. S.) screened 10% of these (n = 614). The agreement between reviewers was very good (Cohen's κ = 0.88; Landis & Koch, 1977). In addition, the first author reviewed 20% of titles and abstracts of all publications (n = 1536), whereas the second reviewer (F. S.) screened 10% of these (n = 154). Again, the agreement between reviewers was high (Cohen's κ = 0.91; Landis & Koch, 1977). Through the phase 2 screening, 393 potentially relevant articles were identified. The most common reason for exclusion at this stage was a lack of information regarding PCC (n = 3624). Full texts were retrieved for all papers identified in phase 2, which were indicated as meeting the inclusion criteria by at least one of the authors. Unpublished or unavailable articles were retrieved with inter-library loans and by contacting the first two authors with two attempts per author.
At the final stage, the focus was on identifying papers that examined facilitators or barriers to PCC (phase 3: eligibility). The eligibility of all retrieved full texts (n = 523) was assessed by the first author (D. G.), whereas the second reviewer (L. C.) screened 10% (n = 52) of these chosen at random. The second reviewer also cross-checked full texts that the first reviewer indicated as meeting the inclusion criteria (n = 21) and full texts that the first reviewer was not fully confident to exclude (n = 10), with very good agreement (Cohen's κ = 0.99). In the case of disagreement (n = 1), a third  Table S2 for the full list of reasons for excluding the publications). Full texts were included if the studies explored views and experiences of PCC as either primary or secondary aims of the study.
The final sample constituted 23 publications, 21 included through the search and an additional two identified in the reference lists of relevant publications.

Data Extraction
Data were extracted from each included study using a data extraction form developed by the authors (T. V. and D. G.) specifically for this review, drawing on best practice guidance (Centre for Reviews and Dissemination, 2008;Higgins, Green, & Collaboration, 2008). Extracted variables included authors, publication year, aim of the study, study design, type of analysis, setting, sample size, participants, PCC tools or interventions, barriers to PCC, facilitators of PCC, key outcomes and limitations. Data were extracted from all papers in parallel by two reviewers (D. G. and F. S.) for quality checking. Any discrepancies were discussed.
Facilitators and barriers were extracted at any level: (a) patient-level and carer-level factors (e.g., motivation and beliefs); (b) professional-level factors (e.g., attitude towards PCC or shared decision-making and motivation); (c) organizational-level (e.g., organizational climate and culture, and leadership); and (d) structural and sociocultural context (e.g., politics, funding and communitylevel factors). Facilitators and barriers could be reported by professionals (e.g., clinicians), service users and carers (e.g., parents and legal guardians).

Risk of Bias Assessment
The tool for assessing risk of bias in qualitative studies, developed within the Critical Appraisal Skills Programme (Critical Appraisal Skills Programme, 2014), was used. The tool includes 10 criteria (e.g., 'Was there a clear statement of the aims of the research?') helping to determine the validity of the studies. The possible responses to nine of the questions are 'yes', 'no' or 'can't tell'. The response should be justified based on the available probes for each question. The final question explores the extent to which the research can be considered as valuable. There are three criteria on which a judgement should be made: (a) if the contribution of the study to existing knowledge (e.g., practice or policy) was discussed; (b) if new areas where research is needed were identified; and (c) how the findings can be used in other populations. In the present review, studies received 1 point for each criterion met; thus, the value of the research was presented by a score between 0 and 3. The studies were assessed in parallel by the first author (D. G.) and the co-author (D. H.) reaching high agreement (Cohen's κ = 0.98; Landis & Koch, 1977); any discrepancies in responses were discussed, and a final response option was agreed.

Synthesis of Results
A narrative synthesis (Popay et al., 2006) was used to provide a critical evaluation of evidence on factors affecting provision of PCC in child and young people's mental health services, examining the perspective of professionals, service users and carers. It addition, it examined similarities and differences between these factors as reported by different stakeholders. The presentation of the results and discussion of the findings begin by looking at the perspective of the professionals, as it was the dominant narrative in the research.

Study Characteristics
As shown in Table 2, most studies were conducted in the UK (n = 10), four in the USA and five elsewhere in Europe (e.g., Sweden and Ireland). The rest of the studies were carried out in Australia (n = 2), Hong Kong (n = 1) and Canada (n = 1). In terms of the aims of included studies, eight studies primarily focused on exploring experiences and beliefs related to PCC (n = 2; Abrines-Jaume et al., 2014; Grealish, Tai, Hunter, & Morrison, 2013), whereas other studies looked into various aspects of service users' general experience of mental health services.
Data were collected mainly using semi-structured interviews (n = 11), a combination of methods (e.g., interviews and focus groups; n = 7), whereas the analyses used were thematic analysis (n = 9) and interpretative phenomenological analysis (n = 5). Authors of two studies did not report their analytic approach (LeFrançois, 2008;Street, 2004).
There was a high level of variation in the study settings, ranging from child and young people's mental health services (n = 5), other specialized mental health services (e.g., psychiatric clinics, psychiatric emergency services and eating disorders; n = 14) and community-based services (n = 2). Finally, authors of two studies used professional registers to recruit professionals, rather than conducting the study in specific settings (Kovshoff et al., 2012;Tam-Seto & Versnel, 2015).

Risk of Bias Assessment
Factors Influencing Person-centered Care (Table 3)

Professional-level Factors
One of the most prominent factors coded at the professional level that was reported by professionals, service users and carers was a lack of sharing information regarding treatment. This was predominantly described as being a barrier to PCC (Buckley et al., 2012;Coyne et al., 2015;Hart, Saunders, & Thomas, 2005;Iachini, Hock, Thomas, & Clone, 2015;Ma & Lai, 2014;Simmons, Hetrick, & Jorm, 2011Street, 2004;Wisdom, Clarke, & Green, 2006); however, it was reported to be a facilitator when it did occur (Buckley et al., 2012;Bury, Raval, & Lyon, 2007;Iachini et al., 2015;Ma & Lai, 2014;Simmons et al., 2011). Equally valued as a factor influencing PCC was when service users and carers were listened to and their opinions respected and validated. When this occurred, it was perceived as a facilitator to PCC and was reported from studies examining healthcare professionals' young people's and carers' perspectives (Grealish, Tai (Buckley et al., 2012;Coyne et al., 2015;Grealish et al., 2013;Wisdom et al., 2006). Professionals reported apprehension to changing practice because of potential safeguarding concerns and also feeling 'clunky' or unskilled in how to involve service users in decision-making (Abrines-Jaume et al., 2014). Similarly, professionals reported a tension over service users' age/capacity and PCC (LeFrançois, 2008; also, see service user-level/carer-level factors; Simmons, Hetrick, & Jorm, 2013). Another barrier related to age was a reluctance to discuss sexual side effects of medication with service users (Simmons et al., 2013). Challenges in first aligning views amongst a multi-disciplinary team were mentioned by professionals as being a barrier to then involving service users in care delivery (Simmons et al., 2013). In addition, service users reported the disparity in expertise with professionals, in terms of language (Grealish, Tai, Hunter, & Morrison, 2013) and a lack of specialist knowledge (Harper, Dickson, & Bramwell, 2014), as a barrier to PCC.
In contrast, being flexible in their approach and trusting young people to be involved were reported by professionals as facilitators to PCC in overcoming the aforementioned barriers (Abrines-Jaume et al., 2014;Kovshoff et al., 2012;Molesworth & Crome, 2011). It was also acknowledged by professionals, service users and carers that additional effort-'going that extra mile'-is necessary to ensure that PCC is implemented (Abrines-Jaume et al., 2014;Buckley et al., 2012;Oruche, Downs, Holloway, Draucker, & Aalsma, 2014).

Service User-level/Carer-level Factors
Service users' capacity to be involved in decisionmaking, because of age and severity of symptoms, and concerns about confidentiality were raised as key barriers to PCC by professionals, service users and carers (Idenfors, Kullgren, & Salander Renberg, 2015;LeFrançois, 2008;Oruche, Downs, Holloway, Draucker, & Aalsma, 2014;Simmons, Hetrick, & Jorm, 2011Tam-Seto & Versnel, 2015;Wisdom, Clarke, & Green, 2006). However, only professionals cited that capacity to consent to treatment is determined by age and not the stage of development, which not only has ethical and legal implications but may also cause concerns if, for instance, age and developmental stage are not aligned (see also service-level factors; Simmons et al., 2013). In addition, although service users may occasionally not be able to fully participate in decision-making with PCC, they advocated their greater involvement at times when it was appropriate (LeFrançois, 2008;Tam-Seto & Versnel, 2015).
Parental involvement was reported to be a factor influencing PCC according to professionals, service users and carers (Grealish, Tai, Hunter, & Morrison, 2013;Harper, Dickson, & Bramwell, 2014;Iachini, Hock, Thomas, & Clone, 2015;Kovshoff et al., 2012;Oruche, Downs, Holloway, Draucker, & Aalsma, 2014;Tam-Seto & Versnel, 2015). Service users trusted carers to act as surrogates for PCC to make decisions on their behalf when they were particularly unwell (Grealish et al., 2013), and in general, they felt more supported when a parent or relative was involved (Iachini et al., 2015;Kovshoff et al., 2012;Tam-Seto & Versnel, 2015). Involving carers in treatment appeared to benefit both service users and carers themselves, and it was promoted by both groups, as well as by professionals (Oruche et al., 2014). Carers reported having a better understanding of the illness, and they felt better equipped to manage the illness (Oruche et al., 2014).
Nonetheless, parental involvement was not exclusively described in positive terms, as it was reported as being overly intrusive at times (Harper, Dickson, & Bramwell, 2014). Service users felt that parents were seen as the primary 'service user', reducing the young person's role in PCC. Presence of parents during the session also contributed to self-censorship, where both service users and carers felt 'inhibited to speak in front of each other' (Coyne et al., 2015;p. 565). When service users had a choice of seeing professionals without carers, in services for 16-18 year-olds, this mitigated the potential barrier of parental over-involvement (Harper et al., 2014). Service users described PCC as becoming easier as they matured into young adults and developed skills and confidence for self-expression (Harper et al., 2014). Professionals mentioned that service users' preconceptions about mental health (e.g., stigma) and previous experiences with mental health services (e.g., a lack of PCC) may be a barrier to service users' engagement with a service and, in turn, PCC (Simmons, Hetrick, & Jorm, 2013;p. 11). Similarly, service users reported that a strong desire to appear 'normal' might also prevent PCC as service users may deny their diagnoses and minimize symptoms to both themselves and professionals (Wisdom, Clarke, & Green, 2006).
Extensive policies and regulations were seen by professionals and service users as barriers to PCC as they were inflexible and often prevented the provision of individualized treatment based on service users' needs (Idenfors, Kullgren, & Salander Renberg, 2015;Pelto-Piri, Engstrom, K., & Engstrom, 2013;Tam-Seto & Versnel, 2015). Similarly, having a rigid structure to treatment provision, based on pre-conceived plans, could be a barrier to PCC according to service users; nonetheless, a complete lack of structure was also undesirable (Tam-Seto & Versnel, 2015). Service users described a lack of flexibility for professionals to depart from a service's operating procedures as resulting in service users feeling they had no choice and autonomy (Grealish, Tai, Hunter, & Morrison, 2013;Offord, Turner, & Cooper, 2006;Pelto-Piri et al., 2013;Wisdom, Clarke, & Green, 2006). Inflexibility in treatment provision was also attributed by professionals to the fact that treatment decisions were often made before service users were seen (e.g., by other professionals in the assessment team, by the General Practice), which was ultimately seen as a barrier to PCC (Simmons, Hetrick, & Jorm, 2013).
In order to mitigate challenges related to the application of PCC, professionals encouraged nurturing a collaborative team culture, because multi-disciplinary working amongst the team then trickled through to encouraging PCC with service users (Simmons, Hetrick, & Jorm, 2013).
Service users highlighted an importance of providing parents with continued support, particularly when service users were unwell, as not being able to access any help would leave their carers feeling unsupported and isolated (Grealish, Tai, Hunter, & Morrison, 2013). As indicated by carers, such support could also be provided by other community-based services; however, it is necessary that the primary mental health providers are aware of the availability of these services (Iachini, Hock, Thomas, & Clone, 2015).
Carers also reported a lack of information as a barrier to PCC, but this was mainly due to confidentiality policies, which meant that information could not be shared with a carer as the young person was over a certain age, even if this did not necessarily reflect their developmental stage (Simmons, Hetrick, & Jorm, 2011). Finally, carers emphasized that mental health professionals should be culturally competent to provide PCC, as cultural background may have a strong impact on perception of service users and their carers (Iachini, Hock, Thomas, & Clone, 2015).

Context-level Factors
The two factors coded at the context level were barriers related to a lack of resources regarding youth mental health reported by professionals. Professionals reported that a lack of research evidence with the populations they see (e.g., about medications) prevented them from in turn sharing evidence and information with service users (Simmons, Hetrick, & Jorm, 2013). Professionals in Australia reported that funding restrictions meant that not only were service users offered a limited number of sessions but also appointments with carers were not subsidized; hence, service users had to miss school to attend sessions even if the focus of work was with the carer, which also consequently resulted in fewer available sessions for work focusing on the young person (Simmons et al., 2013).

DISCUSSION
Because of an increasing focus on care provided in mental health services according to a person-centred approach, the aim of the present research was to systematically review factors influencing PCC in mental health services for children and young people as reported by professionals, service users and carers. This review is particularly needed as previous reviews focused on physical health settings (Gravel, Legare, & Graham, 2006;Legare, Ratte, Gravel, & Graham, 2008), and the only such review conducted in mental health settings included exclusively adult populations (Bee, Price, Baker, & Lovell, 2015). Interestingly, we found similar facilitators and barriers to PCC in child and young people's mental health as reported in adult mental health, which suggests that key recommendations may help improve PCC across both settings.
Findings of the present research, in line with the previous review (Bee, Price, Baker, & Lovell, 2015), suggest that there is an urgent need to improve the information provision for service users and carers within mental health services, as this was one of the most predominant barriers to PCC reported by service users in child/youth and adult services. Information should be shared in a language that is jargon free and comprehensible for service users and carers in order to redress the perceived power imbalance with professionals reported by service users in both child and adult settings (Bee et al., 2015;Bury, Raval, & Lyon, 2007;Harper, Dickson, & Bramwell, 2014). Providing information co-produced by service users, for example, may be vital in tackling this barrier (Bee et al., 2015;Simmons, Hetrick, & Jorm, 2013;Street, 2004). It is also essential there is a sufficient level of communication between professionals and service users in order to facilitate information provision as well as to nurture positive relationships; this was also seen as an important factor affecting PCC in both child/youth and adult services (Bee et al., 2015;Grealish, Tai, Hunter, & Morrison, 2013;Lee et al., 2006;Pycroft, Wallis, Bigg, & Webster, 2015;Simmons, Hetrick, & Jorm, 2011).
Effective PCC also requires confidence and knowledge from professionals, which can be attained by training and opportunities to develop practical experience of working within a PCC framework. As demonstrated in both reviews, professionals in both settings reported a lack of expertise in involving service users in care and decision-making (Abrines-Jaume et al., 2014;Bee, Price, Baker, & Lovell, 2015). A collaborative practice may need to be encouraged not only between professionals and service users but also across services and multi-disciplinary teams to avoid communication breakdowns or disagreements in terms of treatment provision (Bee et al., 2015;Simmons, Hetrick, & Jorm, 2013). Service users in both child/youth and adult mental health settings expressed concerns over their capacity to be involved in decision-making during a crisis but at other times were keen to be actively involved in care (Bee, Price, Baker, & Lovell, 2015;Simmons, Hetrick, & Jorm, 2011;Wisdom, Clarke, & Green, 2006). Nonetheless, professionals working across both populations tended to underestimate participants' capacity or willingness to participate in decision-making about their care (Bee et al., 2015;LeFrançois, 2008;Simmons, Hetrick, & Jorm, 2013;Tam-Seto & Versnel, 2015). Irrespective of whether the setting is child or adult mental health, professionals may need to make additional effort to approach PCC in an innovative manner responding to the unique needs of service users (Abrines-Jaume et al., 2014;Bee et al., 2015;Buckley et al., 2012;LeFrançois, 2008;Oruche, Downs, Holloway, Draucker, & Aalsma, 2014).
The key differences between child/youth and adult mental health services were seen at the service user/carer level. The role of carer in the context of child/youth mental health provision was particularly complex, as widely elaborated by professionals, service users and carers, which was not a prominent factor influencing PCC in adult care (Bee, Price, Baker, & Lovell, 2015). Despite the fact that carers were in general supportive and their involvement was sought after by children/young people, they also tended to be described as overly intrusive by service users, leaving them feeling excluded from playing a central role in their treatment (Harper, Dickson, & Bramwell, 2014). Moreover, children/young people appeared to be more likely to refrain from sharing their experience in an open manner in the presence of carers, whereas carers felt isolated if they were not receiving detailed information about the treatment, even if that was due to confidentiality regulations (Bee et al., 2015;Coyne et al., 2015). Thus, professionals in child/youth mental health services ought to pay close attention to the delicate balance between service users' autonomy and parental involvement whilst reassuring service users about confidentiality of the information they share. This is particularly important until young people develop confidence in expressing themselves within the services, which may take place when they become adolescents (Harper et al., 2014).
This research was conducted and reported according to the best practice guidelines (Centre for Reviews and Dissemination, 2008;Higgins, Green, & Cochrane Collaboration, 2008;Moher, Liberati, Tetzlaff, & Altman, 2009). We conducted a thorough search in seven academic databases, sources of grey literature, and we scanned reference lists of relevant publications. Although we employed a wide theoretical framework in defining PCC, due to a varied use of the term, we have no assurance that we have captured all relevant studies of PCC for example, from countries with differing conceptualization of PCC. Thus, future research would benefit from a scoping review of theories of PCC helping to clarify what constitutes PCC, particularly in the context of child and young people's mental health services that would lead the way for the development of theory-driven interventions to promote PCC. Furthermore, the current review focused exclusively on qualitative studies; hence, future systematic reviews should examine quantitative evidence of PCC to examine the effectiveness of PCC. Finally, in the current study, we were interested in the perspective of young person/child as a service user. Nonetheless, gaining insight into the views of parents or the entire family as service users, for instance, within a family-centred approach, would further add to our understanding of facilitators and barriers to PCC.
The findings of the present research suggest some key recommendations to facilitate PCC. Improving the information provision for service users and carers, in terms of its quality and quantity, and communicating it in an easily understandable fashion are urgently needed. In addition, a greater focus should be put on the role of relationships in the process of PCC provision. Professionals should also receive further support, in the form of training in PCC, to improve their confidence and knowledge, allowing them the opportunity to develop practical experience of working within a PCC framework. Similarly, professionals should be supported to use PCC in a flexible manner to ensure it meets the unique needs of service users and is responsive to times when PCC may be less appropriate, such as during crisis. Drawing on similar reviews from adult mental health services (Bee, Price, Baker, & Lovell, 2015), these recommendations may help to facilitate PCC in mental services across settings for a range of professionals, services users and carers.
Our review demonstrates that despite a current drive for PCC in child and young people's mental health settings with a strong input from service users and their carers, the care provided is still far from being implemented according to PCC principles (Department of Health, 2015). Partial responsibility for this may lie with increasing bureaucracy in services and growing emphasis on a performance culture that limits the resources and flexibility in providing truly PCC (Innes, Macpherson, & McCabe, 2006). In order to diminish the impact of these challenges, commissioners and service providers must be committed to developing a workforce characterized by an ability and willingness to listen to, trust and believe in children's/young people's capacity to be involved in care, whilst providing a choice of interventions and sufficient information (Department of Health, 2015).