Protocol

Methods of review and inclusion criteria were specified in a research proposal that was reviewed for feasibility, a priori, by all authors. Keywords and search terms were generated by the second author (JF); however, all authors provided input to generate the final list prior to database searching. All authors are qualified: Four authors (SM, BW, AT, SM) are currently or have previously been educators on pediatric acute psychiatric inpatient units; one author (JF) is a licensed clinical psychologist with expertise in pediatric psychiatric interventions.

Eligibility Criteria

Articles retained for the final analysis met the following criteria: (a) peer-reviewed research published in academic journals (i.e., qualitative or quantitative designs, literature reviews) or grey literature (e.g., theses/dissertations, theoretical papers, white papers, technical papers, newsletters, government documents); (b) focus on school-aged youth (ages 6–18 years old); (c) focus on youth diagnosed with a mental health condition who are/were admitted to an acute psychiatric inpatient unit; (d) inclusion of some aspect of transitioning youth post-discharge to school/academic routines; and (e) published in English. As a result, articles were excluded if they focused on (a) youth with medical needs; (b) a medical admission for youth with a mental health diagnosis; and (c) post-discharge transition to a non-school setting. No other data restrictions or publication status specifications were applied.

Information Sources

Data Extraction

Data were extracted using a spreadsheet developed for this study. Basic article information, including title, year of publication, author, publishing journal, and type (e.g., peer-reviewed article, grey literature), was coded. Next, the assigned author dyad team read each article. Based upon the full-text review, the following data were extracted and synthesized:

1. Barriers or challenges when transitioning youth from acute psychiatric care to school
2. Significance of need or reasons for a transition process
3. Key factors aiding the transition process
   1. Student voice (expanded to “Stakeholder Voice” through synthesis)
   2. Point person
   3. Recommendations or accommodations
   4. Transition meeting
   5. Other key factors noted upon full-text review
4. Other potentially important information

Search Results

The database searches resulted in a total of 1,330 articles (see Figure 1 for PRISMA flow chart). Twenty-four articles were added to ensure inclusiveness of the search. After this was complete and duplicates were removed, a total of 1,183 articles were retained for further analysis. During Phase One, review of the titles and abstracts of the articles yielded a total of 48 articles. During Phase Two, 17 articles were retained after the initial full-text review and 6 additional were identified by hand-searching their reference lists. During data extraction, an additional four articles were excluded due to content not being focused specifically on transitions from acute psychiatric settings to school. Thus, a total of 19 articles were retained for qualitative synthesis. Out of these original 19 articles, 11 were empirical peer-reviewed studies, 3 were literature reviews, and 5 were considered grey literature. After the updated search in March of 2022, five more articles were found that met criteria and were added to the list. Three were empirical peer-reviewed studies; two were grey literature (including one dissertation). Most of the articles were recently published; 19 of the total 24 were published in 2010 or later, two were published between 2000 and 2010, and three were published between 1964 and 1992.

Student Perspective

Ten articles highlighted youth perspectives during or after their transition back to school. Outcomes suggest that students need increased emotional and academic support. Youth experienced elevated levels of anxiety after discharge in the areas of peer relationships (88%), followed by coping skills, academic performance, and school staff relationships (Weiss et al., 2015). Preyde et al. (2017) found that 32.3% of youth changed schools because of reintegration difficulties. Marraccini et al. (2022) categorized transitioning students’ self-reported areas in need of support into social-emotional experiences, academic experiences, and parent engagement. Thus, the lack of support during the transition period affects students’ immediate academic performance and has widespread implications.

Caregiver Perspective

Five articles highlighted caregiver perspectives. Caregiver-specific themes included desire for stronger hospital-to-school transition processes; elevated levels of caregiver fatigue, stress, and strain; and anxiety for their child’s future. Caregivers with sole responsibility for their child’s transition back to school experienced high levels of distress (Blizzard et al., 2016; Tisdale, 2014). Articles suggest that the absence of formalized transition processes places increased responsibility and burden on caregivers. Given that the family unit is in crisis, it is unreasonable to assume that caregivers can coordinate educational plans for their child, especially as caregivers likely have no formal training in education or mental health.

School Personnel Perspective

Six articles focused on school personnel perspectives. Across articles, common relevant themes included an overall acknowledgment of the need for a supportive process, a desire to help, and a lack of formal processes or training to implement a dedicated transition system. In a survey of school staff, only 16% claimed to have a formal transition process in place (Marraccini et al., 2019). However, when schools implemented informal methods to aid reintegration post- discharge, including check-ins with staff (Center for Mental Health in Schools at UCLA [CMHS], 2014; Tisdale, 2014; Tougas et al., 2019) and/or a slower school transition (Clemens et al., 2011; Marraccini et al., 2019; Preyde et al., 2017; White et al., 2006; White et al., 2017), students had improved outcomes. Thus, even the adoption of simple measures and methods can be helpful.

Hospital Personnel Perspective

Four articles included hospital personnel perspectives (see Table 1). Of these articles, three focused on rehospitalization concerns and/or lack of structured transition processes. Further, hospital personnel noted that the absence of or errors in communication between the psychiatric hospital/acute setting and the school of record contribute to increased rehospitalization risk (CMHS, 2014). Given the high level of work acute psychiatric unit staff employ to support their patients, improved communication between psychiatric hospital and school settings needs immediate attention.

Barriers/Challenges When Transitioning Patients From Acute Psychiatric Care to School

Barriers and challenges exist for successful school transitions after an acute inpatient psychiatric admission. Existing barriers are best interpreted through the lens of specific stakeholders (e.g., student, caregiver, school staff, hospital). Further, a general and overarching barrier in fostering a successful school transition is limited interdisciplinary collaboration and resource sharing between education and medical systems (CMHS, 2014; Savina et al., 2014; Simon & Savina, 2010).

Transition Coordinator/Point People

There is strong support for a specific transition point person or coordinator (Blizzard et al., 2016; CMHS, 2014; Hall & DuBois, 2020; White et al., 2006). Across 16 articles, a point person was noted as critical for communicating student needs and/or translating information between the medical and educational worlds. This individual takes the lead on navigating the transition planning and implementation. Ideally, the coordinator begins transition planning prior to discharge from the hospital (Clemens et al., 2010; Clemens et al., 2011; Marks, 1987; Simon & Savina, 2005). For example, Blizzard et al. (2016) indicate that a school transition specialist, a role specifically designated within a pediatric acute psychiatric unit, serves as the main transition coordinator. In this pre-determined transition coordinator role, the individual bridges communication between the hospital and school and facilitates collaboration among stakeholders to develop a plan that addresses the strengths and needs of families and youth.

There is no consensus in the literature on whether the transition coordinator, or lead point person, is best selected from the hospital or the school setting. Loeper (2021) suggested that hospital-based occupational therapists are ideal to serve as transition coordinator, given their expertise in teaching coping skills and developing environmental accommodations. Others list various hospital and school-based employees, such as school psychologists or social workers, as options to consider for a point person. Regardless of who fills the point person role, their main and most important responsibility is facilitating collaboration between the home school and the acute psychiatric hospital to ensure a successful transition. As ensuring clear communication is critical, we suggest that both a hospital point person and a school point person be identified, with one of them being the central transition coordinator.

Incorporating Key Stakeholder Voice

Incorporating student voice was one of the predetermined categories necessary in building a successful transition framework from acute psychiatric settings to schools. However, across 22 articles, outcomes revealed the need to expand this concept into “Key Stakeholder Voice.” This new category indicates that there are four key stakeholders whose input is essential to create effective and individualized back to school transition plans: student, caregiver, hospital, and school.

Recommended Supports

Twenty-two articles provided specific recommendations and supports (see Table 1). These supports and recommendations were broken down into two sections: formal and informal.

Transition Meetings

Before a youth returns to school, there is a need for a transition meeting with key stakeholders to allow coordination of all parties (see Table 1; n = 18 articles). Where the meeting occurs and who is present varies (Clemens et al., 2011; White et al., 2017). Those present at the meeting (whether in person, phone, or virtually) should include, at minimum, the student, caregiver, school point person, hospital point person, and outpatient therapist (Clemens et al., 2011). Other school personnel who may also be necessary include nurse, teachers, counselors, and/or school-based therapist.

Other Key Factors/Considerations

Additional key factors that should be considered when planning for the transition back to school were noted across 17 articles.

Significance of Need, Barriers in Transition Planning

Numerous challenges exist, delaying an ideal acute psychiatric hospital to school transition. Navigating the path of a multisystem continuum of support is complex. However, all stakeholders are searching for the same goal that cannot wait: a more supported transition. The available interdisciplinary research points to many problematic outcomes due to limited formal hospital-home-school transition planning currently being practiced (McLeer et al., 1992; Marks, 1987; Preyde et al., 2017; Preyde et al., 2018; Savina et al., 2014; Tougas et al., 2019; Weiss et al., 2015; White et al., 2006). Rehospitalization risk for youth remains high (Clemens et al., 2010; CMHS, 2014; Preyde et al., 2018; Savina et al., 2014; Simon & Savina, 2005; Tougas et al., 2019; Weiss et al., 2015; White et al., 2017; White et al., 2006), and the prognosis for those who have been hospitalized for inpatient psychiatric care is riddled with ongoing mental health needs and school-related concerns (Johnson & Rubin, 1964; Marks, 1987; Marraccini et al., 2019; Preyde et al., 2018; Tisdale, 2014). Students need specific plans in place to feel supported and capable of success. Caregivers need clear explanations and willing, caring partners to help them navigate complex processes like insurance claims, 504 or IEP evaluations, and school-based mental health care. Schools need ongoing professional development focused on the prevalence of mental illness in school-aged youth, effective tools and interventions, and the development of hospital-home-school transition planning administrative processes. Finally, psychiatric staff need a straightforward solution to support transitions without having to dedicate already scarce resources to non-reimbursable services.

Stakeholder Voice

Outcomes show that a supportive and successful transition includes the perspectives of multiple stakeholders. Students, caregivers, school personnel, and hospital personnel are all needed to provide insight on the student’s areas of concern, strengths, and educational plan. It is imperative stakeholders work collaboratively to inform next steps in the transition. Without one of these key stakeholders involved, predicted success of the transition plan will lessen. However, involving whoever is available is a crucial step towards the ideal transition until sound relationships and norms can be established.

Caregivers desire support in navigating the transition process (Clemens et al., 2011; Weiss et al., 2015). It is important that parents understand the importance of the transition and of sharing of information between the hospital and school teams early in their child’s hospitalization. The legal guardian must sign a release of information (Simon & Savina, 2005); schools and/or hospitals should have these forms prepared and ready to discuss with caregivers. Understanding caregivers’ concerns about their child’s school can assist in identifying areas to target when transition planning. The hospital and school point persons should quickly establish who will lead the process of keeping caregivers informed of updates.

Transition plans should incorporate plans to support the student’s academic, social/relational, and emotional concerns. For student academic concerns, for example, having a concrete plan for make-up work during the transition process helps in reducing transition distress (Clemens et al., 2010; Weiss et al., 2015). If social/relational concerns exist, the hospital point person can role-play scenarios with the youth during admission; the school point person, in turn, can set up creative ways to support these interactions post-discharge (Preyde et al., 2017). For emotional concerns, youth should work towards understanding their triggers and identify coping skills. Mental health professionals can assist by establishing a coping skill plan with the youth at discharge and re-entry to help them identify emotions, understand the impact of these emotions, and practice various ways of coping (Clemens et al., 2010; Preyde et al., 2018).

Hospital stakeholder voice may be the most difficult perspective to gain. Many factors may contribute to the absence of the hospital stakeholder, including nonbillable service rendering, limited availability of key medical providers and/or mental health providers, and possible limited knowledge of providers on specific educational implications of psychiatric diagnoses. While these barriers may limit the collaborative nature of the stakeholder team and negatively impact the success of the transition plan, there are alternatives. For example, school personnel can consider including the voice of the student’s outpatient mental health therapist or a school-based mental health professional to give clinical insight. It may also be helpful to request the patient’s discharge summary from the caregiver.

For school personnel voice, the greatest area of need involves supports or training to facilitate gaining knowledge on acute psychiatric admission to school transitions (Blizzard et al., 2016; Marks, 1987; McLeer et al., 1992; Savina et al., 2014). School personnel have all but yelled from the rooftops that they need guidance, particularly from mental health professionals and hospital staff. They want effective coordination between the school and the mental health team (Blizzard et al., 2016; Marks, 1987; Simon & Savina, 2010; White et al., 2017). Without proper preparation for school re-entry, students may exhibit disruptive behaviors (Blizzard et al., 2016; Tougas et al., 2019). Further, the transition team should solicit all stakeholder input and carefully consider expectations and resources to identify possible gaps. Unrealistic expectations are often set for schools that are not possible given current resources. Brainstorming creative solutions with the transition team can help in ensuring the student’s needs are met and supports are realistic.

Transition Coordinator and Point People

A key point consistently supported was the importance of identifying a specific transition coordinator to mediate between the student, caregivers, school, and hospital staff. Caregivers report that transitioning their child to school on their own can be difficult and frustrating; not surprisingly, therefore, relying on caregivers to navigate the process alone yields unsuccessful outcomes (Blizzard et al., 2016; Hall & DuBois, 2020; Johnson & Rubin, 1964; Marks, 1987; McLeer et al., 1992; Tisdale, 2014; Weiss et al., 2015). Identifying a specific point person can alleviate caregiver stress and burden. The point person has many responsibilities, but their main purpose is to connect the school, caregivers, student, and hospital to create a plan for moving forward with the school transition.

An ideal transition would have a specific point person on both the school and the hospital side (Blizzard et al., 2016; Clemens et al., 2010, 2011; CMHS, 2014; Hall & DuBois, 2020; Iverson, 2017; Marks, 1987; Marraccini et al., 2019; Savina et al., 2014; Simon & Savina, 2010; Tisdale, 2014; Weiss et al. 2015; White et al., 2006; White et al., 2017), with one being elected as the ultimate transition coordinator. The purpose of these roles is to communicate accurate information between the two settings. Our outcomes listed many roles, responsibilities, and persons that could serve as the point person. In the end, the main thing is that point person is available and able to coordinate and communicate stakeholder voices.

Relying on the student voice to identify the school point person or support persons may be necessary to ensure a positive transition outcome. The expectation that anyone can fill this role is false. The student needs to feel safe and supported; if rapport and relationship are not established with the school point person, the plan will not be implemented successfully and the student will continue to feel unsupported (CMHS, 2014; Marks, 1987; McLeer et al., 1992; Marraccini et al., 2019; Savina et al., 2014). The school support person should have a clear understanding of expectations and attitudes that need to be present to support the student. The last item to consider is time. The person in this position needs to be able to have adequate time to support the student (White et al., 2017).

Recommendations/Accommodations

It is critical that both formal and informal supports are in place for transitioning students. The principal areas where students need supports are academic, social, and emotional. The types of accommodations that will create a safe and appropriate school environment can be developed via student, caregiver, hospital staff, and school staff feedback. This may include creating a safety plan and/or coping skills plan for school, determining if the school is an appropriate fit, and making changes to the student’s access to educational learning. The hospital point person can provide the school point person with relevant medical information, including coping skills plans to translate into a Section 504 Plan or IEP accommodations, and informal supports that align with mental health treatment. A process like this supports each stakeholder and ensures goals targeting the student’s mental health and education are aligned.

Transition Meeting

A comprehensive transition meeting should occur before the student returns to school. Persons involved in the meeting should include as many of the stakeholders as possible, including caregiver(s), school personnel, counselor, school nurse, school psychologist, hospital representative (e.g., social worker, school transition specialist), and (if age-appropriate) the student. Starting communication early in the hospitalization to understand family/student needs and existing school issues ensures that there is adequate time to develop a transition plan that encompasses all of the needs, abilities, and resources of all stakeholders, and that any ancillary needs (e.g., changing educational plans, training staff, obtaining additional services/resources) are addressed before school reintegration occurs.

Other Key Factors and Considerations