Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-029300 on 15 August 2019. Downloaded from http://bmjopen.bmj.com/ on November 30, 2023 at Univesity Autonomous of Barcelona. Conceptual framework for personal recovery in mental health among children and adolescents: a systematic review and narrative synthesis protocol Anna Ballesteros-Urpi,1,2 Mike Slade,3 David Manley,4 Hector Pardo-Hernandez‍ ‍ 5,6 To cite: Ballesteros-Urpi A, Abstract Slade M, Manley D, et al. Introduction Personal recovery has been defined as ‘a Strengths and limitations of this study Conceptual framework for profound personal and unique process for the individual personal recovery in mental ►► This systematic review will include both published to change their attitudes, values, feelings, goals, abilities health among children and and unpublished literature, hence reducing the risk and roles in order to achieve a satisfactory, hopeful and adolescents: a systematic of publication bias. review and narrative productive way of life, with the possible limitations of ►► Duplicate and independent screening and data ex- synthesis protocol. BMJ Open the illness’. However, research on personal recovery traction will minimise the risk of error when iden- 2019;9:e029300. doi:10.1136/ has focused almost exclusively on adults. This project tifying eligible studies and extracting relevant data. bmjopen-2019-029300 aims to systematically review the available literature ►► We expect heterogeneity in the included studies on definitions of personal recovery among children ►► Prepublication history for which may make it difficult to summarise data for and adolescents with mental health conditions and to this paper is available online. the development of a recovery conceptual frame- To view these files, please visit undertake a narrative synthesis to develop a conceptual work for children and adolescents with mental Protected by copyright. the journal online (http://​dx.​doi.​ framework of recovery. health conditions. org/​10.​1136/​bmjopen-​2019-​ Methods and analysis Systematic review and narrative 029300). synthesis consisting (1) searching scientific literature databases, (2) handsearching, (3) citation tracking, Received 21 January 2019 (4) grey literature searching, (5) web-based searching to change their attitudes, values, feelings, Revised 14 July 2019 and expert consultation. We will include qualitative and goals, abilities and roles in order to achieve Accepted 17 July 2019 quantitative studies or systematic reviews providing a satisfactory, hopeful and productive way a definition, theoretical or conceptual framework, of life, with the possible limitations of your domains or dimensions of personal recovery among illness’.1 Personal recovery differs from eligible participants. The study will follow standard clinical recovery which mainly focuses on systematic review methodology for study selection and reducing symptoms and improving func- data extraction. We will assess quality of the evidence using tools appropriate for each study design. We will tioning levels.2 3 Although clinical improve- develop a new conceptual framework using a modified ment has an impact on personal recovery, narrative synthesis approach, as follows: (1) describing healthcare staff can go further by working eligible studies and conducting a preliminary synthesis, collaboratively to support mental health (2) determining relationships within and between studies service users to live a satisfactory, hopeful and (3) determining the robustness of the synthesis. and productive life. Ethics and dissemination We obtained a waiver of In recent years, national health approval from our local Research Ethics Committee. programme, especially in English-speaking Results will be disseminated via publications in countries, have explored the potential that international peer-reviewed journals and conference the personal recovery process can offer to proceedings. increase patient satisfaction and experi- This study will result in a theoretical framework that is based on an exhaustive review of the literature and ence.4 One of the most accepted theoret- © Author(s) (or their ical frameworks at present to understand the input of experts in the field of recovery. We expect employer(s)) 2019. Re-use that this framework will foster a better understanding personal recovery is CHIME, a compila- permitted under CC BY-NC. No commercial re-use. See rights of the stages and processes of recovery in children and tion of five interrelated recovery processes and permissions. Published by adolescents with mental health conditions. Connectedness, Hope and optimism about the BMJ. PROSPERO registration number CRD42018064087. future, Identity, Meaning in life and Empow- For numbered affiliations see erment5–7 (figure 1). CHIME was developed end of article. through a systematic review and narra- Correspondence to Introduction tive synthesis of the existing literature on Dr Hector Pardo-Hernandez; Personal recovery has been defined as ‘a personal recovery frameworks and defini- ​hpardo@​santpau.c​ at profound personal and unique process… tions.5 The scientific search of this review Ballesteros-Urpi A, et al. BMJ Open 2019;9:e029300. doi:10.1136/bmjopen-2019-029300 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-029300 on 15 August 2019. Downloaded from http://bmjopen.bmj.com/ on November 30, 2023 at Univesity Autonomous of Barcelona. Figure 2 Summary of the systematic review methodology. framework components, although they highlighted the importance of including parents in the recovery process. This scoping review, however, has methodological Figure 1 Connectedness, Hope and optimism about the limitations, including a very simple search strategy of future, Identity, Meaning in life and Empowerment recovery framework. the available literature (with the terms ‘mental health’, ‘recovery’ and either ‘child’, ‘adolescent’ or ‘CAMHS’) and the exclusion of recovery literature focused on spanned until 2009, and no studies focused on children specific mental health disorders (eg, psychosis). The or adolescents were identified. Protected by copyright. study relied heavily on the CHIME recovery framework Applying currently available recovery-focused inter- and did not explore the potential of developing new ventions in younger populations may present unique frameworks. challenges. For instance, connectedness in a child This project aims to advance the available evidence on or adolescent is linked to the relationship with their recovery among children and adolescents with mental parents and family and to their dependence on many health conditions by systematically reviewing the available aspects of everyday life.8 Similarly, the relationship literature on the definitions of personal recovery among between children and adolescents with the peer group children and adolescents with mental health conditions and the effect of this relationship on the development 18 years of age or younger. We aim to implement an of identity and meaning in life is not exhaustively exhaustive search strategy and to implement a narrative reflected in the current recovery approach.9 Peers may synthesis of this evidence to develop a conceptual frame- exert an important influence via a sense of belonging, work of recovery specific to this population. constructive or destructive relationships with members of the same or opposite sex, bullying and so on.8 Regarding identity and meaning in life, childhood and Methods and analysis adolescence are stages of change, definition and clar- Study design ification, whereas for adults identity and definition of This study is a systematic review with a modified narra- self, while ever evolving, are largely set. A diagnosis of tive synthesis (figure 2). This review protocol was a mental illness may create a schism in this develop- prepared following the Preferred Reporting Items for mental process; the process of accepting the condition Systematic Reviews and Meta-Analyses Protocols (PRIS- and dealing with symptoms, the associated stigma and MA-P).11 This systematic review will be carried out with the response of family and peers will influence identity the support of CHIME for Adolescents (CHIME-A), and the definition of self. Recovery, therefore, must an international consortium of professionals with a recognise this dynamism and reflect progress in this common interest in the field of mental health recovery process; not simply a return to the initial state, prior to among children and adolescents (https://www.​ the diagnosis.8 researchintorecovery.​com/​chime-​a). To our knowledge, the only available evidence The systematic review will be reported in accordance on recovery frameworks for younger population is with the PRISMA statement.12 a scoping review that aimed to determine whether personal recovery-oriented mental health practice is Types of studies applicable to children and adolescents with mental We will include qualitative or quantitative empirical health issues.10 Authors found that recovery for young studies involving at least three participants that provides people appears to be consistent with CHIME recovery a definition of personal recovery among people 2 Ballesteros-Urpi A, et al. BMJ Open 2019;9:e029300. doi:10.1136/bmjopen-2019-029300 Open access BMJ Open: first published as 10.1136/bmjopen-2019-029300 on 15 August 2019. Downloaded from http://bmjopen.bmj.com/ on November 30, 2023 at Univesity Autonomous of Barcelona. experiencing mental health conditions who are 18 or Box 1 Published literature searches younger; or that provides a theory, theoretical frame- work, conceptual framework, domains or dimensions Electronic searches of personal recovery. Systematic reviews with similar Scientific databases scopes will also be included. Clinical practice guidelines MEDLINE (PubMed) and editorials will be excluded, as well as studies with EMBASE one or two participants, since studies with such a small PsycINFO (Ovid) sample size may not be generalisable or achieve satura- CINAHL tion. Language of publication will be limited to English International Bibliography of social sciences (EBSCO host) and Spanish. Sociological abstracts ASSIA (Applied Social Sciences Index and Abstracts) Type of participants Web of Science (core collection) Participants and health conditions Scopus Individuals 0–18 years of age who have experienced Handsearching mental health disorders, either diagnosed or self-re- Table of contents ported. We will classify mental health conditions in British Journal of Psychiatry accordance with the 2017/2018 International Classifi- Journal of Child & Adolescent Mental Health cation of Diseases (ICD)-10, section ‘F01-F99 Mental, Clinical Child Psychology and Psychiatry Behavioural and Neurodevelopmental disorders’ which Social Science & Medicine Journal defines mental health disorders as ‘a clinically recognis- Revista de la Asociación Española de Neuropsiquiatría Journals publishing a high proportion of eligible studies able set of symptoms or behaviour associated in most Abstracts Conference proceedings (2010–2018) cases with distress and with interference with personal European Network for Mental Health Service Evaluation (ENMESH) functions.’ (https://www.​who.​int/​classifications/​icd/​ International Association for Youth Mental Health en/​bluebook.​pdf?​ua=​1). Refocus on Recovery conference Eligible studies in relevant systematic reviews Settings Leamy et al5 Protected by copyright. Individuals in any setting including but not limited to Slade et al7 hospitals, primary care centres or community mental Naughton et al10 health settings. Type of outcomes measures the screening process, as well as included studies in We will consider the following outcome measures: (1) eligible systematic reviews. We will search proceedings any definition of personal recovery among participants; from relevant conferences in the field of recovery and (2) a theory, theoretical framework, conceptual frame- mental Health among youth: European Network for work, domains; (3) dimensions of personal recovery Mental Health Service Evaluation, Refocus on Recovery among eligible participants. conference and the International Conference on Youth Mental Health. All handsearching will be limited to Searches 2009–2018 (box 1). Scientific databases We will perform systematic searches in the most Citation tracking important literature databases as well as those most We will assess all studies citing the Leamy et al5 study, relevant to the field of mental health and social studies searched via Google Scholar (available at: https://​ (box 1). All searches will be limited to 2009 onwards to scholar.​g oogle.​c o.​u k/​s cholar?​o i=​b ibs&​h l=​e n&​c ites=​ complement the Leamy et al5 2011 searches, until 30 150376588524122793). September 2018. We will re-cover the Leamy et al5 2011 We will also screen all studies included in the Leamy searches to verify that no papers on recovery applicable et al5 review (box 3), in the recently published review to our population of interest are missed. on this matter10 and in another one developed by our The search strategy in its PubMed form is presented research team7 (box 2). in box 2; it will be adapted for the different databases we will consult. This strategy, developed in consultation Grey literature searching with a health sciences librarian, was adapted from the We will search OpenGrey (‘recovery’ and ‘mental health’ CHIME systematic review. OR ‘CHIME’). We will also conduct different Google searches; since we expect a large number of results, we Handsearching will consider only the first 100 hits (box 3). We will handsearch the table of contents of journals that, based on the experience of the research team, have Web-based searching a record of publishing material on personal recovery We will search on-line repositories (‘recovery’ and ‘mental (box 1). In addition, we will consult journals publishing health’ OR ‘CHIME’) with a specific focus on recovery in a high proportion of studies found to be eligible via mental health (box 3). Ballesteros-Urpi A, et al. BMJ Open 2019;9:e029300. doi:10.1136/bmjopen-2019-029300 3 Open access BMJ Open: first published as 10.1136/bmjopen-2019-029300 on 15 August 2019. Downloaded from http://bmjopen.bmj.com/ on November 30, 2023 at Univesity Autonomous of Barcelona. consulting a third investigator. Two independent reviewers Box 2 Search strategy (PubMed version) will then review all papers eligible for full-text assessment. 1. Mental health OR mental illness* OR mental disorder* OR mental Discrepancies will be solved by consensus or by consulting disease*OR mental problem a third investigator. 2. Recover* 3. theor* OR framework*OR model OR dimension OR paradigm OR Data extraction and management concept* For each study, we will extract its full reference, description 4. (#2 AND #3) of participants (including country and age profile), sample 5. (#1 AND #4) size, methodology, service setting and definition of recovery. 6. Psychol* health OR psychol* illness* OR psychol* disorder OR psy- Data extraction will be performed individually with an inde- chol* problem OR psychiatr* health, OR psychiatry* illness* OR pendent author verifying a random 10% sample to ensure Psychiatr* disorder OR psychiatr* problem accuracy. If we identify any missing data, we will contact 7. theme* OR stages OR processes study authors. 8. (#2 AND #7) 9. (#6 AND #8) Analysis of subgroups 10. CHIME [(tiab]) We will analyse subgroups per age, specifically participants 11. Minors OR minors* OR boy OR boys OR boyfriendOR boyhood OR 12–18 years of age. We will also assess studies including girl* OR kid OR kids OR child OR child* OR children* OR school- patients with ADHD or autism separately. In both cases we child* OR schoolchild OR school child[(tiab]) OR school child*[(tiab]) OR adolescen* OR juvenil* OR youth* OR teen* OR under*age* OR will attempt to determine if there are any differences in pubescen* OR pediatricspaediatrics[(mh]) OR pediatricpaediatric* study findings. OR paediatric* OR peadiatric* OR school [(tiab]) OR school*[(tiab]) OR prematur* OR preterm* Risk of bias assessment 12. (#5 OR #9 OR #10) AND (#11) Due to the expected heterogeneity of potentially eligible studies, we will adopt a multi-pronged approach to assess risk of bias. We will use the Critical Appraisal Skills Expert consultation Programme (CASP) checklist for qualitative studies;13 we will rate studies presenting serious concerns in over two Protected by copyright. We will consult experts in the field as identified by the CHIME-A consortium about potentially eligible studies CASP items as having ‘serious methodological limitations’ (box 3). and those presenting serious concerns in two items as having ‘moderate methodological limitations’. The rest will be Data collection and analysis classified as high quality. We will use the Confidence in the Study selection Evidence from Reviews of Qualitative Research (CERQual) We will use EndNote to collate all references and remove tool to assess the overall quality of the evidence of qualita- duplicates. Two independent reviewers will assess all titles tive studies. For quantitative and mixed methods studies, and abstracts to determine whether a full text review we will use the Mixed Methods Appraisal Tool.14 We will not is needed. We will solve discrepancies by consensus or assess the quality of doctoral theses, books, book chapters and government reports. We will use risk of bias assessment results to gauge the confidence we can place on the identi- Box 3 Other sources that will be searched fied evidence, research gaps and guidance for interpreting findings. Additionally, we will analyse separately studies clas- Citation tracking sified as of high quality. Studies citing Leamy et al5 Grey literature (“recovery” and “mental health” OR Data synthesis and analysis “CHIME”) We will undertake analysis using narrative synthesis,15 OpenGrey following the approach and building on the theory under- pinning the CHIME Framework. First, we will comprehen- Google searches (“recovery” and “mental health” OR “CHIME”) (“recovery” and “mental health” and “child”) sively assess and summarise the results of eligible studies. (“recovery” and “mental health” and “adolescent”) We will then conduct a preliminary thematic synthesis of 100 hits from a Google search the definitions, theories, theoretical frameworks, concep- tual frameworks, domains or dimensions identified in the Web-based searching eligible studies. We will do so by grouping studies according Scottish Recovery Network to study type and setting; we will tabulate results and iden- Recovery Devon Boston University Repository of Recovery Resources tify conceptual overlaps, similarities and differences and Rethink will explore possible explanations for these, considering National Mental Health Development Unit narratives at the level of form, structure and content. We Social Perspectives Network will identify overarching themes and related subthemes and will determine the frequency with which themes appear in Expert consultation the included papers via vote counting. The preliminary Consult experts in the field synthesis will then be refined and discussed among study 4 Ballesteros-Urpi A, et al. BMJ Open 2019;9:e029300. doi:10.1136/bmjopen-2019-029300 Open access BMJ Open: first published as 10.1136/bmjopen-2019-029300 on 15 August 2019. Downloaded from http://bmjopen.bmj.com/ on November 30, 2023 at Univesity Autonomous of Barcelona. 4 authors, with a specific emphasis on common themes and Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK 5 related sub-themes, resulting in an initial conceptual frame- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain work of recovery. To minimise bias in the analysis process, the 6 CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain primary analyst team have multi-professional (social worker, nurse, psychologist) and multidisciplinary (methodologist, Acknowledgements Anna Ballesteros Urpi is a PhD candidate in the Department educational, health services research, management) exper- of Education at the Universitat de Barcelona (Barcelona, Spain). Mike Slade is tise, and the wider analyst team also involves occupational supported by the National Institute for Health Research Nottingham Biomedical Research Centre. Authors would like to thank the members of the CHIME-A therapy, psychometric, peer research, sociology and health Consortium for their input during the development of this manuscript. research expertise. The analyst team include researchers Contributors Study idea: ABU, MS, DM, HPH. Study design: ABU, MS, DM, HPH. involved in the development of the CHIME Framework Drafting of the first version of the article: ABU. Critical revision of the article: ABU, and researchers with no previous involvement. Afterwards, MS, DM, HPH. Final approval of the article: ABU, MS, DM, HPH. we will explore relationships within and between studies Funding Anna Ballesteros Urpi is supported by a Sabbatical Leave Grant from in relation to this initial conceptual framework, which will Hospital Clinic (Barcelona, Spain). allow further discussion and the development of an over- Competing interests None declared. arching framework. We will explore whether variability in Patient consent for publication Not required. study design, population or setting can explain differences Ethics approval We have obtained a waiver of approval from the Clinical Research within studies and will contrast emerging themes against Ethics Committee at the Hospital Clínic of Barcelona (Barcelona, Spain). the preliminary synthesis in order to identify discrepancies Provenance and peer review Not commissioned; externally peer reviewed. and to assess robustness. Lastly, we will assess the robustness Open access This is an open access article distributed in accordance with the of the overarching framework through consultation with Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which experts and study authors and by comparing results in high- permits others to distribute, remix, adapt, build upon this work non-commercially, er-quality studies with the overall synthesis. and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. Patient and public involvement Patients were not involved in the development of this protocol. However, the research question we address in Protected by copyright. References this project aims to fill an evidence gap on the concept 1. Anthony WA. 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Guidance on the conduct of 3 School of Health Sciences, Institute of Mental Health, University of Nottingham, narrative synthesis in systematic reviews. A product from the ESRC Nottingham, UK methods programme version; 2006. Ballesteros-Urpi A, et al. BMJ Open 2019;9:e029300. doi:10.1136/bmjopen-2019-029300 5