An Interview study with Professionals on Shared Decision-Making in Child and Adolescent Mental Health

An Interview study with Professionals on Shared Decision-Making in Child and Adolescent Mental Health | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An Interview study with Professionals on Shared Decision-Making in Child and Adolescent Mental Health Francisco José Eiroa-Orosa, Iona Roura-Roca This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5985208/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Shared Decision-Making (SDM) is a paradigm that involves collaboration between healthcare professionals and service users to reach decisions jointly. This approach is based on the exchange of information, identification of service users’ values and preferences, analysis of treatment options, and consensus on an action plan. The present study aims to explore the beliefs and attitudes professionals regarding this model, in a context where its implementation has not yet begun in services for children and adolescents but is starting in the adult mental health system. Methods A qualitative investigation was conducted through thematic analysis of semi-structured interviews with various mental health professionals. Results While SDM offers potential benefits, its implementation entails a series of requirements, limitations, and dilemmas that must be addressed. In the child and adolescent context, it is particularly complex to establish specific ages for applying this model and to determine in which cases it is appropriate. Conclusions The adoption of SDM would represent a significant advancement that could contribute to improving the well-being of service users. children shared decision-making thematic analysis qualitative research youth Introduction Within collaborative practices, shared decision-making (SDM) in healthcare represents a paradigm shift, encompassing a set of processes that recognise and empower service users’ capacity to actively participate in decisions affecting their health and well-being [ 1 ]. SDM models consider the expertise of both professionals, who contribute their knowledge of diagnosis, prognosis, and treatment, and service users, who provide invaluable insights into the various factors surrounding them and influencing their health and well-being [ 2 , 3 ]. At its core, SDM involves information exchange, identification of service users’ values and preferences, deliberative discussion of treatment options, and reaching a consensual decision on a treatment plan [ 4 – 7 ]. A growing body of evidence suggests that SDM is associated with greater satisfaction and better quality decisions in terms of knowledge, decisional conflict, and values, both in physical health [ 8 – 10 ], mental health [ 11 , 12 ] and addiction recovery [ 13 ] services. Notably, in mental health care, SDM is associated with greater treatment adherence and self-management of well-being [ 11 , 14 ]. In an effort to broaden the scope of SDM, recent years have seen proposals to extend the evidence generated in adult health contexts to the fields of child and adolescent physical [ 15 – 18 ] and mental health [ 19 , 20 ]. A scoping review [ 19 ] identified and described SDM approaches used in child and adolescent mental health (CAMH). These approaches were categorised into six distinct groups: therapeutic techniques, psychoeducational information, decision aids, action planning or goal setting, discussion prompts, and mobilising patients to engage. The review assessed the quality of these approaches against nine essential elements of SDM, finding that the approaches varied in their comprehensiveness. A recent systematic review [ 20 ] focused on SDM interventions specifically tailored for children and youth in mental health settings explored the use of theory, mechanisms of change, and active units of change in SDM interventions. The review identified eight different interventions and found that specific intervention functions such as ‘education’ on SDM and treatment options, ‘environmental restructuring’ using decision aids, and ‘training’ for clinicians were the most used. The review also noted behaviour change techniques like ‘adding objects to the environment’, ‘discussing pros/cons’, and clinicians engaging in ‘behavioural practice/rehearsal’. However, due to the low quality of most included studies and the small number of behaviour change techniques utilised, the links between these elements and increased participation in SDM remain tentative. Despite the methodological limitations highlighted by these reviews, there is evidence of successful implementation strategies both with families [ 21 , 22 ] and directly with adolescents [ 23 , 24 ]. Nevertheless, in the child and adolescent context, implementing SDM presents unique challenges due to young people’s developmental and legal status [ 25 ]. Their evolving cognitive and emotional capacities affect their ability to participate in decision-making, and their lack of legal autonomy necessitates collaboration with parents or guardians [ 26 ]. Moreover, disagreements between young service users and their caregivers are frequent, and decision-making capacity does not always correlate with age [ 17 ]. Many young service users also struggle with low motivation or confidence to engage in the process [ 27 ]. Since many enter treatment involuntarily, this can affect their engagement, highlighting the need for efforts to foster their agency [ 24 ]. Actively involving young people in SDM, even when treatment is externally initiated, can improve outcomes and promote a sense of ownership in their care [ 28 ]. In this context, parents can act either as facilitators or barriers depending on their involvement [ 26 , 29 , 30 ]. Their perspectives, along with that of other stakeholders, can lead to conflicts that require mediation to ensure the child’s voice is heard and considered [ 24 , 30 ]. Professionals play a crucial role in navigating these dynamics, as their insights and mediation skills are essential for balancing the diverse interests involved. Research indicates that successful implementation of SDM in CAMH services requires clinicians to nurture positive relationships and demonstrate key attitudes, such as preparedness to invest effort, trust in young people, and flexibility in applying the approach [ 31 , 32 ]. However, professionals may disagree with the concept of SDM, lack motivation or adequate preparation for its implementation [ 30 ]. They must balance ethical and legal obligations, prioritising the child’s safety and well-being, including mandatory reporting of abuse or intervening in cases of harm [ 24 ]. Furthermore, successful communication is critical in overcoming barriers to SDM, where inappropriate terminology or insufficient communication skills can hinder the process [ 16 , 33 , 34 ]. Additionally, institutions must provide the necessary resources and support to implement these practices effectively [ 24 , 32 ]. Despite these challenges, including children and young people in decision-making has demonstrated significant benefits. It can increase their sense of being valued, improve self-esteem, and promote self-care, thus contributing to their overall well-being [ 35 ]. Therefore, although complex, implementing SDM in the child and adolescent context represents a valuable opportunity to improve mental health care [ 20 ]. In light of these considerations, the present study aims to explore the views and experiences of CAMH professionals regarding SDM in a territory where its implementation is beginning in the adult mental health system but without current or planned SDM implementation in CAMH services. Specifically, the objectives are to examine the perspectives of different professionals on SDM, identify the barriers and facilitators to its implementation in the child and adolescent context, and understand the perceived benefits and challenges for children, young people, and their families. Methods This study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 36 ] and Standards for Reporting Qualitative Research (SRQR) [ 37 ] guidelines to ensure comprehensive and transparent reporting. Sampling and recruitment This study involved eleven mental health professionals recruited through snowball sampling. Initial participants were identified through the first author’s professional network, and subsequent participants were recruited based on referrals from these initial contacts. Participants were included if they were professionals specialising in CAMH with at least five years of experience in the field. Exclusion criteria included professionals who were not currently practising in CAMH. The sample size was determined based on the principle of data saturation, which was achieved after interviewing eleven professionals. According to our analyses, this number was sufficient to capture a diverse range of perspectives. The sample consisted of four social workers, four psychologists, and three psychiatrists, ensuring multidisciplinary representation. The group comprised seven women and four men. Participants came from various healthcare centres in Catalonia, including urban and rural settings, as well as community and hospital facilities. For confidentiality reasons, specific locations of the centres are omitted. Procedure Ethical approval for the study was obtained from the University of Barcelona institutional review board. Interviews were arranged individually with each participant, respecting their availability and preferences. Before proceeding, informed consent was obtained from all interviewees, ensuring their voluntary participation and understanding of the study objectives. Participants were assured of the confidentiality of their responses and their right to withdraw from the study at any time. Data collection Interviews were conducted remotely using the Zoom platform. With the consent of participants, all interviews were recorded and transcribed verbatim for analysis. Each interview lasted approximately 30 minutes. A semi-structured interview format was employed to facilitate a focused yet flexible exploration of participants’ experiences with and perspectives on SDM. This method was chosen to elicit relevant insights while allowing for in-depth discussions. The interview script was designed to address key aspects of the study, including the following questions: To what extent do you think it is possible to implement shared decision programs in infant-youth mental health care? What benefits and difficulties can this type of approach generate? What do you think you would need to put it into practice? Do you think there would be any area or situation in which the preferences of the family, child, or young person should not be considered? Reflexivity The research team comprised professionals with backgrounds in critical psychology, which may have shaped both the data collection and analysis processes. To address this, the team actively engaged in reflexive practices, including regular discussions during team meetings to examine and challenge their own assumptions, biases, and interpretations. Analysis Once the transcriptions were completed, they were organised into an ATLAS.ti hermeneutic unit. A Reflexive Thematic Analysis was conducted following the six phases outlined by Braun and Clarke (2006, 2019): familiarising with the data, generating initial codes, identifying and reviewing themes, defining and naming themes, and producing the final report. This process emphasised grounding the analysis in the existing literature while acknowledging the active role of the researchers in theme development and the importance of reflexivity throughout. To enhance the reliability of the analysis, both researchers independently coded the data. Triangulation sessions were subsequently conducted to compare, discuss, and achieve consensus on codes and themes, resolving any discrepancies through an iterative process of reflection, dialogue, and refinement. Results Four theme categories were identified: requirements, benefits, limitations, and dilemmas, in addition to an independent theme consisting of fragments in which professionals referred to the current existence of SDM elements (Current implementation). The Requirements category includes the themes of professional attitudes, working with young people, working with families, and systemic changes. The Benefits category is formed by engagement, autonomy, and shared responsibility. The Limitations category consists of resource constraints, paternalism, and family barriers. Finally, the Dilemmas category includes age, complex situations, information management, and individualised support. Below, we present the definitions of the categories and themes generated by the researchers, along with illustrative verbatim quotations. The supplementary material offers a comprehensive overview of these themes, including the frequency and proportion of each theme’s occurrence. While these quantitative details are included for transparency, we adopt a cautious approach, emphasising that frequency should not be interpreted as a direct indicator of a theme’s significance. Instead, we encourage readers to view these figures within the broader context of our interpretative process. Current implementation Five of the eleven participants believe that elements of SDM are already being implemented in their practice. However, there is a consensus that there is still significant room for improvement: ‘I think it can be done, it is done, but much more could be done’ (participant 6, social worker). Participants noted that while some decisions are made collaboratively, there is a need for more consistent and widespread adoption of SDM practices. They highlighted the progress made and the shift towards a more inclusive and less hierarchical decision-making process: ‘I think there is a part that involves moving from a more paternalistic model of how mental health has been understood. I think we are in a different moment now; the paternalistic model is quite outdated. Mental health professionals today do not think we have to make decisions for patients. Instead, our patients are autonomous and responsible for their lives, and they can start or stop treatment if they like or don’t like it, and that is a responsible decision because one is responsible for what one does with their life’ (participant 3, psychologist). Requirements Participants identified several key conditions as essential for implementing SDM. For the professionals involved in the study, factors such as professional attitudes, specific intervention strategies for the child and adolescent population, engagement with families, and necessary organisational changes were considered indispensable for the successful implementation of SDM. Professional attitudes Reference is often made to the role that the professional should play and the elements that should be considered when carrying out practice compatible with SDM. One of the points on which the different professionals placed the most emphasis was interprofessional collaboration, as well as with affected individuals and their families, thus promoting collaborative and networked work. This collaboration allows for a sum of capabilities and resources, better complementing the history and process of individuals and their families. For instance, professionals highlighted the importance of regular multidisciplinary meetings and joint decision-making sessions to ensure all perspectives are considered: ‘It is also true that when there are many people giving opinions, it is more difficult to reach a decision, but once you reach it, I think the decision made is better’ (participant 11, social worker). Working with young people Another important requirement identified was the need to consider key aspects when working with this specific population. Effective support for young people involves active listening and fostering a strong, trusting relationship with the professional, enabling them to feel confident and comfortable expressing themselves, even in complex situations like hospitalisations. For SDM to be successful, the young person’s participation must be active; they must have the opportunity to make decisions about their own process to truly feel involved. It’s essential to ensure that they understand their voice matters and will be heard: ‘I have always worked on having the person in the middle, at the centre of their process, of their treatment, it always improves. And I have severe cases, very severe cases. Always, always, if you want the person to improve, to be as good as possible, you must always consider their preferences and what they want’ (participant 4, psychologist). Working with families The active involvement of families in the therapeutic process is revealed as a crucial component in CAMH care. Interviewed professionals unanimously highlighted the determining influence of the family environment on the course of treatment and the young person’s overall well-being. The need for a networked and systemic approach that not only focuses on the young service user but integrates and empowers the family as an agent of change is usually emphasised. For example, professionals noted that involving families in treatment planning sessions and providing them with resources and support can significantly enhance treatment outcomes: ‘Networked work, but it’s not just networked work, it’s work with the person, and accompanying the person. The network including the person and the family’ (participant 6, social worker). The interviewees pointed out that when families feel prepared, informed, and supported, they become valuable allies, but it is necessary to accompany them and respect their needs and times: ‘Families need to go through a process, and there are processes that are slower’ (participant 5, social worker). Systemic changes Many professionals agreed on the need for organisational-level changes that can facilitate the implementation of these types of collaborative practices. An example is the need for training to allow a change in approach to professional beliefs and attitudes. This includes not only formal training sessions but also ongoing professional development opportunities: ‘I think that first you have to educate people about what that means, which is the phase we are in, I would say, right? It’s a super new topic that we haven’t experienced in our training, and there is more and more updating and more legislation regarding the topic’ (participant 1, psychiatrist). Additionally, professionals suggested that institutions should provide adequate resources, such as time and space for SDM activities, and develop policies that support and encourage collaborative practices: ‘I think that with the current conditions in public CAMH, thinking that it’s easy to implement is very utopian, because the truth is that... yes, at least from my workplace... I find that there is a long waiting list, people are seen with very loose follow-ups... very insufficient, there aren’t many intensive follow-ups. And that’s it, it’s due to a lack of resources, right’ (participant 10, psychologist). Benefits The interviewees perceive that SDM increases service users’ interest in their treatment, which they believe can enhance treatment engagement and foster greater autonomy. Additionally, they suggest that SDM helps distribute responsibility more evenly between the service user and the professional, rather than placing it solely on the professional. Engagement Therapeutic engagement refers to the degree of active involvement and collaboration that the service user demonstrates in their treatment process. According to the professionals interviewed, when service users have greater awareness of their challenges, find meaning in their experiences, and feel motivated to participate in the treatment process, their level of engagement increases: ‘It involves the person, therefore the person has motivation, the person wants to do, the person will see the usefulness of what they do, why they have to go to visits, why they have to do that thing they don’t feel like doing, why they have to do it this way and not another’ (participant 6, social worker). Autonomy Autonomy refers to the service user’s ability to make decisions for themselves and actively engage in the process of change, independently of the opinions and desires of others. Based on the insights of the professionals interviewed, fostering autonomy through SDM might empower service users to take ownership of their treatment journey: ‘I have always raised the objectives when working with the person. Everything works much better. And if it is also shared with the rest of the professionals, much better, a case always works much better, because the person feels self-responsible for their life, which is what needs to be achieved’ (participant 4, psychologist). Shared responsibility The interviewees highlighted the importance of awareness among service users, families, and professionals regarding their involvement in the treatment process, which promotes active participation. This approach contrasts with placing all responsibility on a single individual, often the professional: ‘A difficulty sometimes for families or the individuals themselves, of ‘you are the one who knows, you have to tell me what I have to do’. We don’t have a magic wand, there is no specific solution, but rather we have to build it together, so it also generates a difficulty for the person themselves and the family to have to take responsibility, just as they have to have an active role in their process, and that sometimes is difficult, because we are used to “I don’t feel well, I go to the doctor, they tell me what I have, they give me the pill and with that I will feel better”, and sometimes it’s not that simple, and less so in mental health’ (participant 7, social worker). Limitations The participants identified several obstacles that hinder the implementation of collaborative practices, including a lack of resources, paternalism, and family barriers. Resource constraints The interviewees highlighted significant resource constraints that hinder the implementation of SDM. These constraints include insufficient time, inadequate staffing, and a lack of common spaces necessary for effective collaboration. The professionals emphasised that these limitations make it challenging to fully adopt and sustain SDM practices within their current work environments: ‘I think that with the conditions that currently exist in public children and adolescent mental health services, thinking that it is easy to implement it is very utopian, because the truth is that... at least from my job position... I find that there is a lot of waiting list, people are seen with very weak follow-up... very insufficient, there are no very intensive follow-ups. And nothing, that’s it, it’s like due to lack of resources, right?’ (participant 9, psychiatrist). Paternalism In the interviews, there were frequent mentions of overprotection by adults towards service users. Several participants acknowledged exhibiting paternalistic attitudes themselves: ‘I think that doctors in general, I am a psychiatrist, still have a very paternalistic attitude, right? You have that, so we’ll put that’ (participant 2, psychiatrist). Deciding on behalf of the person or discussing their situation without their presence are practices that need to be transformed: ‘It requires having joint meetings, not with the young person, with the parents alone, which I think is a mistake that has been made for a long time, which is that professionals only talked to the parents and believed the parents over the young people. So, private spaces must be maintained, but joint meetings must be held. You have to listen to what young people say, I think you also have to listen to what parents say and the young person has to listen to it, they have to know what people around them think and what professionals think, and from there seek a work plan’ (participant 6, social worker). Family barriers Professionals noted that family dynamics, beliefs, and expectations can sometimes hinder the SDM process. For instance, some families may resist collaborative approaches that include young people’s preferences, perceiving them as undermining parental authority or questioning their role as primary caregivers: ‘And sometimes, I’ve even encountered families who, when I've tried to agree on the treatment with an adolescent, tried to see how I dose it... well, some families didn't like that I was agreeing with the kid, you know, that's happened to me too’ (participant 2, psychiatrist). Dilemmas There are dilemmas about characteristics or situations that imply doubts about the possibility of implementing SDM. We have classified the dilemmas into those related to age or developmental stage, complex situations, information management, and personalisation of the approach. Age The age of the service user is an important factor, as it can either hinder or facilitate the SDM process. Professionals highlighted the importance of considering the young person’s legal capacity and advocated for a staggered implementation of SDM. Participants agreed that implementing SDM is more feasible with adolescents than with younger children, but they also noted the complexity of establishing a specific age threshold: Under 12 years old I see it very difficult, and here we really should maintain the family unit in the sense of the child’s living nucleus to make these decisions, and start introducing shared decisions from 12 and in the position of security from 16 years old. The concept of capacity is also raised, referring to cognitive development. In this sense, real age and developmental state are often mentioned as relatively independent and to be considered in more complex contexts: ‘(…) but it is true that we must adapt to the person’s age, to the person’s mental age and their psychopathological state’ (participant 2, psychiatrist). Complex situations Participants demonstrated a strong consensus regarding substantial constraints on the implementation of SDM in scenarios involving acute risks, encompassing both self-harm and potential harm to others. They highlighted particular challenges in cases of significant mental health distress that impact an individual’s ability to engage with reality as perceived by others and reflect on their situation: ‘I believe there are cases where this becomes significantly more complex. Cases characterised by high levels of resistance from the individual, extensive negativity, and complete lack of awareness’ (Participant 6). Under such circumstances, some interviewees posited that professional intervention may be warranted, even in the absence of explicit consent. Additional scenarios that appear to constrain the potential implementation of SDM are related to negligence on the part of primary caregivers: ‘If we detect a situation of risk, we have to protect this child, and protect this child, at some point may involve going against what the family thinks, for example, removing the child from the family if the family is mistreating or neglecting this child, and that can be something that the family doesn’t want and that the child doesn’t want to separate from the family either, but if we detect a risky situation, we have to act, we have a duty to act’ (participant 3, psychologist). Information management In line with existing paternalism as a limitation, and age as a dilemma, the interviewed professionals question what information is appropriate to share with the young person and what level of participation in decisions they can assume, according to their capacity and maturity: ‘At the age of 5, they can express preferences or choose between options, or have this more listening-oriented treatment or be able to express themselves, but I understand that when they are very young there are things they cannot decide, right?’ (participant 10, psychologist). Individualised support Several interviewees emphasised that each situation is unique, with every young person and family experiencing the process differently. This raises the need to tailor treatment considering specific circumstances, environment, prognosis, and available resources: ‘The treatment should be adaptable, not generalised. A person with a certain disorder should not necessarily be treated in ways A, B, and C; there might be a way Z that has to do with what the user knows, what the family knows about this person, and this professional also uses their mind and thinks that they don’t know everything, but rather, should construct jointly’ (participant 7, social worker). Discussion The present study aimed to explore the perspectives of CAMH professionals on the implementation of SDM. The findings provide a multifaceted understanding of this process, underscoring both substantial opportunities and key challenges. This research offers a distinctive contribution by examining the perspectives of CAMH professionals within a context where dedicated SDM implementation programs have not yet been established. Consistent with previous studies [ 40 ], most of the interviewed professionals recognised the potential benefits of SDM. Its capacity to improve treatment engagement and adherence, foster individual autonomy, and promote shared responsibility in the therapeutic process was particularly emphasised. These findings support the idea that SDM can significantly contribute to improving the quality of decisions and satisfaction, as observed in both physical [ 10 ] and mental health [ 11 , 12 ]. However, the implementation of SDM in child and adolescent mental health (CAMH) presents unique challenges compared to adult mental health. The developmental and legal status of minors significantly impacts their ability to participate in decision-making [ 25 ]. Additionally, professionals have a critical responsibility in child protection, which includes mandatory reporting of abuse and intervening in cases of potential harm [ 24 ]. This responsibility can sometimes conflict with the principles of SDM, particularly when immediate protective actions are required. A recurring theme in our results was the fundamental role of the family in the SDM process, appearing in all categories. This omnipresence of the family in the professionals’ discourse reflects the complexity of the child and adolescent context, where the family can act as both a facilitator and a barrier in the SDM process [ 17 , 30 ]. Our findings underscore the need for an approach that actively integrates the family into the SDM process, recognising its determinant influence on the course of treatment. Also consistent with the literature [ 30 , 32 , 41 ] the lack of resources emerged as a significant barrier to the implementation of SDM. Professionals cited shortages of time, staff, and adequate spaces as important obstacles. However, it was also suggested that certain aspects that can facilitate SDM, such as training and changes in professional mindset, could be implemented even with limited resources. Persistent paternalism in some professional practices was identified as another obstacle, reflecting the need for a broader cultural change in mental health care [ 3 , 42 ] In line with previous studies [ 17 ] the question of the young person’s age and ability to participate in SDM emerged as a central dilemma. While some professionals suggested age 12 as a guiding age to initiate full SDM, others advocated for a more flexible approach based on individual capacity. This discussion reflects the complexity of applying SDM in a context where decision-making ability may not directly correlate with age. Additionally, complex situations, such as imminent risky situations or family neglect, were identified as scenarios where the application of SDM could be limited or even counterproductive [ 43 ]. The professionals interviewed emphasised that, from their perspective, in cases involving acute risks, such as self-harm or potential harm to others, or when there is evidence of neglect by primary caregivers, the priority must be the immediate safety and well-being of the child. Our results underscore the need for a personalised and flexible approach in implementing SDM in CAMH. Professional training, collaborative work with families, and adaptation of processes to the individual capacities of young people emerge as key elements for successful implementation. It is important to acknowledge the limitations of this study, including the small sample size and its specific geographical location. Additionally, the absence of perspectives from young people and their families represents a significant limitation that should be addressed in future research. Conclusions The implementation of SDM in CAMH represents a promising but complex advance. Our findings suggest that, despite significant challenges, professionals perceive SDM as a potentially beneficial model that could substantially improve service users’ well-being. Successful implementation will require a gradual approach that addresses identified barriers, including lack of resources and persistent paternalistic attitudes. It will be crucial to develop clear guidelines for navigating the ethical and practical dilemmas specific to the child and adolescent context, particularly regarding the determination of young people’ capacity to participate in decision-making. Finally, this study underscores the need for a broader transformation in mental health care culture, towards a model that truly centres and empowers young people and their families. Although the journey toward fully implementing SDM may be lengthy, the potential benefits make it worthwhile to continue striving in this direction. Declarations Acknowledgments: We would like to thank the interviewed professionals for their selfless contribution. Funding: Francisco José Eiroa-Orosa has received funding from the Ministry of Science and Innovation within the framework of the RYC2018-023850-I and PID2021-125403OA-I00 projects. Ethical information: All subjects gave a written informed consent in accordance with the Declaration of Helsinki. The study was approved by the University of Barcelona Bioethics Commission (IRB00003099). Conflicts of interest: The authors report no conflicts of interest. Author Contribution: F.J.E.-O. designed the study. I.R.-R. served as a co-analyst and wrote an earlier version of the manuscript. F.J.E.-O. supervised the entire project and wrote the final manuscript. Both authors reviewed and approved the final version of the manuscript. References Buedo P, Luna F (2021) Toma de decisiones compartidas en salud mental: una propuesta novedosa. 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Clin Psychol Psychother 24:O1495–O1511. https://doi.org/10.1002/cpp.2106 Hayes D, Edbrooke-Childs J, Town R et al (2023) A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques. Eur Child Adolesc Psychiatry 32:209–222. https://doi.org/10.1007/s00787-021-01782-x Butler AM, Weller B, Titus C (2015) Relationships of Shared Decision Making with Parental Perceptions of Child Mental Health Functioning and Care. Adm Policy Ment Heal Ment Heal Serv Res 42:767–774. https://doi.org/10.1007/s10488-014-0612-y Ramon S (2021) Family Group Conferences as a Shared Decision-Making Strategy in Adults Mental Health Work. Front Psychiatry 12:. https://doi.org/10.3389/fpsyt.2021.663288 Bjønness S, Grønnestad T, Storm M (2020) I’m not a diagnosis: Adolescents’ perspectives on user participation and shared decision-making in mental healthcare. Scand J Child Adolesc Psychiatry Psychol 8:139–148. https://doi.org/10.21307/sjcapp-2020-014 Bjønness S, Viksveen P, Johannessen JO, Storm M (2020) User participation and shared decision-making in adolescent mental healthcare: A qualitative study of healthcare professionals’ perspectives. Child Adolesc Psychiatry Ment Health 14:1–9. https://doi.org/10.1186/s13034-020-0310-3 Liverpool S, Hayes D, Edbrooke-Childs J (2021) An Affective-Appraisal Approach for Parental Shared Decision Making in Children and Young People’s Mental Health Settings: A Qualitative Study. Front Psychiatry 12:1–12. https://doi.org/10.3389/fpsyt.2021.626848 Bjønness S, Grønnestad T, Johannessen JO, Storm M (2022) Parents’ perspectives on user participation and shared decision-making in adolescents’ inpatient mental healthcare. Heal Expect 25:994–1003. https://doi.org/10.1111/hex.13443 Delman J, Clark JA, Eisen SV, Parker VA (2015) Facilitators and Barriers to the Active Participation of Clients with Serious Mental Illnesses in Medication Decision Making: the Perceptions of Young Adult Clients. J Behav Health Serv Res 42:238–253. https://doi.org/10.1007/s11414-014-9431-x Bosch I, Siebel H, Heiser M, Inhestern L (2024) Decision-making for children and adolescents: a scoping review of interventions increasing participation in decision-making. Pediatr Res 1–15. https://doi.org/10.1038/s41390-024-03509-5 Liverpool S, Pereira B, Hayes D et al (2021) A scoping review and assessment of essential elements of shared decision-making of parent-involved interventions in child and adolescent mental health. Eur Child Adolesc Psychiatry 30:1319–1338. https://doi.org/10.1007/s00787-020-01530-7 Hayes D, Edbrooke-Childs J, Town R et al (2019) Barriers and facilitators to shared decision making in child and youth mental health: clinician perspectives using the Theoretical Domains Framework. Eur Child Adolesc Psychiatry 28:655–666. https://doi.org/10.1007/s00787-018-1230-0 Abrines-Jaume N, Midgley N, Hopkins K et al (2016) A qualitative analysis of implementing shared decision making in Child and Adolescent Mental Health Services in the United Kingdom: Stages and facilitators. Clin Child Psychol Psychiatry 21:19–31. https://doi.org/10.1177/1359104514547596 Gondek D, Edbrooke-Childs J, Velikonja T et al (2017) Facilitators and Barriers to Person-centred Care in Child and Young People Mental Health Services: A Systematic Review. Clin Psychol Psychother 24:870–886. https://doi.org/10.1002/cpp.2052 Coyne I (2006) Consultation with children in hospital: Children, parents’ and nurses’ perspectives. J Clin Nurs 15:61–71. https://doi.org/10.1111/j.1365-2702.2005.01247.x Runeson I, Hallström I, Elander G, Hermerén G (2002) Children’s Participation in the Decision-Making Process During Hospitalization: an observational study. Nurs Ethics 9:583–598. https://doi.org/10.1191/0969733002ne553oa Day C (2008) Children’s and young people’s involvement and participation in mental health care. Child Adolesc Ment Health 13:2–8. https://doi.org/10.1111/j.1475-3588.2007.00462.x Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Heal Care 19:349–357. https://doi.org/10.1093/intqhc/mzm042 O’Brien BC, Harris IB, Beckman TJ et al (2014) Standards for reporting qualitative research: A synthesis of recommendations. Acad Med 89:1245–1251. https://doi.org/10.1097/ACM.0000000000000388 Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3:77–101. https://doi.org/10.1191/1478088706qp063oa Braun V, Clarke V (2019) Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Heal 11:589–597. https://doi.org/10.1080/2159676X.2019.1628806 Langer DA, Jensen-Doss A (2018) Shared Decision-Making in Youth Mental Health Care: Using the Evidence to Plan Treatments Collaboratively. J Clin Child Adolesc Psychol 47:821–831. https://doi.org/10.1080/15374416.2016.1247358 Légaré F, Ratté S, Gravel K, Graham ID (2008) Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Educ Couns 73:526–535. https://doi.org/10.1016/j.pec.2008.07.018 Pelto-Piri V, Engström K, Engström I (2013) Paternalism, autonomy and reciprocity: Ethical perspectives in encounters with patients in psychiatric in-patient care. BMC Med Ethics 14. https://doi.org/10.1186/1472-6939-14-49 Hamann J, Heres S (2019) Why and How Family Caregivers Should Participate in Shared Decision Making in Mental Health. Psychiatr Serv 70:418–421. https://doi.org/10.1176/appi.ps.201800362 Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5985208","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":415269565,"identity":"04fc64bd-7573-4846-ab98-fed10170b57c","order_by":0,"name":"Francisco José Eiroa-Orosa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYBAC9oYDDAeAtByIc+ABMVp4DkC0GIO1JBCnBUInNoBI4rQwHj54uKLCLn1+2OGHQFvs5HQbCGlhOJZw8MyZ5NyNt9MMgFqSjc0OENBiz3DG4GBjG3PuxtkJIC0HErcR0sLDcP4DUEt9uuHs9A/EajnDANRyOEFeOodoW44ZHGw4c9xwg3ROwYEEAyL8wiNx+PHHhopqefnZ6Zs/fKiwkyOohUECqsIATBsQUg4C/A0QWr6BGNWjYBSMglEwIgEAZYtMakrMcQUAAAAASUVORK5CYII=","orcid":"","institution":"University of Barcelona","correspondingAuthor":true,"prefix":"","firstName":"Francisco","middleName":"José","lastName":"Eiroa-Orosa","suffix":""},{"id":415269566,"identity":"0c5f3081-61a0-4720-a353-730a1e341128","order_by":1,"name":"Iona Roura-Roca","email":"","orcid":"","institution":"University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Iona","middleName":"","lastName":"Roura-Roca","suffix":""}],"badges":[],"createdAt":"2025-02-08 05:08:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5985208/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5985208/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76290963,"identity":"9a741412-6b15-4fa8-b39a-bb2f0d708d72","added_by":"auto","created_at":"2025-02-14 12:09:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":608740,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5985208/v1/a64f033b-a3e9-4f82-b0dd-9e1d74e63301.pdf"},{"id":76288803,"identity":"b9e233da-75a3-4607-b424-86642c5f68db","added_by":"auto","created_at":"2025-02-14 11:53:05","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":39459,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5985208/v1/10beaa0285d586f17cc6bcaa.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"An Interview study with Professionals on Shared Decision-Making in Child and Adolescent Mental Health","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWithin collaborative practices, shared decision-making (SDM) in healthcare represents a paradigm shift, encompassing a set of processes that recognise and empower service users\u0026rsquo; capacity to actively participate in decisions affecting their health and well-being [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. SDM models consider the expertise of both professionals, who contribute their knowledge of diagnosis, prognosis, and treatment, and service users, who provide invaluable insights into the various factors surrounding them and influencing their health and well-being [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. At its core, SDM involves information exchange, identification of service users\u0026rsquo; values and preferences, deliberative discussion of treatment options, and reaching a consensual decision on a treatment plan [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA growing body of evidence suggests that SDM is associated with greater satisfaction and better quality decisions in terms of knowledge, decisional conflict, and values, both in physical health [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], mental health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and addiction recovery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] services. Notably, in mental health care, SDM is associated with greater treatment adherence and self-management of well-being [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn an effort to broaden the scope of SDM, recent years have seen proposals to extend the evidence generated in adult health contexts to the fields of child and adolescent physical [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and mental health [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A scoping review [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] identified and described SDM approaches used in child and adolescent mental health (CAMH). These approaches were categorised into six distinct groups: therapeutic techniques, psychoeducational information, decision aids, action planning or goal setting, discussion prompts, and mobilising patients to engage. The review assessed the quality of these approaches against nine essential elements of SDM, finding that the approaches varied in their comprehensiveness. A recent systematic review [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] focused on SDM interventions specifically tailored for children and youth in mental health settings explored the use of theory, mechanisms of change, and active units of change in SDM interventions. The review identified eight different interventions and found that specific intervention functions such as \u0026lsquo;education\u0026rsquo; on SDM and treatment options, \u0026lsquo;environmental restructuring\u0026rsquo; using decision aids, and \u0026lsquo;training\u0026rsquo; for clinicians were the most used. The review also noted behaviour change techniques like \u0026lsquo;adding objects to the environment\u0026rsquo;, \u0026lsquo;discussing pros/cons\u0026rsquo;, and clinicians engaging in \u0026lsquo;behavioural practice/rehearsal\u0026rsquo;. However, due to the low quality of most included studies and the small number of behaviour change techniques utilised, the links between these elements and increased participation in SDM remain tentative.\u003c/p\u003e \u003cp\u003eDespite the methodological limitations highlighted by these reviews, there is evidence of successful implementation strategies both with families [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and directly with adolescents [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Nevertheless, in the child and adolescent context, implementing SDM presents unique challenges due to young people\u0026rsquo;s developmental and legal status [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Their evolving cognitive and emotional capacities affect their ability to participate in decision-making, and their lack of legal autonomy necessitates collaboration with parents or guardians [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Moreover, disagreements between young service users and their caregivers are frequent, and decision-making capacity does not always correlate with age [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Many young service users also struggle with low motivation or confidence to engage in the process [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Since many enter treatment involuntarily, this can affect their engagement, highlighting the need for efforts to foster their agency [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Actively involving young people in SDM, even when treatment is externally initiated, can improve outcomes and promote a sense of ownership in their care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In this context, parents can act either as facilitators or barriers depending on their involvement [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Their perspectives, along with that of other stakeholders, can lead to conflicts that require mediation to ensure the child\u0026rsquo;s voice is heard and considered [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Professionals play a crucial role in navigating these dynamics, as their insights and mediation skills are essential for balancing the diverse interests involved.\u003c/p\u003e \u003cp\u003eResearch indicates that successful implementation of SDM in CAMH services requires clinicians to nurture positive relationships and demonstrate key attitudes, such as preparedness to invest effort, trust in young people, and flexibility in applying the approach [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, professionals may disagree with the concept of SDM, lack motivation or adequate preparation for its implementation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. They must balance ethical and legal obligations, prioritising the child\u0026rsquo;s safety and well-being, including mandatory reporting of abuse or intervening in cases of harm [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Furthermore, successful communication is critical in overcoming barriers to SDM, where inappropriate terminology or insufficient communication skills can hinder the process [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, institutions must provide the necessary resources and support to implement these practices effectively [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these challenges, including children and young people in decision-making has demonstrated significant benefits. It can increase their sense of being valued, improve self-esteem, and promote self-care, thus contributing to their overall well-being [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Therefore, although complex, implementing SDM in the child and adolescent context represents a valuable opportunity to improve mental health care [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn light of these considerations, the present study aims to explore the views and experiences of CAMH professionals regarding SDM in a territory where its implementation is beginning in the adult mental health system but without current or planned SDM implementation in CAMH services. Specifically, the objectives are to examine the perspectives of different professionals on SDM, identify the barriers and facilitators to its implementation in the child and adolescent context, and understand the perceived benefits and challenges for children, young people, and their families.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and Standards for Reporting Qualitative Research (SRQR) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] guidelines to ensure comprehensive and transparent reporting.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSampling and recruitment\u003c/h2\u003e \u003cp\u003eThis study involved eleven mental health professionals recruited through snowball sampling. Initial participants were identified through the first author\u0026rsquo;s professional network, and subsequent participants were recruited based on referrals from these initial contacts. Participants were included if they were professionals specialising in CAMH with at least five years of experience in the field. Exclusion criteria included professionals who were not currently practising in CAMH. The sample size was determined based on the principle of data saturation, which was achieved after interviewing eleven professionals. According to our analyses, this number was sufficient to capture a diverse range of perspectives.\u003c/p\u003e \u003cp\u003eThe sample consisted of four social workers, four psychologists, and three psychiatrists, ensuring multidisciplinary representation. The group comprised seven women and four men. Participants came from various healthcare centres in Catalonia, including urban and rural settings, as well as community and hospital facilities. For confidentiality reasons, specific locations of the centres are omitted.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e for the study was obtained from the University of Barcelona institutional review board. Interviews were arranged individually with each participant, respecting their availability and preferences. Before proceeding, informed consent was obtained from all interviewees, ensuring their voluntary participation and understanding of the study objectives. Participants were assured of the confidentiality of their responses and their right to withdraw from the study at any time.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eInterviews were conducted remotely using the Zoom platform. With the consent of participants, all interviews were recorded and transcribed verbatim for analysis. Each interview lasted approximately 30 minutes. A semi-structured interview format was employed to facilitate a focused yet flexible exploration of participants\u0026rsquo; experiences with and perspectives on SDM. This method was chosen to elicit relevant insights while allowing for in-depth discussions. The interview script was designed to address key aspects of the study, including the following questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo what extent do you think it is possible to implement shared decision programs in infant-youth mental health care?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat benefits and difficulties can this type of approach generate?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat do you think you would need to put it into practice?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDo you think there would be any area or situation in which the preferences of the family, child, or young person should not be considered?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eReflexivity\u003c/h3\u003e\n\u003cp\u003eThe research team comprised professionals with backgrounds in critical psychology, which may have shaped both the data collection and analysis processes. To address this, the team actively engaged in reflexive practices, including regular discussions during team meetings to examine and challenge their own assumptions, biases, and interpretations.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eOnce the transcriptions were completed, they were organised into an ATLAS.ti hermeneutic unit. A Reflexive Thematic Analysis was conducted following the six phases outlined by Braun and Clarke (2006, 2019): familiarising with the data, generating initial codes, identifying and reviewing themes, defining and naming themes, and producing the final report. This process emphasised grounding the analysis in the existing literature while acknowledging the active role of the researchers in theme development and the importance of reflexivity throughout. To enhance the reliability of the analysis, both researchers independently coded the data. Triangulation sessions were subsequently conducted to compare, discuss, and achieve consensus on codes and themes, resolving any discrepancies through an iterative process of reflection, dialogue, and refinement.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFour theme categories were identified: requirements, benefits, limitations, and dilemmas, in addition to an independent theme consisting of fragments in which professionals referred to the current existence of SDM elements (Current implementation). The Requirements category includes the themes of professional attitudes, working with young people, working with families, and systemic changes. The Benefits category is formed by engagement, autonomy, and shared responsibility. The Limitations category consists of resource constraints, paternalism, and family barriers. Finally, the Dilemmas category includes age, complex situations, information management, and individualised support.\u003c/p\u003e \u003cp\u003eBelow, we present the definitions of the categories and themes generated by the researchers, along with illustrative verbatim quotations. The supplementary material offers a comprehensive overview of these themes, including the frequency and proportion of each theme\u0026rsquo;s occurrence. While these quantitative details are included for transparency, we adopt a cautious approach, emphasising that frequency should not be interpreted as a direct indicator of a theme\u0026rsquo;s significance. Instead, we encourage readers to view these figures within the broader context of our interpretative process.\u003c/p\u003e\n\u003ch3\u003eCurrent implementation\u003c/h3\u003e\n\u003cp\u003eFive of the eleven participants believe that elements of SDM are already being implemented in their practice. However, there is a consensus that there is still significant room for improvement:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I think it can be done, it is done, but much more could be done\u0026rsquo; (participant 6, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants noted that while some decisions are made collaboratively, there is a need for more consistent and widespread adoption of SDM practices. They highlighted the progress made and the shift towards a more inclusive and less hierarchical decision-making process:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I think there is a part that involves moving from a more paternalistic model of how mental health has been understood. I think we are in a different moment now; the paternalistic model is quite outdated. Mental health professionals today do not think we have to make decisions for patients. Instead, our patients are autonomous and responsible for their lives, and they can start or stop treatment if they like or don\u0026rsquo;t like it, and that is a responsible decision because one is responsible for what one does with their life\u0026rsquo; (participant 3, psychologist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eRequirements\u003c/h3\u003e\n\u003cp\u003eParticipants identified several key conditions as essential for implementing SDM. For the professionals involved in the study, factors such as professional attitudes, specific intervention strategies for the child and adolescent population, engagement with families, and necessary organisational changes were considered indispensable for the successful implementation of SDM.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProfessional attitudes\u003c/h2\u003e \u003cp\u003eReference is often made to the role that the professional should play and the elements that should be considered when carrying out practice compatible with SDM. One of the points on which the different professionals placed the most emphasis was interprofessional collaboration, as well as with affected individuals and their families, thus promoting collaborative and networked work. This collaboration allows for a sum of capabilities and resources, better complementing the history and process of individuals and their families. For instance, professionals highlighted the importance of regular multidisciplinary meetings and joint decision-making sessions to ensure all perspectives are considered:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;It is also true that when there are many people giving opinions, it is more difficult to reach a decision, but once you reach it, I think the decision made is better\u0026rsquo; (participant 11, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eWorking with young people\u003c/h2\u003e \u003cp\u003eAnother important requirement identified was the need to consider key aspects when working with this specific population. Effective support for young people involves active listening and fostering a strong, trusting relationship with the professional, enabling them to feel confident and comfortable expressing themselves, even in complex situations like hospitalisations. For SDM to be successful, the young person\u0026rsquo;s participation must be active; they must have the opportunity to make decisions about their own process to truly feel involved. It\u0026rsquo;s essential to ensure that they understand their voice matters and will be heard:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I have always worked on having the person in the middle, at the centre of their process, of their treatment, it always improves. And I have severe cases, very severe cases. Always, always, if you want the person to improve, to be as good as possible, you must always consider their preferences and what they want\u0026rsquo; (participant 4, psychologist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eWorking with families\u003c/h2\u003e \u003cp\u003eThe active involvement of families in the therapeutic process is revealed as a crucial component in CAMH care. Interviewed professionals unanimously highlighted the determining influence of the family environment on the course of treatment and the young person\u0026rsquo;s overall well-being. The need for a networked and systemic approach that not only focuses on the young service user but integrates and empowers the family as an agent of change is usually emphasised. For example, professionals noted that involving families in treatment planning sessions and providing them with resources and support can significantly enhance treatment outcomes:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;Networked work, but it\u0026rsquo;s not just networked work, it\u0026rsquo;s work with the person, and accompanying the person. The network including the person and the family\u0026rsquo; (participant 6, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe interviewees pointed out that when families feel prepared, informed, and supported, they become valuable allies, but it is necessary to accompany them and respect their needs and times:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;Families need to go through a process, and there are processes that are slower\u0026rsquo; (participant 5, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSystemic changes\u003c/h2\u003e \u003cp\u003eMany professionals agreed on the need for organisational-level changes that can facilitate the implementation of these types of collaborative practices. An example is the need for training to allow a change in approach to professional beliefs and attitudes. This includes not only formal training sessions but also ongoing professional development opportunities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I think that first you have to educate people about what that means, which is the phase we are in, I would say, right? It\u0026rsquo;s a super new topic that we haven\u0026rsquo;t experienced in our training, and there is more and more updating and more legislation regarding the topic\u0026rsquo; (participant 1, psychiatrist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditionally, professionals suggested that institutions should provide adequate resources, such as time and space for SDM activities, and develop policies that support and encourage collaborative practices:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I think that with the current conditions in public CAMH, thinking that it\u0026rsquo;s easy to implement is very utopian, because the truth is that... yes, at least from my workplace... I find that there is a long waiting list, people are seen with very loose follow-ups... very insufficient, there aren\u0026rsquo;t many intensive follow-ups. And that\u0026rsquo;s it, it\u0026rsquo;s due to a lack of resources, right\u0026rsquo; (participant 10, psychologist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBenefits\u003c/h2\u003e \u003cp\u003eThe interviewees perceive that SDM increases service users\u0026rsquo; interest in their treatment, which they believe can enhance treatment engagement and foster greater autonomy. Additionally, they suggest that SDM helps distribute responsibility more evenly between the service user and the professional, rather than placing it solely on the professional.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEngagement\u003c/h2\u003e \u003cp\u003eTherapeutic engagement refers to the degree of active involvement and collaboration that the service user demonstrates in their treatment process. According to the professionals interviewed, when service users have greater awareness of their challenges, find meaning in their experiences, and feel motivated to participate in the treatment process, their level of engagement increases:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;It involves the person, therefore the person has motivation, the person wants to do, the person will see the usefulness of what they do, why they have to go to visits, why they have to do that thing they don\u0026rsquo;t feel like doing, why they have to do it this way and not another\u0026rsquo; (participant 6, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAutonomy\u003c/h2\u003e \u003cp\u003eAutonomy refers to the service user\u0026rsquo;s ability to make decisions for themselves and actively engage in the process of change, independently of the opinions and desires of others. Based on the insights of the professionals interviewed, fostering autonomy through SDM might empower service users to take ownership of their treatment journey:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I have always raised the objectives when working with the person. Everything works much better. And if it is also shared with the rest of the professionals, much better, a case always works much better, because the person feels self-responsible for their life, which is what needs to be achieved\u0026rsquo; (participant 4, psychologist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eShared responsibility\u003c/h2\u003e \u003cp\u003e The interviewees highlighted the importance of awareness among service users, families, and professionals regarding their involvement in the treatment process, which promotes active participation. This approach contrasts with placing all responsibility on a single individual, often the professional:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;A difficulty sometimes for families or the individuals themselves, of \u0026lsquo;you are the one who knows, you have to tell me what I have to do\u0026rsquo;. We don\u0026rsquo;t have a magic wand, there is no specific solution, but rather we have to build it together, so it also generates a difficulty for the person themselves and the family to have to take responsibility, just as they have to have an active role in their process, and that sometimes is difficult, because we are used to \u0026ldquo;I don\u0026rsquo;t feel well, I go to the doctor, they tell me what I have, they give me the pill and with that I will feel better\u0026rdquo;, and sometimes it\u0026rsquo;s not that simple, and less so in mental health\u0026rsquo; (participant 7, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe participants identified several obstacles that hinder the implementation of collaborative practices, including a lack of resources, paternalism, and family barriers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eResource constraints\u003c/h2\u003e \u003cp\u003eThe interviewees highlighted significant resource constraints that hinder the implementation of SDM. These constraints include insufficient time, inadequate staffing, and a lack of common spaces necessary for effective collaboration. The professionals emphasised that these limitations make it challenging to fully adopt and sustain SDM practices within their current work environments:\u003c/p\u003e \u003cp\u003e\u0026lsquo;I think that with the conditions that currently exist in public children and adolescent mental health services, thinking that it is easy to implement it is very utopian, because the truth is that... at least from my job position... I find that there is a lot of waiting list, people are seen with very weak follow-up... very insufficient, there are no very intensive follow-ups. And nothing, that\u0026rsquo;s it, it\u0026rsquo;s like due to lack of resources, right?\u0026rsquo; (participant 9, psychiatrist).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePaternalism\u003c/h2\u003e \u003cp\u003eIn the interviews, there were frequent mentions of overprotection by adults towards service users. Several participants acknowledged exhibiting paternalistic attitudes themselves:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I think that doctors in general, I am a psychiatrist, still have a very paternalistic attitude, right? You have that, so we\u0026rsquo;ll put that\u0026rsquo; (participant 2, psychiatrist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDeciding on behalf of the person or discussing their situation without their presence are practices that need to be transformed:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;It requires having joint meetings, not with the young person, with the parents alone, which I think is a mistake that has been made for a long time, which is that professionals only talked to the parents and believed the parents over the young people. So, private spaces must be maintained, but joint meetings must be held. You have to listen to what young people say, I think you also have to listen to what parents say and the young person has to listen to it, they have to know what people around them think and what professionals think, and from there seek a work plan\u0026rsquo; (participant 6, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eFamily barriers\u003c/h2\u003e \u003cp\u003eProfessionals noted that family dynamics, beliefs, and expectations can sometimes hinder the SDM process. For instance, some families may resist collaborative approaches that include young people\u0026rsquo;s preferences, perceiving them as undermining parental authority or questioning their role as primary caregivers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u0026lsquo;And sometimes, I\u0026rsquo;ve even encountered families who, when I've tried to agree on the treatment with an adolescent, tried to see how I dose it... well, some families didn't like that I was agreeing with the kid, you know, that's happened to me too\u0026rsquo; (participant 2, psychiatrist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eDilemmas\u003c/h2\u003e \u003cp\u003eThere are dilemmas about characteristics or situations that imply doubts about the possibility of implementing SDM. We have classified the dilemmas into those related to age or developmental stage, complex situations, information management, and personalisation of the approach.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eAge\u003c/h2\u003e \u003cp\u003eThe age of the service user is an important factor, as it can either hinder or facilitate the SDM process. Professionals highlighted the importance of considering the young person\u0026rsquo;s legal capacity and advocated for a staggered implementation of SDM. Participants agreed that implementing SDM is more feasible with adolescents than with younger children, but they also noted the complexity of establishing a specific age threshold:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eUnder 12 years old I see it very difficult, and here we really should maintain the family unit in the sense of the child\u0026rsquo;s living nucleus to make these decisions, and start introducing shared decisions from 12 and in the position of security from 16 years old.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe concept of capacity is also raised, referring to cognitive development. In this sense, real age and developmental state are often mentioned as relatively independent and to be considered in more complex contexts:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;(\u0026hellip;) but it is true that we must adapt to the person\u0026rsquo;s age, to the person\u0026rsquo;s mental age and their psychopathological state\u0026rsquo; (participant 2, psychiatrist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eComplex situations\u003c/h2\u003e \u003cp\u003eParticipants demonstrated a strong consensus regarding substantial constraints on the implementation of SDM in scenarios involving acute risks, encompassing both self-harm and potential harm to others. They highlighted particular challenges in cases of significant mental health distress that impact an individual\u0026rsquo;s ability to engage with reality as perceived by others and reflect on their situation:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I believe there are cases where this becomes significantly more complex. Cases characterised by high levels of resistance from the individual, extensive negativity, and complete lack of awareness\u0026rsquo; (Participant 6).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Under such circumstances, some interviewees posited that professional intervention may be warranted, even in the absence of explicit consent. Additional scenarios that appear to constrain the potential implementation of SDM are related to negligence on the part of primary caregivers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;If we detect a situation of risk, we have to protect this child, and protect this child, at some point may involve going against what the family thinks, for example, removing the child from the family if the family is mistreating or neglecting this child, and that can be something that the family doesn\u0026rsquo;t want and that the child doesn\u0026rsquo;t want to separate from the family either, but if we detect a risky situation, we have to act, we have a duty to act\u0026rsquo; (participant 3, psychologist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eInformation management\u003c/h2\u003e \u003cp\u003eIn line with existing paternalism as a limitation, and age as a dilemma, the interviewed professionals question what information is appropriate to share with the young person and what level of participation in decisions they can assume, according to their capacity and maturity:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u0026lsquo;At the age of 5, they can express preferences or choose between options, or have this more listening-oriented treatment or be able to express themselves, but I understand that when they are very young there are things they cannot decide, right?\u0026rsquo; (participant 10, psychologist).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eIndividualised support\u003c/h2\u003e \u003cp\u003eSeveral interviewees emphasised that each situation is unique, with every young person and family experiencing the process differently. This raises the need to tailor treatment considering specific circumstances, environment, prognosis, and available resources:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;The treatment should be adaptable, not generalised. A person with a certain disorder should not necessarily be treated in ways A, B, and C; there might be a way Z that has to do with what the user knows, what the family knows about this person, and this professional also uses their mind and thinks that they don\u0026rsquo;t know everything, but rather, should construct jointly\u0026rsquo; (participant 7, social worker).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to explore the perspectives of CAMH professionals on the implementation of SDM. The findings provide a multifaceted understanding of this process, underscoring both substantial opportunities and key challenges. This research offers a distinctive contribution by examining the perspectives of CAMH professionals within a context where dedicated SDM implementation programs have not yet been established.\u003c/p\u003e \u003cp\u003eConsistent with previous studies [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], most of the interviewed professionals recognised the potential benefits of SDM. Its capacity to improve treatment engagement and adherence, foster individual autonomy, and promote shared responsibility in the therapeutic process was particularly emphasised. These findings support the idea that SDM can significantly contribute to improving the quality of decisions and satisfaction, as observed in both physical [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and mental health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the implementation of SDM in child and adolescent mental health (CAMH) presents unique challenges compared to adult mental health. The developmental and legal status of minors significantly impacts their ability to participate in decision-making [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Additionally, professionals have a critical responsibility in child protection, which includes mandatory reporting of abuse and intervening in cases of potential harm [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This responsibility can sometimes conflict with the principles of SDM, particularly when immediate protective actions are required.\u003c/p\u003e \u003cp\u003eA recurring theme in our results was the fundamental role of the family in the SDM process, appearing in all categories. This omnipresence of the family in the professionals\u0026rsquo; discourse reflects the complexity of the child and adolescent context, where the family can act as both a facilitator and a barrier in the SDM process [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Our findings underscore the need for an approach that actively integrates the family into the SDM process, recognising its determinant influence on the course of treatment.\u003c/p\u003e \u003cp\u003eAlso consistent with the literature [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] the lack of resources emerged as a significant barrier to the implementation of SDM. Professionals cited shortages of time, staff, and adequate spaces as important obstacles. However, it was also suggested that certain aspects that can facilitate SDM, such as training and changes in professional mindset, could be implemented even with limited resources. Persistent paternalism in some professional practices was identified as another obstacle, reflecting the need for a broader cultural change in mental health care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn line with previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] the question of the young person\u0026rsquo;s age and ability to participate in SDM emerged as a central dilemma. While some professionals suggested age 12 as a guiding age to initiate full SDM, others advocated for a more flexible approach based on individual capacity. This discussion reflects the complexity of applying SDM in a context where decision-making ability may not directly correlate with age. Additionally, complex situations, such as imminent risky situations or family neglect, were identified as scenarios where the application of SDM could be limited or even counterproductive [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The professionals interviewed emphasised that, from their perspective, in cases involving acute risks, such as self-harm or potential harm to others, or when there is evidence of neglect by primary caregivers, the priority must be the immediate safety and well-being of the child.\u003c/p\u003e \u003cp\u003eOur results underscore the need for a personalised and flexible approach in implementing SDM in CAMH. Professional training, collaborative work with families, and adaptation of processes to the individual capacities of young people emerge as key elements for successful implementation.\u003c/p\u003e \u003cp\u003eIt is important to acknowledge the limitations of this study, including the small sample size and its specific geographical location. Additionally, the absence of perspectives from young people and their families represents a significant limitation that should be addressed in future research.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe implementation of SDM in CAMH represents a promising but complex advance. Our findings suggest that, despite significant challenges, professionals perceive SDM as a potentially beneficial model that could substantially improve service users\u0026rsquo; well-being. Successful implementation will require a gradual approach that addresses identified barriers, including lack of resources and persistent paternalistic attitudes. It will be crucial to develop clear guidelines for navigating the ethical and practical dilemmas specific to the child and adolescent context, particularly regarding the determination of young people\u0026rsquo; capacity to participate in decision-making. Finally, this study underscores the need for a broader transformation in mental health care culture, towards a model that truly centres and empowers young people and their families. Although the journey toward fully implementing SDM may be lengthy, the potential benefits make it worthwhile to continue striving in this direction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe would like to thank the interviewed professionals for their selfless contribution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Francisco Jos\u0026eacute; Eiroa-Orosa has received funding from the Ministry of Science and Innovation within the framework of the RYC2018-023850-I and PID2021-125403OA-I00 projects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical information:\u003c/strong\u003e All subjects gave a written informed consent in accordance with the Declaration of Helsinki. The study was approved by the University of Barcelona Bioethics Commission (IRB00003099).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e The authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u0026nbsp;\u003c/strong\u003eF.J.E.-O. designed the study. I.R.-R. served as a co-analyst and wrote an earlier version of the manuscript. F.J.E.-O. supervised the entire project and wrote the final manuscript. Both authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBuedo P, Luna F (2021) Toma de decisiones compartidas en salud mental: una propuesta novedosa. 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BMC Med Ethics 14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6939-14-49\u003c/span\u003e\u003cspan address=\"10.1186/1472-6939-14-49\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamann J, Heres S (2019) Why and How Family Caregivers Should Participate in Shared Decision Making in Mental Health. Psychiatr Serv 70:418\u0026ndash;421. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1176/appi.ps.201800362\u003c/span\u003e\u003cspan address=\"10.1176/appi.ps.201800362\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"children, shared decision-making, thematic analysis, qualitative research, youth","lastPublishedDoi":"10.21203/rs.3.rs-5985208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5985208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eShared Decision-Making (SDM) is a paradigm that involves collaboration between healthcare professionals and service users to reach decisions jointly. This approach is based on the exchange of information, identification of service users\u0026rsquo; values and preferences, analysis of treatment options, and consensus on an action plan. The present study aims to explore the beliefs and attitudes professionals regarding this model, in a context where its implementation has not yet begun in services for children and adolescents but is starting in the adult mental health system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative investigation was conducted through thematic analysis of semi-structured interviews with various mental health professionals.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWhile SDM offers potential benefits, its implementation entails a series of requirements, limitations, and dilemmas that must be addressed. In the child and adolescent context, it is particularly complex to establish specific ages for applying this model and to determine in which cases it is appropriate.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe adoption of SDM would represent a significant advancement that could contribute to improving the well-being of service users.\u003c/p\u003e","manuscriptTitle":"An Interview study with Professionals on Shared Decision-Making in Child and Adolescent Mental Health","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-14 11:52:59","doi":"10.21203/rs.3.rs-5985208/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"537326bf-c45c-45d3-b78b-c1b4bbaa4375","owner":[],"postedDate":"February 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-14T11:53:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-14 11:52:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5985208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5985208","identity":"rs-5985208","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}