Changes in inpatient child psychiatry: consequences and recommendations

Demographic & clinical correlates of admission into a specialized psychiatric inpatient service for children and adolescents in Egypt: An observational retrospective study

WHAT IS KNOWN ON THE SUBJECT

Admitting children and adolescents in psychiatric inpatient units is a relatively new and still debatable practice in Egyptian society and in the entire Arab world.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Egyptian young people diagnosed with complex behavioural problems, such as in other parts of the world, desperately need and do get benefit from inpatient psychiatric service. The demographic and clinical characteristics of children in need for such service are not clearly different from those reported in other parts of the world.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

More should be done to spread awareness, remove obstacles, and develop more specialized inpatient units, with trained child psychiatrists and psychiatric nurses to provide best care for children and adolescents diagnosed with severe emotional and behavioural problems in Egypt, the Arab world and other developing countries in the world.

ABSTRACT

Background To our knowledge, this is the first study that aims to investigate the demographic and clinical correlates of admission into a specialized inpatient psychiatric unit for children and adolescents in Egypt and the Arab world. Methods The files of all service users who presented for care in the outpatient service for children and adolescents in Tanta University between July 2017 and December 2019 were reviewed. Of the 1,195 files reviewed, 100 patients were admitted to the inpatient unit for 133 admission episodes with an average duration of 18.5 days per episode. Results The most common diagnosis among admitted children and adolescents was disruptive behaviour disorder. Having a diagnosis of bipolar disorder, eating disorder, or trauma-related disorders powerfully predicted admission. Both physical and sexual abuse also predicted admission, readmission and longer duration of admission. Conclusions The need for admission into specialized psychiatric inpatient units for children and adolescents is comparable to that in other parts of the world. There is an urgent necessity to develop such therapeutic units across the entire Arab world with subsequent need to establish suitable training programs for mental health workers to deal with children and adolescents diagnosed with severe psychiatric disorders in inpatient setting.

Daily behavior ratings among child and adolescent inpatients: the abbreviated Child Behavior Rating Form

OBJECTIVE

Child and adolescent psychiatric inpatient facilities are in need of standardized behavior rating scales to assess continuous change in patient behaviors. This study used daily staff ratings to examine the factor structure and psychometric properties of an abbreviated version of the Child Behavior Rating Form (CBRF-A).

METHOD

Three hundred eighty-seven inpatients, aged 3 to 17 years, were rated daily by unit staff. Subsamples of patients and/or their parents completed additional measures of behavior problems (Child Behavior Checklist, Functional Impairment Scale for Children and Adolescents) to assess the instrument's validity.

RESULTS

Confirmatory factor analyses identified 5 behavior problem dimensions (Oppositionalism, Attention Problems, Overactivity, Withdrawal/Depression, and Anxiety), a second-order Externalizing dimension, and 2 positive behavior dimensions (Positive/Adaptive Social and Compliance/Self-Control). The scales were found to be internally consistent and showed expected age differences, and the scale factor structures were relatively stable over 1- and 2-week intervals. The scales correlated meaningfully with parent ratings of child behavior problems and functional impairment and were predictive of total hospital days.

CONCLUSIONS

The psychometric properties of the CBRF-A appear adequate for daily inpatient rating; additional research is needed to determine the usefulness of the CBRF-A in assessing treatment and medication effects over the hospital stay.

Nurse-parent relationship building in child psychiatric units

PROBLEM

The role of nursing with parents in child psychiatric units has undergone significant change over the years. Historically, nurses had minimal contact with parents; more recently, the nurse's work with parents has intensified.

METHODS

A grounded theory study was undertaken to learn about the process of relationship building between nurses and parents on these units. Interviews and participant observation were used to collect data on 21 nurse-parent interactions.

FINDINGS

Two phases in the relationship, four patterns of interactions in the working phase, and factors that influence these relationships were identified.

CONCLUSIONS

The results provide the practicing nurse with information that should facilitate engaging parents.

Pursuit of the ordinary: short-term inpatient treatment

Short-term inpatient care creates tension between administrative mandates to reduce costs through shortened lengths of stay and staff members' commitment to the philosophy, treatment strategies, and milieu organization associated with extended inpatient care. The attempt to practice as usual within the shortened stay, that is, to do long-term treatment quickly, is bound to fail. Effective short-term care is possible, but only when the culture and treatment approach of the unit are radically altered from those of the traditional model. Short-term inpatient treatment can be understood as the pursuit of ordinary behavior during the inpatient stay. This article offers a set of norms and expectations appropriate for this pursuit.

Economic evaluations and interventions for children and adolescents with mental health problems

Economic evaluations of interventions for children and adolescents with mental health problems are comparatively rare, although the growing need for them is now quite widely recognized. This review paper first explains how demands for such evaluations have built up, and for what reasons, and then considers the response from evaluators. The various modes of economic evaluation are introduced and illustrated. Previous and current research is discussed by reference to five generic research questions commonly addressed in the wider health economics field: What treatment should be provided? When? Where? To whom? How? The review concludes with recommendations as to how economic evaluations should be taken forward in this increasingly important area of intervention.

Parents' perceptions of their child's emotional illness and psychiatric treatment needs

PROBLEM

The purpose of this study was to describe how parents define their child's emotional illness and psychiatric treatment needs.

SUBJECTS

The sample consisted of 19 parents and one grandparent (N = 20) who had recently admitted their child to a short-term psychiatric unit.

METHODS

Qualitative methods, utilizing a semistructured interview. Data were analyzed using the constant comparative method. Substantive codes were combined to derive the key concepts and themes in the interviews.

FINDINGS

The findings of this study center on themes related to parents' efforts to control the current behavioral crisis, treatment acceptability, family needs, explanatory formulations, and securing the child's future.

CONCLUSIONS

Implications for treatment include how nurses might tap into parents' perceptions to facilitate parent' professional communication.

Predictors of outcome of short-term child psychiatric inpatient treatment

In this study, 85 children were prospectively followed after discharge from short-term inpatient treatment. Outcome was defined as functioning within normal range at the follow-up or as improvement in the child's behavior problems. Rutter Parent's Questionnaire was used as a measure on admission and at the 5-month follow-up after discharge. The child's more frequent individual behavior problems, antisocial behavior and disengaged family interaction on admission predicted both functioning outside normal range and less improvement at follow-up. Previous treatment because of developmental or behavioral problems and hyperkinetic symptoms on admission predicted functioning outside normal range. Parent's previous psychiatric hospital treatment was negatively associated with improvement. Pure emotional disorder predicted normal range functioning at follow-up. The child's age, gender, place of treatment and length of short-term treatment were not related to outcome. The results also stress the importance of taking into account both parents' and teachers' evaluations on admission.

Short-term child psychiatric inpatient treatment. Place of residence as one-year outcome measure

In this study, 100 patients consecutively admitted to four child psychiatric inpatient wards in Finland were prospectively followed 12 months after discharge from short-term inpatient treatment. It turned out that 50 patients were discharged back to their previous residence and to outpatient treatment, 40 patients were admitted to long-term inpatient treatment and 10 patients were placed in some institution. The child's antisocial behaviour on admission was the strongest determinant for long-term treatment or placement at the 12 month follow-up. Other predictors of long-term treatment or placement in an institution included a high total score in teacher's behaviour ratings, being referred by a psychiatric agency and living in a semi-rural area. No statistically significant relationship was found in the child's age, gender, parents' education level or occupation, family characteristics, total life events, parent's ratings of total behaviour, total life events, parent's ratings of total behaviour, CGAS ratings by a clinician or a wide range of treatment variables.

A short-term, family-oriented, child and adolescent psychiatric inpatient treatment program

We describe a short-term inpatient treatment program whose purpose is to integrate the different interventions in the child, his or her family, and the outpatient professional network. The interaction between the family and the ward is the basic structural element of child psychiatric inpatient treatment. The child, the family, the professional outpatient network, and the ward community together form an extended therapeutic system. Inpatient treatment can be understood as a coevolving process between these systems. The essential feature in our working model is the continuous, daily nursing staff supervision and a focus on interactions in the extended therapeutic system.

Parent and teacher reports of problem behaviors in child psychiatric inpatients: cross-informant correlations on admission and at 5-month follow-up

The present study compared parent and teacher evaluations of behavioral problems in a sample of school-age child psychiatric inpatients on admission and at 5-month follow-up. Both parents and teachers viewed changes in children's emotional/behavioral problems over the course of the follow-up period rather similarly. In general, parents and teachers viewed children's behavior as significantly improved relative to pretreatment.

Patients' characteristics and consumer satisfaction on an inpatient child psychiatric unit

This paper reports the results of a chart review and consumer satisfaction evaluation of referrals to a tertiary care child psychiatric inpatient unit. The evaluation involved an examination of the types of child and family difficulties treated during the period of the study; the nature and extent of assessment, treatment and follow-up; treatment outcome and parental perception of factors related to treatment outcome; and the satisfaction of both the parents and referral sources. Results indicated that children admitted for treatment were a heterogeneous group with severe difficulties from families with a number of problems. Most parents and referring therapists were very satisfied with the treatment, recommendations and follow-up provided. Significant correlations were observed between the parents' and referring therapist's satisfaction with the service and the extent to which home based problems were addressed during the child's stay in hospital. In addition, some suggestions are given for strategies to improve services. The findings are discussed with special reference to the value of program evaluations for inpatient child psychiatric services.

Private psychiatric hospitalization of children: predictors of length of stay

OBJECTIVE

To quantitatively identify predictors and determinants of length of psychiatric hospital stay for children.

METHOD

Forty-seven demographic, psychosocial stressor, psychopathology, and disposition variables were statistically reviewed as correlates of length of stay in 100 consecutive discharges from a child psychiatry inpatient service (age range 4-12) in a private hospital. Those with strong statistical significance were then analyzed by multiple regression.

RESULTS

Greater severity of psychopathology (measured by the Children's Global Assessment Scale), greater severity of psychosocial stressors (by Axis IV scale), diagnosis of post-traumatic stress disorder, special educational and out-of-home dispositions, and severe tantrums in hospital all strongly predicted longer hospital stay. Diagnosis of adjustment disorder predicted shorter stay. Together these variables explained 57% of the total variance in length of stay.

CONCLUSIONS

The most powerful of these predictor variables could potentially be measured at the time of admission, thus permitting accurate prediction of length of stay. A set of models was generated for this purpose.

Portraits of child psychiatric inpatient treatment in Finland and Norway

This epidemiological point prevalence study explores and compares the content of child psychiatric inpatient treatment and the use of different treatment methods in Finland and in Norway. In Finland the study was carried out in January and in Norway in November, 1988. The material consisted in both countries of all patients in child psychiatric inpatient units on the study day (Finland 237 patients, Norway 243 patients). Most of the child psychiatric inpatients were boys (Finland 75%, Norway 70%). The mean ages for boys were 10.2 years in Finland and 11.9 years in Norway, and for girls 11.3 years and 13.5 years, respectively. In Finland, adjustment disorders (32% vs 7%) and psychoses (8% vs 3%) were more prevalent as reasons for hospitalization than in Norway, where conduct (24% vs 8%) and personality disorders (11% vs 4%) were more dominant. The numbers were nearly the same in both countries for autism (11-13%), attention deficit or hyperkinetic disorders (5-7%) and emotional disorders (20-26%). The planned length of hospital treatment was longer in Norway (22 months) than in Finland (11 months). A dyadic relationship with an environmental therapist or personal nurse (97-100%), and parental guidance (70-75%) were the principle treatment modes. Individual psychotherapy and family therapy were the treatment modes of choice for about one third of the patients. The prevalence of psychiatric medication was twice as high in Finland (20%) as in Norway (11%). The most important forms of medication used were, in Finland, neuroleptics (63% of medicated patients) and antidepressants (14%) and, in Norway, neuroleptics (52%) and psychostimulants (24%).

Recurrent hypersomnia in two adolescent males with Asperger's syndrome

Two individuals with Asperger's syndrome, a rare pervasive developmental disorder, developed recurrent episodes of hypersomnia and abnormal behavior (Kleine-Levin syndrome) during adolescence. The possible etiological role of developmental structural brain anomalies and the differential diagnosis of recurrent hypersomnia and abnormal behavior in patients with pervasive developmental disorders are discussed.

Nursing in child psychiatric milieus: Part II: Mapping conceptual footholds

In the first part of this paper, child inpatient nursing practice was organized into five therapeutic processes (safety, structure, support, involvement and validation). Using this organization of nursing care, three specific practice question are now addressed. One, how will nursing blend their traditional psychosocial orientation with biological psychiatry? Two, how might nurses best respond to the pressure to reduce the length of hospitalization yet still effectively intervene with troubled children? Three, does the traditional milieu therapy model have clinical utility for child inpatient nurses in the 1990's. It is suggested that nursing practice is best supported by multiple midrange theories which clarify children's behavior and give theoretical support to specific nursing interventions.

Predictors of length of stay of psychiatric adolescent inpatients

This study reviewed 158 consecutive admissions to an inpatient adolescent psychiatric service for factors that determine length of hospitalization. Variables associated with length of stay included diagnostic category and the treatment variables of number and type of psychotropic medications prescribed. Patients with disruptive behavior disorders had the shortest hospitalizations, those with anxiety and affective disorders had stays of intermediate length, and patients with psychotic/organic disorders had the longest hospitalizations. Treatment with lithium, neuroleptics, or tricyclic antidepressants was associated with longer stays. Demographic variables and variables describing the social and family situation or level of dangerousness were not significantly associated with length of hospitalization.

Nursing diagnosis vs goal-oriented treatment planning in inpatient child psychiatry

The sharp rise in acute psychiatric beds for children and youth has opened up practice opportunities for child psychiatric nurses. But there is pressure from third party payers to reduce the length of stay on these services which increases demand for effective and efficient care. Timely evaluation, stabilization and discharge of children requires multidisciplinary teamwork. This paper considers the merit of nursing diagnosis in this setting and compares it to a method of multidisciplinary goal setting. The use of nursing diagnoses in child inpatient psychiatry carries some risk of creating parallel systems of care and isolating nurses from the treatment team.

Chronic depression and hospital course in adolescents

Survival curves were used to analyze the relationship between chronicity of depression and hospital course in 48 adolescents with unipolar major depression. The 25 adolescents with chronic depression (defined as a continuous course of depressive illness for 1 year or more) did not differ from those with acute depression in age, gender, or socioeconomic status. Despite similar admission and discharge Children's Depression Rating Scale-Revised scores, adolescents with chronic depression had a significantly slower initial rate of improvement. The study suggests that chronicity of depression has predictive validity with regard to acute hospital course in adolescents.

Planning a continuum of care in child psychiatric nursing. A collaborative effort

A guide for providing a continuum of care for children in need of psychiatric services from the least restrictive services (outpatient care), to a moderately restrictive setting (partial hospitalization), to the most restrictive setting (inpatient care) is described. Movement along the continuum is facilitated by the nurse case manager. Concepts from three theoretical frameworks are integrated to define goals, criteria, and expected outcomes for each level of care along the continuum. They are Neuman's (1982) systems model for nursing practice and education, Caplan's (1961) model for primary prevention of mental disorders in children, and Frances, Clarken and Perry's (1984) differential therapeutics. The continuum provides a guide for nurses and other health care providers to achieve high quality care as economically as possible. It also enhances self-care and self-responsibility for families of disturbed children by offering a sequential graded system of care along the health-illness continuum.

Separation reaction of psychiatrically hospitalized children: a pilot study

This paper reports on the development of the Children's Separation Rating Scale (CSRS), its initial reliability and validity, and clinical/research utility with psychiatrically hospitalized children. The CSRS appears to be a reliable and valid instrument, and useful in distinguishing children's separation reaction from their general psychopathology. Findings from this pilot study support the notion that inpatient treatment programs should address the developmental needs and abilities of the various age groups and the particular deficits reflected in their psychopathology.

Parental substance abuse and suspected child abuse/maltreatment predict outcome in children's inpatient treatment

There has been relatively little empirical study of outcome for school aged children treated in psychiatric hospitals. In earlier studies, four preadmission variables were operationally defined and studied as hypothesized predictors of poor outcome in psychiatric day treatment by the criterion of recommended in-home or out-of-home placements on discharge. The preadmission variables are recent histories of severe aggression and suicidal ideation/behavior in the child and histories of parental substance abuse and reported suspicions of child abuse/maltreatment. In this study, the work has been extended to determine if these four preadmission factors relate to outcome of children treated in inpatient hospitalization. The findings indicate that the parent/family related variables, and not the child variables (nor child diagnosis), are significantly related to out-of-home recommended placements.

Challenges and choices in child and adolescent mental health-psychiatric nursing

Challenges to the profession of child and adolescent mental health-psychiatric nursing, and choices available to address these challenges, are examined. The challenges stem from the large numbers of children in need of mental health services, the many risk factors to which children and families are exposed, and society's inadequate responses. Research evidence demonstrates that the gap between mental health needs and services for children results not from ignorance, but rather from a lack of commitment to providing a coordinated system of mental health services. Nurses are among the most appropriate professionals to address these needs for a coordinated system of care, but are not viewed as child mental health experts by the public or by policymakers. Nurses can demonstrate that child mental health nursing programs are effective by choosing to support programs that work, by conducting research projects that test nursing interventions, and by educating students to meet the needs of children and families for coordinated and cost-effective care. Finally, nurses must publicize their successes so that the public recognizes nursing's role in promoting children's mental health.

Predictors of the use of seclusion on an inpatient child psychiatric unit

Characteristics of 102 children admitted to a child psychiatry unit were analyzed to determine predictability of seclusion use. A subgroup of 36 children was rated using the Zeitlin Coping Inventory. Results showed that frequently secluded children were significantly more likely to have a history of physical abuse, neurological impairment, relatively weaker verbal ability, assaultive behavior, and a suicide attempt in the 6 months prior to admission. They shared a profile of coping behavior, such as more need for environment structure, less ability to successfully meet needs, and more activity and rigidity in their unsuccessful attempts. Three items on the Coping Inventory related to frustration tolerance, response to external controls, and knowledge of what is expected in situations were highly predictive of seclusion use. Results suggest that seclusion may meet specific needs for children and may not always be an indicator of inadequate institutional policies and programs.

Focal inpatient treatment planning

Focal Inpatient Treatment Planning (FITP) is a new method of organizing and choosing among the many data available to the inpatient clinician. FITP emphasizes one Focal Problem, provides criteria for defining it, makes it possible to formulate the problem in operational language, channels free-ranging case discussion into workaday terms, invites the clinician to make explicit a sophisticated view of pathogenesis; including developmental, dynamic, and contextual factors, and ties formulation to intervention through explicit objectives. By requiring language that is jargon-free and accessible to patients and parents, FITP fosters empathy and alliance between the treatment community and the domain of the patient. This paper describes and illustrates FITP and provides guidelines for its implementation by an inpatient child and adolescent psychiatry service.