Adolescent Psychiatric Inpatient Care Research Articles

Staff perspectives on the effects of seclusion in adolescent psychiatric inpatient care.

Nurses are at the forefront of seclusion in adolescent psychiatric units. Understanding nurses and other staff perspectives on the effects of seclusion is critical in the ongoing effort to minimize and eliminate seclusion. The aim of this study was to gain a better understanding of staff attitudes, experiences, and beliefs about the effects of seclusion on both themselves and patients. Thirty-one staff members (including 20 nurses) completed the Attitudes to Seclusion Survey and 24 participated in semi-structured interviews to explore their beliefs and experiences of seclusion use in adolescent psychiatric inpatient care. Analysis of the questionnaire showed overwhelming agreement in the negative impacts of seclusion on patients, while there was uncertainty around the positive impacts of seclusion. Using a combination of the intuitive approach and thematic analysis, five themes were identified from interviews with staff, three unique to nurses: (i) staff were reluctant to use seclusion but felt it was necessary, (ii) nurses felt under-resourcing led to increased chances of seclusion, (iii) staff believed seclusion negatively impacted the patients, (iv) nurses felt their relationships with patients were negatively impacted, and (v) seclusion also had a negative effect on nurses. Clinical recommendations included a systematic and structured approach to debriefing to repair ruptures in the therapeutic relationship; staffing to be based on the acuity of the unit rather than occupancy; alternatives to seclusion that meet the needs of service providers and consumers. Future research should compare staff and patient perspectives, include multiple sites, and greater participation of non-nursing staff.

Constrained nursing: Nurses' and assistant nurses' experiences working in a child and adolescent psychiatric ward.

The role of nurses and nursing in CAP inpatient care is unclear, and nurses are at risk of moral distress due to having to deal with complex demands while lacking organizational support. This study aimed to describe nurses' and assistant nurses' experiences working in child and adolescent psychiatric inpatient care. Eight nurses and seven assistant nurses working in a child and adolescent ward in Sweden participated in the study. Data were collected in 2019 using semi-structured qualitative interviews and subject to qualitative content analysis. Results describe nurses' and assistant nurses' experiences of child and adolescent psychiatric inpatient care in one theme, Constrained nursing, and four categories: Striving to be there for children and parents; Finding a way to manage work; Depending on others; Lacking nursing leadership. Findings suggest that good, person-centred and recovery-oriented nursing practice can exist in CAP inpatient care but remain unrecognized and lacking support due to unclear roles and responsibilities and lack of nursing leadership. This study is reported in accordance with the COREQ guidelines.

Factors behind a remarkable increase in adolescent psychiatric inpatient treatment between 1980 and 2010 – a nationwide register study

Purpose This register-based study aimed to evaluate trends in adolescent psychiatric inpatient care using nationwide data from three consecutive decades. Methods The study population (N 17,112) comprised all Finnish citizens aged 13–17 receiving their first-ever psychiatric inpatient treatment between 1980 and 2010 in Finland. Information on inpatient care in the psychiatric hospital was obtained from the Hospital Discharge Register and the Care Register for Health Care, which contains data on all patients discharged from all Finnish inpatient psychiatric health services. Results Inpatient admissions remained relatively stable until the early 1990s, after which a steady increase was seen, peaking in 2008 and more marked among females than males. In males, there was an increase in inpatient care episodes for externalizing disorder or mood disorder, and in females for mood disorder. Duration of first inpatient care decreased over time, but level of functioning on admission remained stable or even deteriorated. Females, patients first admitted in the 1980s or diagnosed with schizophrenia were more likely to be re-hospitalized during adolescence. Conclusions We reported an increase in adolescent psychiatric inpatient care from the latter half of the 1990s up to 2010, which could be explained by societal and policy changes. In particular, as the study period progressed a significant increase was seen in admissions of females and a global reduction of length of stay (LOS) with no concomitant increase in re-hospitalizations.

'Don't abandon me': Young people's experiences of child and adolescent psychiatric inpatient care supporting recovery described in blogs.

Child and adolescent psychiatric (CAP) inpatient care has the potential to support or hinder young people’s mental‐health recovery. Research describing inpatient care from the perspective of young people is rare. Personal blogs provide an opportunity to further understand how inpatient care relates to young people’s recovery processes. This study aimed to explore young people’s experiences of CAP inpatient care supporting mental‐health recovery. The study is reported in accordance with the COREQ guidelines. Data were created during 2018 from twenty‐seven personal blogs describing first‐hand experiences of being a patient in a CAP inpatient care facility in Sweden and analysed using a method for interpretive description. Information in blogs suggests they were written by women, a majority of which had experienced eating disorders. Findings describe young people’s experiences of CAP inpatient care supporting mental‐health recovery in an interpretive explanation with one theme, ‘Don’t abandon me’, and three sub‐themes: ‘Listen to me’, ‘Believe in me’, and ‘Allow me to feel safe’. This study adds to the growing body of empirical work suggesting the importance of the concept of recovery in young people’s mental health. To support recovery, CAP inpatient care needs to focus on developing the content of care rather than minimizing the length of the stay. User experience should be at the heart of efforts aimed at improving services.

Acceptability of the health-related quality of life instrument EQ-5D-Y-5L among patients in child and adolescent psychiatric inpatient care.

AimThe generic EuroQol 5 Dimensions Youth 5 Level (EQ‐5D‐Y‐5L) measures health‐related quality of life among children from 8 years. Respondents report their health on five dimensions with five severity levels and rate their overall health on a visual analogue scale (EQ VAS). The aim of the study was to explore acceptability of the EQ‐5D‐Y‐5L instrument among patients in child and adolescent psychiatric inpatient care.MethodsA convenience sample of patients within a psychiatric inpatient care clinic in Region Stockholm, Sweden, was used. Follow‐up questions were answered directly after filling in the EQ‐5D‐Y‐5L. Conventional qualitative content analysis was chosen to analyse the open‐ended questions on how they perceived answering the instrument.ResultsIn total, 52 patients (83% girls), mean age 15.4 years (range 13‐17), were included. Three themes emerged: generic content of the EQ‐5D‐Y‐5L descriptive system; design and wording of the EQ‐5D‐Y‐5L descriptive system and the EQ VAS; self‐reporting health with the EQ‐5D‐Y‐5L descriptive system and the EQ VAS.ConclusionThe inclusion of physical health dimensions was perceived as positive, but some patients considered the descriptive system too generic. The results indicate that these patients in general could self‐report their health in a meaningful way with the EQ‐5D‐Y‐5L instrument.

Supported discharge service versus inpatient care evaluation (SITE): a randomised controlled trial comparing effectiveness of an intensive community care service versus inpatient treatment as usual for adolescents with severe psychiatric disorders: self-harm, functional impairment, and educational and clinical outcomes

Clinical guidelines recommend intensive community care service treatment (ICCS) to reduce adolescent psychiatric inpatient care. We have previously reported that the addition of ICCS led to a substantial decrease in hospital use and improved school re-integration. The aim of this study is to undertake a randomised controlled trial (RCT) comparing an inpatient admission followed by an early discharge supported by ICCS with usual inpatient admission (treatment as usual; TAU). In this paper, we report the impact of ICCS on self-harm and other clinical and educational outcomes. 106 patients aged 12–18 admitted for psychiatric inpatient care were randomised (1:1) to either ICCS or TAU. Six months after randomisation, we compared the two treatment arms on the number and severity of self-harm episodes, the functional impairment, severity of psychiatric symptoms, clinical improvement, reading and mathematical ability, weight, height and the use of psychological therapy and medication. At six-month follow-up, there were no differences between the two groups on most measures. Patients receiving ICCS were significantly less likely to report multiple episodes (five or more) of self-harm (OR = 0.18, 95% CI: 0.05–0.64). Patients admitted to private inpatient units spent on average 118.4 (95% CI: 28.2–208.6) fewer days in hospitals if they were in the ICCS group compared to TAU. The addition of ICCS to TAU may lower the risk of multiple self-harm and may reduce the duration of inpatient stay, especially in those patients admitted for private care. Early discharge with ICCS appears to be a viable alternative to standard inpatient treatment.

EQ-5D-Y-5L as a patient-reported outcome measure in psychiatric inpatient care for children and adolescents \u2013 a cross-sectional study

BackgroundPsychiatric disorders have a major individual and societal impact. Until now, the association between health-related quality of life and physical disorders has been far more investigated than the association with psychiatric disorders. Patient-reported outcome measures makes it possible to capture the patient perspective to improve treatments and evaluate treatment outcomes. The aim of this study is to measure health-related quality of life with the EQ-5D-Y-5L among patients in child and adolescent psychiatric inpatient care and to test the instrument’s psychometric properties in terms of feasibility and construct validity.MethodsData were collected at the child and adolescent psychiatric inpatient facility in Region Stockholm. A questionnaire including the EQ-5D-Y-5L instrument, the Strengths and Difficulties Questionnaire with an impact supplement and a self-rated health question, was administered for self-completion using paper and pencil, with an interviewer present. The Chi-square test was used to investigate differences in proportion of reported problems in the EQ-5D-Y-5L dimensions and the Mann-Whitney U test was used for differences in mean EQ VAS scores. Feasibility was assessed by investigating proportion of missing and ambiguous answers and Spearman’s and Pearson’s correlation were used to examine construct validity.ResultsIn total 52 adolescents participated in the study and the majority were girls. The most common diagnosis at admission was depressive episode/recurrent depressive disorder. All participants reported problems on at least one dimension. Most problems were reported in the dimension ‘feeling worried, sad or unhappy’, where 64% reported severe or extreme problems. Mean EQ VAS score was 29.2. Feasibility was supported and construct validity indicated as some of the hypothesised correlations between the EQ-5D-Y-5 L and the Strengths and Difficulties Questionnaire were found, however, for ‘doing usual activities’ and ‘having pain or discomfort’ the correlations were weaker than hypothesised.ConclusionsThis is the first study where the newly developed EQ-5D-Y-5L instrument has been used in psychiatric inpatient care for youth. Participants reported problems in all severity levels in most of the EQ-5D-Y-5L dimensions; mean EQ VAS score was considerably low. Feasibility of the EQ-5D-Y-5L was supported, however other psychometric properties need to be further tested in a larger sample.

Characteristics of Adolescent Psychiatric Inpatients in Relation to Their History of Preceding Child Psychiatric Inpatient Care.

Among psychiatric inpatients aged 13 to 17, various familial and clinical characteristics were compared between those with and without a previous history of specialized child psychiatric care (CPSY versus non-CPSY). CPSY adolescents were younger (boys: odds ratio [OR], 0.7; girls: OR, 0.4) at admission to adolescent psychiatric inpatient care, and they more likely had mothers with psychiatric problems (boys: OR, 4.0; girls: OR, 4.8) and child welfare placement background (boys: OR, 2.8; girls: OR, 6.7) compared with non-CPSY adolescents. CPSY girls were also characterized as having unemployed mothers (OR, 3.1) and engaging in nonsuicidal self-injury (OR, 3.1), whereas CPSY boys were diagnosed with anxiety (OR, 2.7) or conduct disorder (OR, 2.8). Based on our study, family-focused care and intervention services are required to prevent continuity of psychiatric disorders from childhood into adolescence.

Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial

SummaryBackgroundIntensive community treatment to reduce dependency on adolescent psychiatric inpatient care is recommended in guidelines but has not been assessed in a randomised controlled trial in the UK. We designed a supported discharge service (SDS) provided by an intensive community treatment team and compared outcomes with usual care.MethodsEligible patients for this randomised controlled trial were younger than 18 years and had been admitted for psychiatric inpatient care in the South London and Maudsley NHS Foundation Trust. Patients were assigned 1:1 to either the SDS or to usual care by use of a computer-generated pseudorandom code with random permuted blocks of varying sizes. The primary outcome was number of inpatient bed-days, change in Strengths and Difficulties Questionnaire (SDQ) scores, and change in Children's Global Assessment Scale (CGAS) scores at 6 months, assessed by intention to treat. Cost-effectiveness was explored with acceptability curves based on CGAS scores and quality-adjusted life-years (QALYs) calculated from the three-level EuroQol measure of health-related quality of life (EQ-5D-3L), taking a health and social care perspective. This study is registered with the ISRCTN Registry, number ISRCTN82129964.FindingsHospital use at 6 months was significantly lower in the SDS group than in the usual care group (unadjusted median 34 IQR 17–63 vs 50 days, 19–125, p=0·04). The ratio of mean total inpatient days for usual care to SDS was 1·67 (95% CI 1·02–2·81, p=0·04), which decreased to 1·65 (0·99–2·77, p=0·057) when adjusted for differences in hospital use before randomisation. Scores for SDQ and CGAS did not differ between groups. The cost-effectiveness acceptability curve based on QALYs showed that the probability of SDS being cost-effective compared with usual care was around 60% with a willingness-to-pay threshold of £20 000–30 000 per QALY, and that based on CGAS showed at least 58% probability of SDS being cost-effective compared with usual care irrespective of willingness to pay. We recorded no adverse events attributable to SDS or usual care.InterpretationSDS provided by an intensive community treatment team reduced bed usage at 6 months' follow-up but had no effect on functional status and symptoms of mental health disorders compared with usual care. The possibility of preventing admissions, particularly through features such as reduced self-harm and improved reintegration into school, with intensive community treatment should be investigated in future studies.FundingSouth London and Maudsley NHS Trust.

Process of Building Patient-Nurse Relationships In Child And Adolescent Psychiatric Inpatient Care: A Grounded Theory Approach In Japan

Objective: The objective of the present study is to describe the process of building closer patient-nurse relationships in child and adolescent psychiatric inpatient care. Nurses play important roles in psychiatric inpatient care for children and adolescents, and their care can affect every facet of their daily life. The efficacy of treatment depends on the nurses’ ability to build intimate patientnurse relationships. Methods: A qualitative methodology, based on the tenets of grounded theory approach, was taken. Semi-structured in-depth interviews were conducted with 18 expert nurses and analyzed using a constant comparative method. Results: ‘Developing emotional attachment’ was identified as the core category, substantiated by four interrelated stages: ‘Becoming a target of attachment’; ‘Forming an attachment’; ‘Expanding the target of attachment’; and ‘Preparing to be a target of attachment’. We found that in developing emotional attachments with inpatient children or adolescents, expert nurses achieved a balance between appropriate psychological distance from - and their own increased attachment to - those inpatients. Conclusions: The “expert” nurses become a target of attachment for their patients and then successfully extend that to other nurses during professional nursing intervention.

P-174 – Prise en charge de l'enfant polytraumatisé en réanimation pédiatrique

Les tentatives de suicide (TS) de l’adolescent représentent une préoccupation importante de santé publique ayant conduit à de nombreux travaux scientifiques, mais peu auprès de jeunes adolescents. Nous avons étudié les caractéristiques épidémiologiques et le devenir psychique sur 1 an des adolescents ayant été admis dans un service d’urgences pédiatriques de Marseille pour une tentative de suicide, grâce à l’existence d’un réseau hôpital–ville en charge de l’organisation de leur suivi. Cinq cent dix-sept adolescents de moins de 15 ans et 3 mois ont été inclus dans l’étude entre octobre 2002 et décembre 2010. Quatre-vingt-six pour cent étaient des filles, moins d’⅓ vivaient chez leurs 2 parents et près de 27 % présentaient des difficultés importantes de scolarisation. Le procédé suicidaire faisait appel à une intoxication médicamenteuse (IM) pour 83,9 % d’entre eux. Quatre-vingt-dix pour cent d’entre eux ont pu être hospitalisés et bénéficier d’une évaluation pédopsychiatrique. Près d’¼ présentaient des éléments dépressifs. À leur sortie de l’hôpital et durant l’année ayant suivi, la prise en charge psychique était optimale pour 35 % et totalement absente pour 21,4 % d’entre eux. Quinze pour cent des adolescents ont fait au moins une récidive pendant l’année d’observation et 2 d’entre eux sont décédés. Ce taux est inférieur à ceux documentés dans les études réalisées auprès d’adolescents de moins de 18 ans. À l’instar de quelques auteurs, nous constatons que les procédures visant à coordonner les professionnels de santé et à améliorer l’accès au soin psychique des jeunes adolescents permettent de diminuer le risque de récidive.Adolescents who attempt suicide are a major concern. A growing body of literature seeks to explain this phenomenon and to identify its predictive factors, but relatively little information is available and children and adolescents under 15 years of age who present to general hospitals because of a suicide attempt. This study aimed to describe the demographic, social, medical, and psychological characteristics of a large sample of 517 French adolescents aged not more than 15 years 3 months. A second purpose was to measure observance of psychological care in a 1-year follow-up. Third, we aimed to document the reattempt rate during the follow-up in this population of young adolescents. Following the French official recommendations, a systematic 72-h hospitalization as well as a somatic, social, and psychological assessment was proposed to every suicide attempter after his or her admission to the emergency department. The adolescent was followed for 1 year after the suicide attempt, called the index episode. This follow-up was organized by two physicians, one of whom was not associated with the care of any of the patients. It consisted in seeking regular information as well as organization and/or optimization of the patient's psychological care, which was delivered in dedicated structures for adolescents, in outpatient care by a psychiatrist, or in an adolescent psychiatric inpatient care unit. In case of a repeated suicide attempt or persistence of alarming symptoms, this follow-up was prolonged for 1 more year. Patient data were compiled by experienced clinicians during initial assessment and alongside the 1-year follow-up through patient self-reports, but also through interviews with informants (family members, social professionals) and clinical sources (general practitioner, psychiatrist, etc.). The areas covered were the characteristics of the index episode, those of the population at the time of the index episode, as well as those of the 1-year follow-up including observance to the care and potential repetition of the suicide attempt. The mean age was 14 years with a minimum of 7 years 9 months. The vast majority of the population was female (86.1%), less than one-third lived with both parents, and 27% had academic problems. The most frequent means of suicide attempt was medication (83.9%), 92.6% of adolescents were hospitalized following the index episode, only 7.5% of them were admitted to adolescent psychiatric unit inpatient care following the initial care. Psychiatric evaluation was documented for 93.3% of the adolescents. Half (n = 222) had at least one symptom of a psychiatric disorder. One-year follow-up data were available for 394 adolescents: 40 had not yet completed the year and 83 were lost to follow-up. Among the analyzable population of 391 adolescents, 35.3% were optimally observant of the care proposed and 21.4% did not observe treatment. Fifty-nine youths (15%) were referred to the hospital because of a repeated suicide attempt. Two of the patients who repeated the suicide attempt within the year had died. The findings from this study are informative with regard to prevention and intervention efforts with suicidal young and very young adolescents. First, repetition of the suicide attempt in young adolescents is not rare since nearly 15% of the cohort were repeaters within the year following the index episode. Nevertheless, intensive care and follow-up resulting in good attendance appeared to have a positive impact on the repetition of the suicide attempt.

Effects of Ward Interventions on Repeated Critical Incidents in Child and Adolescent Psychiatric Inpatient Care

Effects of Ward Interventions on Repeated Critical Incidents in Child and Adolescent Psychiatric Inpatient Care. The aim of this study was to evaluate the effects of several ward interventions (transition to an open ward concept, individualized treatment plans, tiered crisis-management, staff training, quality control) on repeated critical incidents, non-restrictive and restrictive measures. The outcome variables were compared in two time periods, 2007 and 2011. The study included 74 critical incident reports of 51 child and adolescent inpatients that had at least one hospital stay and one critical incident in the selected time periods. Aggressive, self-harming, and absconding incidents were included. The quantitative results suggest that ward interventions can contribute to a reduction of repeated critical incidents and restrictive measures. The qualitative evaluation suggests a cultural change of crisis management.

Relational stressors as predictors for repeat aggressive and self-harming incidents in child and adolescent psychiatric inpatient settings

This study examined whether relational stressors such as psychosocial stressors, the therapist's absence and a change of therapist are associated with repeat aggressive or self-harming incidents in child and adolescent psychiatric inpatient care. The study data were derived from critical incident reports and chart reviews of 107 inpatients. In multinomial regression analysis, patients with repeat aggressive or self-harming incidents were compared with patients with single incidents. Results suggested that a higher number of psychosocial stressors and a change of therapist, but not the therapist's absence are predictors for repeat aggressive and self-harming incidents. There was a high prevalence of therapist's absence during both, single and repeat, incidents. Repeat aggressive incidents were common in male children and adolescents with disruptive behavior disorders. Repeat self-harming incidents were common in adolescent females with trauma-related disorders. Patients with repeat aggressive or self-harming incidents had a higher number of abnormal intrafamilial relationships and acute life events than patients with single incidents. Interventions to reduce a change of therapist should in particular target children and adolescents with a higher number of psychosocial stressors and/or a known history of traumatic relational experiences. After a first incident, patients should have a psychosocial assessment to evaluate whether additional relational support is needed.

The Relation between Excellence and Experience with Regard to Child and Adolescent Psychiatric Inpatient Care

The Relation between Excellence and Experience with Regard to Child and Adolescent Psychiatric Inpatient Care

Tentatives de suicide : étude descriptive d’une cohorte de 517 adolescents de moins de 15 ans et 3 mois

Adolescents who attempt suicide are a major concern. A growing body of literature seeks to explain this phenomenon and to identify its predictive factors, but relatively little information is available and children and adolescents under 15 years of age who present to general hospitals because of a suicide attempt. This study aimed to describe the demographic, social, medical, and psychological characteristics of a large sample of 517 French adolescents aged not more than 15 years 3 months. A second purpose was to measure observance of psychological care in a 1-year follow-up. Third, we aimed to document the reattempt rate during the follow-up in this population of young adolescents. Following the French official recommendations, a systematic 72-h hospitalization as well as a somatic, social, and psychological assessment was proposed to every suicide attempter after his or her admission to the emergency department. The adolescent was followed for 1 year after the suicide attempt, called the index episode. This follow-up was organized by two physicians, one of whom was not associated with the care of any of the patients. It consisted in seeking regular information as well as organization and/or optimization of the patient's psychological care, which was delivered in dedicated structures for adolescents, in outpatient care by a psychiatrist, or in an adolescent psychiatric inpatient care unit. In case of a repeated suicide attempt or persistence of alarming symptoms, this follow-up was prolonged for 1 more year. Patient data were compiled by experienced clinicians during initial assessment and alongside the 1-year follow-up through patient self-reports, but also through interviews with informants (family members, social professionals) and clinical sources (general practitioner, psychiatrist, etc.). The areas covered were the characteristics of the index episode, those of the population at the time of the index episode, as well as those of the 1-year follow-up including observance to the care and potential repetition of the suicide attempt. The mean age was 14 years with a minimum of 7 years 9 months. The vast majority of the population was female (86.1%), less than one-third lived with both parents, and 27% had academic problems. The most frequent means of suicide attempt was medication (83.9%), 92.6% of adolescents were hospitalized following the index episode, only 7.5% of them were admitted to adolescent psychiatric unit inpatient care following the initial care. Psychiatric evaluation was documented for 93.3% of the adolescents. Half (n=222) had at least one symptom of a psychiatric disorder. One-year follow-up data were available for 394 adolescents: 40 had not yet completed the year and 83 were lost to follow-up. Among the analyzable population of 391 adolescents, 35.3% were optimally observant of the care proposed and 21.4% did not observe treatment. Fifty-nine youths (15%) were referred to the hospital because of a repeated suicide attempt. Two of the patients who repeated the suicide attempt within the year had died. The findings from this study are informative with regard to prevention and intervention efforts with suicidal young and very young adolescents. First, repetition of the suicide attempt in young adolescents is not rare since nearly 15% of the cohort were repeaters within the year following the index episode. Nevertheless, intensive care and follow-up resulting in good attendance appeared to have a positive impact on the repetition of the suicide attempt.

Why do girls freak out? Exploring female rage among adolescents admitted to adolescent forensic psychiatric inpatient care

Objective: To explore the characteristics of girls displaying frequent aggressive behaviors on an adolescent forensic psychiatric ward. Materials and methods: On an adolescent forensic ward, demographics, family, treatment, crime and victimization histories, diagnoses, and symptoms of all adolescents are collected in a cumulative database. Regarding these, girls displaying excessive aggressive behaviors were compared with other girls, all the boys, and boys displaying frequent aggressive behaviors. Their case histories were further qualitatively explored to find characteristics associated with female violence in the literature. Results: The studied girls were the most severely ill among adolescents admitted, and had suffered most the unfortunate backgrounds with parental mental disorders, poor parental management, early caregiver disruption, community disorganization, lack of social support, and being victims of sexual abuse. They displayed a wide range of psychiatric symptoms on different symptom dimensions. Conclusion: Treatment cannot focus solely on aggression management. Extensive psychiatric needs have to be met.

The ethical landscape of professional care in everyday practice as perceived by staff: A qualitative content analysis of ethical diaries written by staff in child and adolescent psychiatric in-patient care

BackgroundAlthough there has been some empirical research on ethics concerning the attitudes and approaches of staff in relation to adult patients, there is very little to be found on child and adolescent psychiatric care. In most cases researchers have defined which issues are important, for instance, coercive care. The aim of this study was to provide a qualitative description of situations and experiences that gave rise to ethical problems and considerations as reported by staff members on child and adolescent psychiatric wards, although they were not provided with a definition of the concept.MethodsThe study took place in six child and adolescent psychiatric wards in Sweden. All staff members involved with patients on these wards were invited to participate. The staff members were asked to keep an ethical diary over the course of one week, and data collection comprised the diaries handed in by 68 persons. Qualitative content analysis was used in order to analyse the diaries.ResultsIn the analysis three themes emerged; 1) good care 2) loyalty and 3) powerlessness. The theme ‘good care’ contains statements about the ideal of commitment but also about problems living up to the ideal. Staff members emphasized the importance of involving patients and parents in the care, but also of the need for professional distance. Participants seldom perceived decisions about coercive measures as problematic, in contrast to those about pressure and restrictions, especially in the case of patients admitted for voluntary care. The theme ‘loyalty’ contains statements in which staff members perceived contradictory expectations from different interested parties, mainly parents but also their supervisor, doctors, colleagues and the social services. The theme ‘powerlessness’ contains statements about situations that create frustration, in which freedom of action is perceived as limited and can concern inadequacy in relation to patients and violations in the workplace.ConclusionsThe ethical considerations described by child and adolescent psychiatric care staff are multifaceted and remarkably often concern problems of loyalty and organization. These problems frequently had a considerable influence on the care provided. It seems that staff members lack a language of ethics and require both an ethical education and a forum for discussion of ethical issues.

The use of coercive measures in adolescent psychiatric inpatient treatment: a nation-wide register study

To evaluate the extent and trends in the use of seclusion/restraint in psychiatric inpatient treatment of adolescents aged 12-17 years in Finland. The National Hospital Discharge Register data comprising all psychiatric inpatient treatment periods of 12- to 17 year-olds in Finland during the period 1996-2003 was used. Time trends, regional variation and patient characteristics related to the risk of being subjected to seclusion/restraint in psychiatric inpatient treatment are reported. The average prevalence of use of seclusion and restraint was 1.71/10,000/year over the study period. Use of seclusion/restraint in adolescent psychiatric inpatient care first increased, peaking in 1999-2001, and then decreased. The decrease occurred after stricter legislative control of use of seclusion/restraint was introduced in 2002, despite that involuntary treatment periods did not decrease. Considerable regional variation was seen in the use of seclusion/restraint. A greater proportion of girls than boys were secluded/restrained. Seclusion/restraint was most common in schizophrenia, mood disorders and conduct disorder. Legislative control had the desired immediate impact on the use of seclusion/restraint in adolescent psychiatric inpatient care. Legislative control is, however, not strong enough to ensure homogenous practices across the country, as there is many-fold regional variation in figures for using seclusion and restraint.

'Living in an alternative reality': adolescents' experiences of psychiatric inpatient care.

To date minimal research has investigated adolescent psychiatric inpatient care from a service-user perspective. Semi-structured interviews were conducted with 10 adolescents with experience of psychiatric inpatient care. Interviews were analysed using the grounded theory method (Glaser & Strauss, 1967). A core category, 'Living in an Alternative Reality', reflected the unusual nature of the hospitalisation experience. Adolescents reported feelings of restriction and disconnection and used various relational and practical strategies to cope with hospitalisation. Results suggest that psychiatric hospitalisation can cause strong affective reactions in adolescents, and may affect psychological constructs such as identity and self-esteem.

Involuntary commitment and detainment in adolescent psychiatric inpatient care

To evaluate whether adolescents committed to psychiatric inpatient care are the most disturbed, and whether psychosocial factors other than psychiatric symptoms are associated with commitment to and detainment in psychiatric care among adolescents. The case histories of 187 13- to 17-year-old adolescents consecutively admitted to the study clinic were scrutinized with the help of a structured data collection form. Psychiatric, demographic and family-related characteristics of those referred involuntarily (n = 93) and voluntarily (n = 94), and those detained involuntarily (n = 42) and treated on a voluntary basis (n = 145) were compared. Involuntary referral and involuntary detainment were associated with psychotic symptoms, temper tantrums and breaking property, involuntary referral also with violent and hostile behaviours and suicidal ideation and talk. They were not associated to family adversities, previous treatment history or sociodemographic factors. The risk for being committed when presenting with aggressive behaviours was greater in girls. Involuntary referral and detainment in adolescents is associated with symptom severity, and not with aspects of the adolescent's living conditions. This is in agreement with the legislation. Gender bias resulting in girls' greater risk of being involuntarily committed if displaying aggressive behaviours may be an ethical and legal problem.