Adolescent Ward Research Articles

Registration of aggressive incidents in an adolescent forensic psychiatric unit and implications for further practice

Although aggression is part of daily life in psychiatric units for adolescents, empirical data on its prevalence are sparse. Only few studies have described prevalence of aggressive incidents in adolescent psychiatric wards, and data in forensic psychiatric care are even more limited. Available studies reported high prevalence rates of aggression, ranging from 0.4 to 2.4 incidents of aggression per day across (forensic) child and adolescent psychiatric units. Between 27 and 78 % of all admitted youth committed an aggressive act. In this study, we collected systematically registered data of all aggressive incidents from the first 2 years (2010-2012) on a newly established forensic adolescent psychiatric unit, which used a formal aggression management program embedded in the social competence model, which is based on early intervention in the 'chain of behavior' to prevent any further escalation. The inclusion of also minor aggressive incidents is unique in the literature and the clinical relevance is highlighted. A mean of one incident a day took place, with each adolescent involved in at least one incident. Notably, 1.7 aggressive incidents per month made seclusion of restraint use necessary. Based on the social competence theory, the aggression management model suggests intervening early in the cascade of aggression, in order to prevent further escalation and reduce the need for intrusive interventions. Evidence supported that aggression is a contextual event, as external factors clearly influence the incidence of aggression. Aggression management should be built on both relational and structural security.

Neonatal Intensive Care and Child Psychiatry Inpatient Care: Do Different Working Conditions Influence Stress Levels?

Introduction. Nurses often experience work-related stress. High stress can negatively affect job satisfaction and lead to emotional exhaustion with risk of burnout. Aim. To analyse possible differences in biological stress markers, psychosocial working conditions, health, and well-being between nurses working in two different departments. Methods. Stress was evaluated in nurses working in a neonatal intensive care unit (NICU) (n = 33) and nurses working in a child and adolescent psychiatry inpatient ward (CAP) (n = 14) using salivary cortisol and HbA1c. Salivary cortisol was measured three times a day on two consecutive days during two one-week periods, seven weeks apart (= 12 samples/person). Psychosocial working conditions, health, and well-being were measured once. Results. NICU nurses had better social support and more self-determination. CAP nurses had a lower salivary cortisol quotient, poorer general health, and higher client-related burnout scores. Conclusion. When comparing these nurses with existing norm data for Sweden, as a group their scores reflect less work-related stress than Swedes overall. However, the comparison between NICU and CAP nurses indicates a less healthy work situation for CAP nurses. Relevance to Clinical Practice. Healthcare managers need to acknowledge the less healthy work situation CAP nurses experience in order to provide optimal support and promote good health.

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.

Assessing the Educational Needs of Mental Health Nurses Working in an Adolescent Inpatient Psychiatric Ward in Japan

In Japan, preregistration education is not sufficient to prepare nurses to work as child adolescent mental health nurses. Nominal group technique (NGT) using focus group discussions, and Knowles' Adult Learning Theory, were used to examine the continuing educational needs of nurses in a Japanese adolescent mental health unit. Nurses caring for adolescent patients with mental health issues need continuing education. This research demonstrates the utility of nominal group technique in needs analysis in this context. Educational priorities include instruction on patients' developmental stage, promoting patient self-sufficiency, and strategies for meeting the needs of families. A family-centered care approach is recommended.

149. Who Uses an Adolescent Ward? Trends in Subspecialty Admissions to a General Adolescent Inpatient Unit in a Tertiary Children's Hospital

Advocates of adolescent health have long argued for the development of dedicated inpatient units. In Australia, adolescent wards have been established in all but one of the major children's hospitals and will be a feature of all three new children's hospitals currently being built (in Melbourne, Brisbane and Perth). Despite growing interest in the development of adolescent inpatient facilities, and evidence they improve quality, there is little in the published literature describing the case-mix of those admitted to an adolescent ward.

‘Le moment de la lune’. An auto-ethnographic tale of practice about menarche in a children’s hospital

Auto-ethnographic accounts can highlight unsaid moments of professional practice. In this case, my auto-ethnographic tale 'Le moment de la lune' re-inscribes subjugated knowledge about menstruation and occupational therapy practice in the era before adolescent wards. This fictional tale is written in direct dialogue with an article that was published in this journal at a particular point in my own career as an occupational therapist. In the tale I am 'writing in' what was not written about in my article and in occupational therapy generally. This 'writing-in'/re-inscribing is the research method. My previous article 'Normal spaces' published in this journal in 1985, was organised around principles and generalities of youth-specific practice. The original article had little locating the personal or evoking the body and a heavy reliance on the literature. Issues of gender and culture were largely absent, or, perhaps, 'written out'. The corresponding tale of embodied sexuality, 'Le moment de la lune', articulates something of local complex practice and the particularity of individual therapeutic work to do with menstruation in self-care. Points of tension in 'Normal spaces' are elaborated and I explain how 'Le moment de la lune' problematises supporting menarche in a children's hospital. Now practice has moved on with dedicated adolescent wards in all major children's hospitals. Nevertheless, occupational therapy practice around issues of menstrual self-management is still under-documented. Writing about unspoken moments of practice can have ethical implications for expanding the ways occupational therapy practice can be written and understood.

Trends in prescribing of psychotropic medications for inpatient adolescents in Israel: A 10 years retrospective analysis

We examined the trends in prescribing psychotropic drugs to children and adolescents within an inpatients adolescent psychiatric ward in Israel. Data of 414 subjects, ranging from 12- to 22-year-old, covering the years 1997, 2002 and 2007, was examined retrospectively. Analyzed variables included the number and type of drug prescriptions per patient at discharge, the subjects’ age at discharge and the number of diagnoses per patient at discharge. Analysis of variance (ANOVA) with repeated measures was used to evaluate changes between the three calendar years, along the 10-year study period, while Pearson χ 2 test was performed for categorical variables. Over the study period the mean age at discharge decreased significantly, by about a year and a half, the mean number of diagnoses increased significantly, from 1.6 to 2.4 diagnoses per patient and the total number of drugs prescribed at discharge increased significantly from 1.48 to 1.93 per patient. Overall, the number of patients who were prescribed mood stabilizers increased by 14%, those who were prescribed antidepressants increased by almost 24%, almost 16% in antipsychotics prescriptions and 51.5% in prescriptions of atypical antipsychotics. Typical antipsychotic prescriptions decreased by 35.5% and accordingly, the number of patients who were prescribed agents for the treatment of extra-pyramidal side effects decreased by almost 24%. Due to a low number of inpatients with attention deficit and hyperactivity disorder (ADHD), no significant statistical conclusion could be drawn regarding trends in psychostimulant prescriptions. Our findings agree with other published studies from the last two decades. The growing use of psychotropic agents in children and adolescents merit a continuous concern with regard to their effects on the developing brain and impact on quality of life and to authorizing these drugs for use in specific young age subgroups.

The Power Of Human-To-Human Contact

The Power Of Human-To-Human Contact Viesia Novosielski When I was twelve, I appreciated my need to be locked up. I was aware of the threat I posed to myself. I accepted that a certain amount of my autonomy needed to be sacrificed in the interest of my own safety. I felt safe in the hospital but that safety came with a price. In 1990–1991 I was hospitalized for a year and a half, first on the children’s unit of a private hospital and then the adolescent ward of a state hospital for children. In this article I address those who work to help people with psychological conditions and try to show what helps, and doesn’t help. The cost of safety was that the hospital dehumanized both staff and patients. This ran counter to their efforts to help children because help cannot be dehumanizing. You are trying to help human beings, not pathologies. One way that the hospital dehumanized children was that clinical attitudes, protocols and language facilitated an us-versus-them divide between hospitalized children and the staff. This made the staff who worked with us on a day-to-day basis seem amorphous and interchangeable. They had power and authority, we didn’t. Their point of view had validity, ours didn’t. Usually we interacted with them and reacted towards them as if their individuality had been submerged into their role as staff. Reflecting back on my hospitalization I realized that you can’t dehumanize someone else without dehumanizing yourself. And mutual dehumanization was the unfortunate modus operandi in the hospital. Some staff persons tempered their professional roles with human warmth that was more compassionate for the both of us. I was always happy when a staff person didn’t treat me as a walking pathology seething with weird symptoms and bizarre behavioral patterns. It was a pleasure when they treated me as a human and I got to treat them like they were human in return. I treasured those occasions when our encounters and communications transcended our roles and we related to each other as people aware of our shared humanity. [End Page 23] Two examples of the dehumanizing effect of clinical attitudes, protocols and language were apology reports and contracts for safety. My first experience with an apology report was when I was upset by a staff woman’s insensitive way of supervising my shower, staring at me straight on, hands on her hips. When I called her insensitive I was forced to write her an apology report that stated who I was apologizing to and why. The staff didn’t ever have to apologize, unless they wanted to. Contracting for safety meant not only did the kids have to promise not to hurt themselves or others, but since the contract for safety matched the circumstances under which the kids were restrained, the kids had to promise not to engage in such an objectionable way for a certain amount of time or get put into a “safety coat” (a straight jacket). If you had sworn and verbally abused staff, you had to promise not to swear and verbally abuse staff for half an hour. If you were physically restrained, as I once was, because I had tried to comfort and calm myself by doing yoga, you had to promise not to upset staff by contorting your body in strange ways for 30 minutes to avoid the safety coat. If you broke the contract for safety you were immediately put into a safety coat. To successfully contract for safety it was necessary to calm down or at least be very convincing about pretending to be calm. Most contracts for safety weren’t successful. Many times kids downright refused to contract for safety. Help can’t be dehumanizing, yet a small amount of dehumanization (with restraints) is necessary, as a last resort, to keep us safe. The use of restraints can be justified by the rationale that they are sometimes necessary to keep kids from hurting themselves or others. Unfortunately, sometimes the hospital put us in restraints for no valid reason, instead of out of the necessity of keeping us safe. For physical and...

Lystarstol 1983-2008 - innlagnir, sjúkdómsmynd og lifun

Information is scarce concerning the incidence of anorexia nervosa (AN) in psychiatric facilities in Iceland. The aim of this study was to describe the incidence of admissions, comorbidity and mortality of patients who were admitted to psychiatric units in Iceland, diagnosed with AN in 1983-2008. The study is retrospective. 140 medical records with an AN or atypical eating disorder diagnosis according to the ICD-9 and ICD-10 were reviewed. Final sample was 84 patients with confirmed AN diagnosis. Five men and 79 women were admitted to a psychiatric inpatient ward for the first time diagnosed with AN. Average age was 18.7 years. Incidence of admissions for both sexes in the first part of the study period (1983-1995) was 1.43/100.000 persons/year, 11-46 years old, but in the second part (1996-2008) 2.91. The increase was statistically significant (RR=2.03 95% CI 1.28-3.22) and can mainly be explained by an increased incidence of admissions to the children- and adolescent psychiatric wards (CAW). Mortality of women was 2/79 (2.5%) and standard mortality rate 6.25. The average length of stay was 97 days, 67.3 days in adult units and 129.7 days in CAW (p<0.05). In the study period 51 patients (60.7%) were only admitted once. One patient had compulsory admission on his first admission but ten (11.9%) had at some point compulsory admission. The body mass index increased in average from admission to discharge from 15.3 to 17.5 kg/m2. A correlation was found between self harm and suicide attempts and compulsory admissions. The study revealed an increased incidence between periods. This might reflect a real increase of AN in the society. Mortality rate was lower than expected.

How adolescent patients use ward space

This paper is a report of a study of the use of ward space in a purpose-built adolescent ward and the influence of that space on both adolescent patients and nurses. A separate ward environment gives adolescent patients opportunities to be with peers, have privacy and independence and be nursed away from younger children. The aim of adolescent wards is to cater for these differences and to set routines around this age group. Data were collected between 2002 and 2003 by participant observation and interview. In total 35 observations were undertaken of both adolescents and nursing staff, with associated interviews. A further 17 semi-structured individual nurse and 11 adolescent interviews were conducted, aimed at exploring the use of ward space. Patient demographics, ward policies and patient information sheets were also used. Adolescent patients created their own spaces on the ward from personal effects that were of interest to them. These spaces show nurses who they are. Adolescent patients want to be identified as more than 'just' a patient when they are in hospital. What the creation of these spaces does is assist the adolescent patient in escaping the homogeneity of the ward by cutting across its activities. By understanding patients through their self-created spaces, nurses can improve the capacity of adolescents to contribute to their own care, whilst enhancing their care experiences through understanding and collaboration.

The Reliability and Validity of Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and Life-time Version - Persian Version.

The validity and reliability of a Persian version of the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL-P) was evaluated. The K-SADS-PL-P was administered to 102 inpatients (mean age = 15.3 yrs, SD = 1.81) in a child and adolescent psychiatric ward. The psychometric properties were evaluated in comparison to the results of clinical diagnosis. The K-SADS-PL-P showed good-to-excellent concurrent validity in diagnosing current major disorders. Test-retest reliabilities of most of the current diagnoses were also good to excellent. The Persian version of the K-SADS-PL provides reliable and valid youth psychiatric diagnoses.

Confidentiality, consent and privacy: a challenge even in a specialist young person unit

Background Confidentiality, consent and an age-appropriate environment are important in a young people9s unit and are the cornerstones of major health policy documents such as the National Service Framework1 and You9re Welcome2. Methods Two written questionnaires on a broad range of issues were completed by 49 young people (n=24 comparing to NSF standards, n=25 comparing to You9re Welcome Criteria) on a general adolescent ward in a teaching hospital providing secondary, tertiary and quaternary medical and surgical services. Results If not offered the chance a consultation alone, would you have liked the chance to see a doctor alone: Yes 47%, No 53% (n=15). Conclusion Overall patient satisfaction ratings of 92% demonstrate excellent general care of young people who reported the ward to be young person friendly. Despite positive general feedback, improvements in explanation of confidentiality, consent and privacy are needed. Patients on our adolescent unit are under the care of multiple medical and surgical teams, both adult and paediatric. Rapid turnover of doctors and teams without adolescent-specific training add further challenges in providing an appropriate service. Training is essential to provide doctors with the skills, knowledge and understanding to engage with young people and ensure that they feel they are listened to, in a safe and private environment.

Does Aggressive Refeeding in Hospitalized Adolescents With Anorexia Nervosa Result in Increased Hypophosphatemia?

Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group. A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary children's hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded. The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007). These data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.

Adolescence in the Atlantic: Charity Boys as Seamen in the Spanish Maritime World

AbstractThis article examines life at a maritime orphanage and at sea for wards of the Royal School of San Telmo in Seville, which operated between 1681 and 1847. At its heart is a microhistorical analysis of Francisco de Cáceres Martínez, a ward whose life is traced from the time he entered the orphanage as a twelve-year-old in 1788 until he became an assistant pilot in 1802. This examination of the lives of Cáceres and other adolescent wards of the San Telmo orphanage sheds light on the experiences of young sailors and charity wards dispatched to sea, both of which were common in early modern maritime fleets but about whom details are often scarce. It also shows connections between their lives on land and at sea. The case of Cáceres and other San Telmo wards illuminates interactions among these youths, orphanage administrators, and Spanish naval officials, especially in the late eighteenth century. These interactions reveal that the same society and culture that tapped orphaned boys to meet Spanish maritime demands also afforded a measure of maneuverability to at least some of them, as wards used the language and institutions of a patriarchal system to navigate the eighteenth-century maritime world.

Adolescent and young adult health in a children's hospital: Everybody's business

To guide the development of adolescent health training and the planning of future services, accurate data describing health service use by adolescents and young adults are needed. To describe admission rates for adolescents (12-17 years) and young adults (age 18 years and over) attending a specialist children's hospital over an 8-year period. Specific objectives were to describe the (i) proportion of adolescents and young adults admitted under different specialties; (ii) age range, with emphasis on those 18 years and over; and (iii) proportion of patients admitted to the general adolescent ward. Data on adolescent and young adult admissions to Princess Margaret Hospital (PMH) were collected prospectively from July 2000 to June 2008. Adolescents and young adults accounted for one fifth (range 18-22%) of all admissions to PMH. Over the 8-year period, the number of adolescent and young adult admissions increased from 3935 (54% males) to 4967 (56% males) per year. The proportion admitted to the general adolescent ward ranged from 22% to 36%. The three specialties admitting the most adolescents and young adults were General Surgery (11-13%), Orthopaedics (11-13%) and Oncology/Haematology (10-14%). The age range was: 12-14 years (57-67%); 15-17 (30-39%); 18+ (2-5%). At least 15 patients aged 20 or over were admitted each year, mostly for Dental or Plastic Surgery. Adolescent and young adult health is part of the core business of paediatrics. This should be reflected in the planning of future paediatric services. All trainees require some basic training, regardless of heir specialty area.

Commentary on Hutton A (2008) An adolescent ward; ‘in name only ’Journal of Clinical Nursing 17, 3142–3149

Commentary on Hutton A (2008) An adolescent ward; ‘in name only ’<i>Journal of Clinical Nursing</i> 17, 3142–3149

An adolescent ward; ‘in name only?’

The aim of the study was to explore how an adolescent ward was used by the two main users, nurses and adolescents, on a purpose-built adolescent ward. In Australia, caring for the adolescent is part of paediatric nursing and many Australian hospitals boast of 'adolescent-only facilities'. These wards are established on the premise that adolescent patients are a 'special' group deserving their own ward space. With the development of adolescent wards, set ideals around what this type of environment provides have also arisen. These ideals are increased privacy and independence for the patient, a chance for peer interaction, to be nursed by specially trained staff and to provide opportunities for adolescent patients to participate in their own care. This study used ethnography to gain a perspective of how ward space was used. Data were collected using participant observation and formal and informal interviews. Data were then analysed using the works of Lefebvre and Foucault. This study found that patient allocation, nursing observation and patient labels impact on how adolescent patients are nursed. Patients are expected to fit in, accepting all ministrations of nursing and staff. On this ward, nursing work was paramount. Nurses treated the adolescent patient like any other. In saying this, the adolescent patient still found ways to adapt to the ward space and its rules and routines; so in this sense, the ward still worked for them, even if nursing work was paramount. This study contributes to current discourse on the formation of specialized facilities in general, as it shows that no matter how a ward space is set up, if the space is not used in that way, then the purported purpose of that ward space will be lost.

Psychotropic medication use in the child and adolescent psychiatry wards of a French hospital

The aim of this study was to investigate the use of psychotropic medication in children and adolescents hospitalised in a psychiatric ward. A prospective analysis of psychotropic drug prescriptions was conducted for all patients hospitalised in two acute psychiatric hospitalisation units of a paediatric teaching hospital in Paris, France. The study group consisted of 187 patients and was characterised in terms of age, sex, prior psychiatric hospitalisation and DSM-IV-Tr diagnosis. All prescriptions were assessed for off-label use. Overall, 46% of patients received at least one dose of psychotropic medication. Antipsychotic drugs were the most frequently prescribed drugs (44%), regardless of diagnosis. Ninety percent of patients who received antipsychotic drugs did not have psychosis. We found that 69% of the 421 prescriptions written were for off-label uses. The percentage distribution of off-label prescriptions by medication class was as follows: antipsychotic drugs, 90%; anxiolytics, 28%; stimulants, 26%; antidepressants, 89%; antiepileptic drugs, 89% and antiparkinsonian drugs, 91%. The extensive use of drugs for off-label indications in children and adolescents suggests that prospective post-marketing studies should be carried out to evaluate efficacy and safety.

Better care on adolescent wards

Better care on adolescent wards