Child Psychiatric Inpatient Unit Research Articles

Managing Type 1 Diabetes in an Inpatient Child Psychiatric Care Setting.

Individuals with diabetes are at increased risk for psychological, behavioral, and social problems. Comorbid mental illness and diabetes present a unique set of challenges for people with diabetes and their health care providers, particularly in an inpatient setting. Psychiatric symptoms before admission may affect type 1 diabetes management, and mental status and behavior can affect individuals' ability to cooperate with treatment while they are inpatients. This article describes a clinical protocol to manage type 1 diabetes and maximize patient safety in an acute inpatient child psychiatric unit.

Uncovering the Mental World of Children: Attachment Quality, Mental State Talk, and Children’s Drawings

ABSTRACT The present study utilized archival data to uncover trends associated with children’s drawings, attachment quality, and mental state talk (MST). Two samples of 5–12-year-old children and their caregivers were recruited: one child sample from a public elementary school (n = 54), and the other from consecutive admissions to a child psychiatric inpatient unit (n = 45). Children completed drawings of family, primary caregiver, and self. Drawings were coded using the Formal Elements (FE) and Content rating scales designed to identify selective content and organizational qualities. Attachment quality and MST were obtained using the Attachment Story Completion Task and Children’s Apperception Test. Consistent with the first hypothesis, attachment quality demonstrated a marginally significant positive relationship with Content scores of inpatient children’s family drawings. Consistent with the second hypothesis, attachment quality demonstrated a significant positive relationship with MST in both samples. Consistent with the third hypothesis, MST demonstrated a significant positive relationship with Content scores of nonpatient children’s caregiver drawings, FE scores of nonpatient children’s family drawings, and both Content and FE scores of inpatient children’s family drawings. Drawings hold promise as tools to access children’s internal working models and mental states. Clinical implications are discussed.

Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study

BackgroundThere has been a global effort to reduce the use of restrictive interventions (RIs) in healthcare settings. In order to reduce unnecessary RIs, it is essential to understand their use in mental health settings. To date, there have been few studies examining the use of RIs in child and adolescent mental health settings, with no such studies in Ireland.AimsThe purpose of this study is to examine the prevalence and frequency of physical restraints and seclusion and to identify any associated demographic and clinical characteristics.MethodsThis is a 4-year retrospective study of the use of seclusion and physical restraint in an Irish child and adolescent psychiatric inpatient unit from 2018 to 2021. Computer-based data collection sheets and patient records were retrospectively reviewed. Eating disorder and non-eating disorder samples were analysed.ResultsOf 499 hospital admissions from 2018 to 2021, 6% (n = 29) had at least one episode of seclusion and 18% (n = 88) had at least one episode of physical restraint. Age, gender and ethnicity were not significantly associated with rates of RI. Unemployment, prior hospitalization, involuntary legal status and longer length of stay were significantly associated with higher rates of RIs in the non-eating disorder group. Involuntary legal status was associated with higher rates of physical restraint in the eating disorder group. Patients with a diagnosis of eating disorder and psychosis had the highest prevalence of physical restraints and seclusions respectively.ConclusionsIdentifying youth who are at greater risk of requiring RIs may allow early and targeted intervention and prevention.

Factors Associated with Readmissions to a Child Psychiatric Inpatient Unit

ABSTRACT Readmission of youth to psychiatric inpatient care has several negative consequences, including increased risk of suicide and need for more frequent hospitalizations, disruption of education, and high cost of care for families as well as hospitals. Previously identified factors predicting readmission to psychiatric inpatient care for youth have included a wide variety of clinical diagnoses, indicating inconsistency in the association between diagnoses and risk of readmission. Instead, the current study focuses on behavioral definitions derived from chief complaints for psychiatric inpatient readmissions. The present study explores the relationship between chief complaint and readmission for patients ages 5–12 who were readmitted within 30 days post-discharge and over 30 days post-discharge from an inpatient psychiatric unit. Results demonstrated that when compared to patients without aggression as their identified chief complaint, patients whose chief complaint was identified as aggression-only and aggression-plus-other-factors were more likely to be readmitted within 30 days post-discharge and to have significantly more 30-day readmissions. Additionally, compared to patients without SI as their identified chief complaint, patients with SI-only as their identified chief complaint were found to be less likely to be readmitted within 30 days and have significantly fewer 30-day readmissions. These results suggest that physical aggression is a unique factor that may increase the risk of readmission for patients 5–12 years old. The results may be particularly useful in identifying crucial treatment components when establishing standards of care for inpatient psychiatric units, though further investigation is needed.

1.66 Rates of Self-Reported Childhood Trauma in Youth Who Are Psychiatrically Hospitalized: Comparisons to a Population-Based Representative Community Sample

Youth who are psychiatrically admitted often underreport traumatic experiences during clinical interviews. To guide trauma-informed care (TIC) on a child and adolescent psychiatric inpatient unit, rates of self-reported trauma were compared to a community sample. We hypothesized that psychiatrically admitted youth will report higher rates of childhood emotional, physical, and sexual abuse than youth from a matched community sample, including those with clinically significant psychiatric symptoms.

Reducing seclusion use in an Australian child and adolescent psychiatric inpatient unit

BackgroundIn inpatient psychiatric units, seclusion (isolation in a locked room) is recommended only as a last resort for serious aggression or agitation. In response to an increase in seclusion during 2015, an 8-bed child and adolescent inpatient unit implemented a suite of multidisciplinary interventions. This study examines changes in seclusion rates following intervention implementation and assesses whether specific patient factors were associated with seclusion rates before and after interventions. MethodMulti-modal interventions, comprised of patient treatment plans, intake and handover meetings, staff supervision and debriefing sessions, were implemented from January 2016. We compared quarterly seclusion rates (episodes per 1000 patient days) across a thirteen-year period, from July 2008 to June 2021. Change in seclusion rates following intervention was evaluated using a segmented regression analysis. We examined whether patient factors were associated with seclusion rates, and whether the duration of seclusion episodes differed before and after interventions. ResultsThere was a 100% reduction in seclusion rates in the 6 months following intervention implementation, from 28.4 episodes per 1000 patient days in July–September 2015, to 4.7 episodes in January–March 2016, reaching 0.0 episodes by April–June 2016. This reduction was maintained until April–June 2021. Most patients with seclusion events before and after intervention implementation had a neurodevelopmental disorder diagnosis and a minority of patients accounted for most seclusion events. There was a 65% reduction in the average duration of seclusion episodes following interventions, however this was not statistically significant. LimitationsDue to a crisis in staff morale, interventions were implemented simultaneously, preventing an understanding of whether a single intervention accounted for change. While not addressed in the current study, assessing perceptions of staff, children and parents following intervention implementation may have elucidated barriers and facilitators to change. ConclusionsMultidisciplinary, patient-centered interventions may be effective for long-term reduction of seclusion rates in inpatient psychiatric units. These findings highlight patient factors associated with seclusion reduction which should be considered when implementing interventions.

What Do We Do When Things Fall Apart? Rapid Creation of a Pilot Psychiatric Intensive Care Unit in Response to Increased Acuity on a Psychiatric Inpatient Unit for Children and Adolescents

ABSTRACT The past two decades have seen a sharp increase in suicide and psychiatric hospitalizations for children and adolescents. While many youth are served well in the inpatient psychiatry setting, a subset of this population does not stabilize during an average length of stay and with the typical therapeutic interventions provided by an inpatient unit. This study examines the creation of a psychiatric Intensive Care Unit (ICU) for patients who exhibited the most severe and acute mental illness, self-injury, and aggressive behaviors on a child and adolescent psychiatric inpatient unit. The ICU was created in response to increasing numbers of restraints, assaults, and patient and staff injuries in the months preceding creation of the program and potential contagion effect of safety issues amongst patients. Post-implementation, nominal reductions in safety metrics were found in both the ICU and general milieus for patient and staff injuries and assaults. Nominal decreases in restraints and self-injury were also found in the ICU. Significant decreases in property destruction were found in both milieus and restraints significantly decreased in the general milieu. In addition, patients who participated in the ICU milieu were less likely to be re-admitted to an inpatient psychiatric unit following hospitalization. Overall, the ICU was well-received by staff and patients’ caregivers.

The experience of parents faced with the admission of their adolescent to a child and adolescent psychiatric inpatient unit. A qualitative study with focus groups

The admission of an adolescent to a child and adolescent psychiatric inpatient unit has a serious impact on the entire family unit. The emotional experience of those primary caregivers has been scarcely studied qualitatively despite being recommended by previous research. This study aims to examine the experience of parents of adolescents with mental health needs that required psychiatric hospitalization in a child and adolescent unit. Qualitative cross-sectional research was carried out under the recommendations of Grounded Theory with three Focus Groups of parents (N = 22) of adolescents who required psychiatric hospitalization in a child and adolescent ward. The COREQ quality criteria were applied. The parental experience implies a high level of emotional suffering modulated by feelings of guilt, stigma, parental awareness of their child’s illness and the passage of time. The use of Prochaska’s and Diclemente’s trans-theoretical model of health behavior change is useful in understanding the parental experience.

Debate: Inpatient units must enhance the system of care.

Child or adolescent psychiatric inpatient units are expensive; therefore, a lot is expected of them. Short stay units are best used for diagnostic clarification, the initiation and supervision of complex treatment, and acute containment of risk. Longer stay units provide a recovery-focused programme to address mental health problems that have not responded to intensive treatment in other settings. Both types of unit form part of the wider system of care that supports young people with mental health problems. The operational characteristics of such units will ensure timely, safe and effective interventions to young people who will likely go on to receive most of their clinical care in the community.

The Impact of a New On-site Inpatient Psychiatric Unit in an Urban Pediatric Emergency Department.

The objective of this study was to describe the impact of opening an inpatient child psychiatric unit in an urban tertiary care pediatric emergency department (PED). A retrospective chart review was performed of pediatric patients seen in the PED at a large tertiary care center who presented for a primary psychiatric concern before opening of the inpatient psychiatric unit within the same hospital and 6 months following, allowing for a 6-month adjustment period. Patients were identified via query of the ED Cube model, an institutional database by a "behavioral health" flag that is documented in triage. Patients were excluded if subsequent chart review did not reveal a psychiatric concern and the patient did not undergo psychiatric evaluation during the PED visit. Charts were reviewed for baseline patient demographics, psychiatric interventions performed, and disposition. Additional flow metrics obtained were PED volume, percentage of psychiatric visits, and length of stay for both psychiatric-related visits compared with the general population. Visits to the PED for psychiatric evaluation increased 135% from 91 to 226 after initiation of an inpatient psychiatric unit. There was no difference in baseline patient demographics or rate of medical/mechanical restraints used. Percentage of behavioral health patients admitted to medical units decreased, although overall admission rate remained stable. Length of stay for behavioral health patients was longer after opening of the unit and remained significantly higher than the general population before opening of the inpatient unit, 363 minutes versus 177 minutes, respectively, and further lengthened after to 418 minutes versus 188 minutes. Patients presenting for psychiatric evaluation are a significant burden to PED flow both in volume and time for evaluation and boarding. This is to the detriment of patients seeking appropriate mental health services and to the rest of patients in the PED. Both inpatient and outpatient psychiatric services are overwhelmed creating a downstream affect; limited resources delays disposition and increases boarding in the PED. Further resources are needed to appropriately address psychiatric concerns, such as dedicated psychiatric holding units and brief PED interventions targeted to safety planning and interventions.

Child psychiatry: a model for specific goals for in-patient treatment linked to resources and limitations in out-patient treatment.

I present a rationale for two different types of in-patient child psychiatric unit: 24/7 intensive units and 24/5 child and family units. Intensive units address safety requirements. The developing personality of young people is at the centre of in-patient approaches on the child and family units. This requires attachment-informed practice. Families must always be involved and placement of units must facilitate their participation. The primary skill characterising these units is use of the milieu for therapy and combining this with family therapy. In other words, nurses and allied professionals need to be the dominant force in unit development, under the reflective guidance of consultants and clinical psychologists.

Utility of the ADOS-2 in children with psychiatric disorders.

The Autism Diagnostic Observation Schedule (ADOS-2) is commonly used in the diagnosis of autism spectrum disorder (ASD). Although it has demonstrated good sensitivity and specificity in research settings, relatively little is known about its utility and accuracy in children and adolescents with co-occurring psychiatric disorders. We investigated this topic in children with acute psychiatric disorders. Our sample consisted of 58 patients, aged 9-18years, admitted to a child and adolescent psychiatric inpatient unit with a suspected diagnosis of ASD. Both Modules 3 and 4 demonstrated low sensitivity (Module 3: 58.3%; Module 4: 55.6%) and specificity (Module 3: 56.5%; Module 4: 59.5%). These findings suggest that the ADOS-2 should be interpreted with caution while screening for autism in children with complex psychiatric disorders.

39.1 AGGRESSIVE BEHAVIOR IN MENTAL HEALTH SERVICES: A HOSPITAL SYSTEMS APPROACH TO IMPROVE SAFETY AND DIMINISH RISK

Aggression is a frequent cause for admission to child and adolescent psychiatric inpatient units. Violent behavior in the inpatient unit is a serious threat to the safety of patients and staff and poses high risk to hospitals and care systems. The threat of violence can impair the development of the healing environment and derail treatment. Aggressive behavior can pose severe injury risk to staff, create perception of an unsafe environment, and lead to high staff burnout and turnover. Participants will learn the resulting impact of various forms of aggression on patient safety, patient treatment progress, staff job satisfaction, and safety of care providers. They will also gain insight into methods of risk assessment, prediction, and mitigation planning and methods to improve safety and treatment conditions.

Evaluation of early and very early onset schizophrenic disorder cases in a child and adolescent psychiatric inpatient unit

Evaluation of early and very early onset schizophrenic disorder cases in a child and adolescent psychiatric inpatient unit

Therapeutic Assessment With Child Inpatients

ABSTRACTGrowing evidence supports Therapeutic Assessment (TA), a collaborative and therapeutic approach to psychological assessment, as an effective method for enhancing motivation for and engagement with psychotherapy across a variety of clinical populations and treatment settings. However, to date there are no known studies assessing the use of TA in child psychiatric inpatient settings. This article briefly reviews the structure of child and family TA, enumerates the challenges and risks associated with short-term inpatient stays, and proposes a path for integrating TA into these units as a way to enhance the quality of care and reduce the risk of rapid rehospitalization. The authors provide three case examples from a child psychiatric inpatient unit, each using a modified version of TA and each integrating assessments into brief family interventions. The authors conclude with suggestions for best practice for child psychiatric inpatient TAs.

Paradigm shifts in inpatient psychiatric care of children: Approaching child- and family-centered care.

This article describes the components of child- and family-centered care, including a review of the literature about the delivery of family-centered care and the barriers that often prevent the provision of such care. The article describes an inpatient child psychiatric unit that has implemented an approach to care that embraces these principles. The changes in structures and policies that the unit adopted are described, with specific examples cited as illustrations of the components of this care. To describe the elements of child- and familycentered care and the ways in which this model of care may be implemented on inpatient child psychiatric units. Literature review including journal reports and articles and books. Preliminary outcomes are encouraging in the decrease in use of practices such as restraint and seclusion, and physical holds. Further research examining parents' satisfaction is warranted in determining the success of such endeavors.

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

BackgroundLong-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.Case presentationA Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.ConclusionsThe case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Trends in child and adolescent psychiatric diagnoses in a Romanian Inpatient Unit between 1990 and 2014

Objective. This paper aims to describe trends in diagnostic data in discharged patients from a regional child and adolescent psychiatric inpatient unit in Romania, over a 25-year period (1990-2014). Method. Data on discharge diagnosis of the 30854 patients from the study timeframe were analyzed. Diagnostic formulations in the years prior to ICD implementation were converted into ICD-10 specific disorders/ class of disorders. Results. Results showed a significant increase in proportion of autism spectrum disorders and hyperkinetic disorders over time and a significant decrease of stress related, dissociative and somatoform disorders. The number of psychotic disorders was constant over time, mood disorders had peak frequencies in 2003 and 2014 and anxiety disorders has a twofold increase from 2007 to 2014. Conclusions. This study demonstrates a major shift in the patterns of mental health disorders diagnosed among children and adolescents at our clinic over the last 25 years. Defining the current mental health needs of young people and adjusting service delivery in child and adolescent psychiatric settings have become of great importance in recent years.

In this day and age why is it still so hard to find the right type of help? Carers’ perspectives regarding child and adolescent mental health services: a qualitative study

ABSTRACTObjective: To identify perceptions and experiences of children and young people accessing mental health services in one state in Australia from the perspective of their carer.Method: Semi-structured interviews were employed in this qualitative study with 11 carers of children admitted to a child and adolescent psychiatric inpatient unit. Interviews were audiotaped, transcribed and coded. Thematic analysis following the guidelines of Braun and Clarke [(2013). Successful qualitative research: A practical guide for beginners. London: Sage] was applied to the interview data. This method of analysis includes: data familiarisation, code generation, theme search, theme review, theme definition and naming and report preparation.Results: Three overarching themes emerged: experiences prior to admission; expectations about admission and the inpatient experience. Contrary to previous research, satisfaction with mental health services was found to be greater in inpatient units. Dissatisfaction with community-based mental health services focussed on poor accessibility, long waiting times, exclusion from therapy sessions and incomplete assessments that often warranted additional specialist intervention. Carers living in country, rural and remote regions of the state were most vocal in dissatisfaction with community-based services.Conclusions: Carer perceptions of the inpatient unit as the most desirable and appropriate form of mental health intervention for their child go against the current shift in treatment focus to provide care in the least restrictive environment, that is the community. This has implications for future service delivery and design and supports research that has highlighted carer satisfaction to being closely linked to factors other than clinical improvement.

Impact of an Inpatient Psychiatric Unit on Pediatric Emergency Mental Health Care

Mental health complaints are a frequent presentation to the pediatric emergency department (PED). It is unclear if having an on-site inpatient pediatric psychiatric unit impacts pediatric mental health care in the acute setting. The objective of this study was to compare PED mental health care between a pediatric tertiary care center with an associated inpatient child psychiatric unit (PAPED) and one that does not (NOPED) with the hypothesis that children have longer lengths of stay (LOS) at the PED without an inpatient unit. This was a retrospective, observational study of all mental health presentations aged 1 to 18 years to 2 tertiary care PEDs from March 2012 to June 2013 with a final mental health diagnosis International Classification of Diseases, Ninth Revision code. A total of 1409 patient encounters comprised the study group. The PAPED had a significantly higher rate of admission 41.3% versus 18.8% (P < 0.0001). The LOS was significantly longer at the NOPED compared with the PAPED with a visit of 15.6 versus 6.3, respectively (P < 0.0001). When LOS was stratified for disposition, patients requiring admission from the NOPED had a significantly longer LOS of 33.4 compared with an emergency department LOS of 8.1 at the PAPED (P < 0.0001). Mental health care in the PED seems to be affected by having an associated inpatient child psychiatric unit. Further research needs to address this growing problem and ways to utilize community resources to develop safe outpatient plans and divert admission if possible.