Child Psychiatric Inpatient Unit Research Articles

Intervention Strategies for Treating Traumatized Siblings on a Pediatric Inpatient Unit.

This article examines the course of treatment for 2 traumatized siblings in an acute inpatient child psychiatric unit following severe physical abuse by their mother. In treating these 2 boys, the authors used intervention strategies that can be applied to the treatment of other traumatized siblings in institutional settings. Issues of self-worth, survivor guilt, and conflictual sibling dynamics are illustrated as they relate to the treatment. In addition, transference-countertransference dynamics are examined.

Characteristics of the Residents of In-Patient Child and Adolescent Mental Health Services in England and Wales

This study describes the characteristics of the young people who use the full range of child and adolescent psychiatric in-patient units in England and Wales. Consultant psychiatrists or key workers were asked to complete a structured schedule about every resident on a census day – 19 October 1999. Schedules were returned from 71 of the 80 units in England and Wales, concerning 663 residents. Residents aged 13 or under had a wide range of diagnoses and more were male (58%). In contrast, two-thirds of residents aged 14–18 were categorized into one of three diagnostic groups – eating disorder, schizophrenia, delusional or psychotic disorders or mood disorders – and about two-thirds were female. In-patients had more severe problems than a group of young people using community services, particularly with hallucinations and delusions, emotional and related problems and problems of self-care and independence. The range of disorders treated by these units demonstrates the need for a range of specialist in-patient services to be available to children and adolescents in all regions.

The Staffing of Inpatient Child and Adolescent Mental Health Services.

There is a need for more accurate information regarding the staffing of Child and Adolescent Psychiatric inpatient units. This is both to facilitate clinical governance and to allow planning and focused further development of these services. Postal surveys were sent to all units in England and Wales. Seventy-three percent (n = 1060) of the 1460 staff employed by the units were nurses; 43% of nurses were unqualified. On average there was one consultant psychiatrist for every 25 patients. Only 12% of nurses working on a 'census' day held a specialist qualification in nursing children. The use of agency and bank staff was higher in independent sector units than in NHS units (37% vs 10% of all nurses who worked a shift on the census day). Some child and adolescent inpatient units are not staffed by a multi-disciplinary team. There is evidence of problems of recruitment and retention of nurses.

Feasibility of Dialectical Behavior Therapy for Suicidal Adolescent Inpatients

To evaluate the feasibility of dialectical behavior therapy (DBT) implementation in a general child and adolescent psychiatric inpatient unit and to provide preliminary effectiveness data on DBT versus treatment as usual (TAU). Sixty-two adolescents with suicide attempts or suicidal ideation were admitted to one of two psychiatric inpatient units. One unit used a DBT protocol and the other unit relied on TAU. Assessments of depressive symptoms, suicidal ideation, hopelessness, parasuicidal behavior, hospitalizations, emergency room visits, and adherence to follow-up recommendations were conducted before and after treatment and at 1-year follow-up for both groups. In addition, behavioral incidents on the units were evaluated. DBT significantly reduced behavioral incidents during admission when compared with TAU. Both groups demonstrated highly significant reductions in parasuicidal behavior, depressive symptoms, and suicidal ideation at 1 year. DBT can be effectively implemented in acute-care child and adolescent psychiatric inpatient units. The promising results from this pilot study suggest that further evaluation of DBT for adolescent inpatients appears warranted.

A salutogenic investigation and treatment of conduct disorder (CD).

This article reports results from a long-term follow-up of adolescents with conduct disorder who have been patients at an inpatient child psychiatric unit in Lund, Sweden. Up to now, a total of 186 adolescents have participated in the follow-up study. The subjects are a heavily symptom-loaded group with many problems during their childhood. The study includes self-rating that describe psychiatric symptoms, sense of coherence, family climate and an interviewer rating on health. The follow-up paints a relatively positive picture; approximately 30-50% of the subjects have improved their lives and have an acceptable life situation according to the concepts of "love well", "play well", "work well" and "expect well".

Distribution and characteristics of in-patient child and adolescent mental health services in England and Wales

BackgroundLittle is known about the current state of provision of child and adolescent mental health service in-patient units in the UK.AimsTo describe the full number, distribution and key characteristics of child and adolescent psychiatric in-patient units in England and Wales.MethodFollowing identification of units, data were collected by a postal general survey with telephone follow-up.ResultsEighty units were identified; these provided 900 beds, of which 244 (27%) were managed by the independent sector. Units are unevenly distributed, with a concentration of beds in London and the south-east of England. The independent sector, which manages a high proportion of specialist services and eating disorder units in particular, accentuates this uneven distribution. Nearly two-thirds of units reported that they would not accept emergency admissions.ConclusionsA national approach is needed to the planning and commissioning of this specialist service.

Distribution and characteristics of in-patient child and adolescent mental health services in England and Wales.

Little is known about the current state of provision of child and adolescent mental health service in-patient units in the UK. To describe the full number, distribution and key characteristics of child and adolescent psychiatric in-patient units in England and Wales. Following identification of units, data were collected by a postal general survey with telephone follow-up. Eighty units were identified; these provided 900 beds, of which 244 (27%) were managed by the independent sector. Units are unevenly distributed, with a concentration of beds in London and the south-east of England. The independent sector, which manages a high proportion of specialist services and eating disorder units in particular, accentuates this uneven distribution. Nearly two-thirds of units reported that they would not accept emergency admissions. A national approach is needed to the planning and commissioning of this specialist service.

Variations in the costs of child and adolescent psychiatric in-patient units.

Child and adolescent in-patient care is a highly specialised service, ideally requiring planning at a national level, but there are no routine data collections specifically for these services. To estimate unit costs for child and adolescent psychiatric in-patient units and to analyse the variations in costs between units. Data collection alongside a national survey with cost estimations guided by principles drawn from economic theory. Bivariate and multivariate analyses are employed to identify cost influences. Fifty-eight units could provide sufficient data to allow calculation of the cost per in-patient day; mean= pound 197 (s.d.=71.6; 1999-2000 prices). The management sector, type of provision, number of rooms, capacity and location explained nearly half of the cost variation. Child and adolescent psychiatric in-patient units are an expensive resource, with personnel absorbing two-thirds of the total costs. Costs per in-patient day vary fourfold and the exploration of cost variations can inform commissioning strategies.

Invited commentary on: Variations in the costs of child and adolescent psychiatric in-patient units

The great majority of young people with mental health problems never need admission to hospital. A small number, however, require some kind of in-patient provision. In comparison with North America and many parts of Europe, such provision has now become relatively uncommon in the UK. Although the remaining services are widely believed to be costly, there are no national data collections that provide accurate economic data. To begin to meet this need, the Department of Health commissioned a national study to explore the costs of these units, which ran in parallel with the National In-patient Child and Adolescent Psychiatry Study (NICAPS).

Characteristics of the Detained and Informal Child and Adolescent Psychiatric In-Patient Populations.

This project surveyed the use of the Children Act and the Mental Health Act in in-patient child and adolescent mental health services in England and Wales. Data were collected as a day census from child and adolescent psychiatric inpatient units, questionnaire forms completed by consultant psychiatrists or key-workers. Returns were received from 71 of the 80 units. One hundred and twenty-seven of the 663 patients had been admitted formally, the great majority under a section of the Mental Health Act. Compared with those admitted informally, those admitted formally were older, contained a higher proportion of males and had 'adult-type diagnoses', mainly schizophrenia, mood disorders and personality disorder. The clinical and psychosocial characteristics of formal and informal patients were consistent with these differences. This study provides a timely and useful snapshot of the use of the Acts in this population.

Psychiatric Disorders and Cigarette Smoking Among Child and Adolescent Psychiatry Inpatients

We surveyed 120 patients admitted to a child and adolescent psychiatric inpatient unit regarding their cigarette smoking history, reasons for smoking, patterns of use, and psychiatric comorbidity (chart review). We administered the Social Phobia and Anxiety Inventory and the modified Fagerstrom Tolerance Questionnaire. Only six of 47 current smokers had a chart diagnosis of nicotine dependence. Logistic regression derived that the odds ratio for being a current smoker was: Caucasian race=5.56,older age=1.3, depressive disorders=4.02, conduct disorder (CD)=12.96, cannabis abuse/dependence=24.6. Hence, cigarette smoking is highly prevalent but underdiagnosed in this population.

Treatment utilisation and trauma characteristics of child and adolescent inpatients with posttraumatic stress disorder.

Few empirical studies have addressed the impact of trauma exposure and posttraumatic stress disorder (PTSD) on treatment utilisation and outcome in South African youth. This study was undertaken to document demographic, clinical, and treatment characteristics of child and adolescent inpatients with PTSD. A retrospective chart study of all patients presenting to a child and adolescent inpatient unit was conducted between 1994-1996. For children and adolescents diagnosed with PTSD; demographic, diagnostic and treatment variables, including trauma type, family history, and delays in treatment seeking, were documented. Child and Adolescent Psychiatric Inpatient Unit, Tygerberg Hospital, Cape Town. Children and adolescents (2 to 18 years) presenting to an inpatient unit (n = 737). 10.3% (n = 76) met diagnostic criteria for PTSD. Gender differences were clearly evident: PTSD was six times more prevalent in girls (65 with PTSD were female and 11 were male); girls were most likely to have experienced rape or sexual abuse while boys were most likely to have witnessed a killing. Psychotherapy was the most common intervention for PTSD, followed by treatment with a tricyclic antidepressant. 97.4% of children and adolescents who were treated demonstrated significant improvement. Delays in seeking treatment and problems with the primary support group were highly prevalent. PTSD is a common disorder that is responsive to treatment with psychotherapy and/or tricyclic antidepressants in child and adolescent inpatients. These findings underscore the importance of early identification and treatment of childhood PTSD in mental health settings, in particular tertiary service institutions.

A follow-up study of beliefs held by parents of children with pervasive developmental delay.

Little is known about the effects of parental beliefs on children with disorders such as pervasive developmental delay (PDD). A six-question, semistructured, videotaped interview was used to gather preliminary descriptive data from 44 caregivers regarding beliefs about their PDD children (ages 3-15 years). Children and caregivers were selected by purposive sampling from a preadmission waiting list for a child psychiatric inpatient unit. While responses varied, most caregivers shared concerns about delayed child development, appropriateness of school placement, and future planning. In addition, some indicated they possess inaccurate beliefs regarding the intention of child behavior as well as the PDD diagnosis. All indicated a need for direction in how to effectively help the children. Parental responses to the interview questions support the author's clinical observations regarding the need for nurse-conducted parent training programs. Parent training should focus on correcting inaccurate parental beliefs and teaching effective ways to promote child development and manage maladaptive behaviors.

A 15 month follow-up study of children admitted to a child psychiatric inpatient unit

AbstractObjectives: This study focused on measuring symptomatology and self-esteem in children admitted to an inpatient child psychiatric unit.Method: Twenty-six children consecutively admitted to a child psychiatric unit were assessed using the Rutter Parent Interview, the Birleson Depression Scale and the Harter Self Perception Profile for Children. Children were followed up at three and 15 months post-discharge and the same measures administered.Results: A stay in the unit was linked with a significant reduction in overall symptomatology and this was particularly so for emotional-type symptoms at both follow-up points and for hyperactive-inattentive symptoms at 15-month follow-up. The unit did not appear to be successful at reducing conduct symptoms at either followup. Nor did self-esteem change significantly following an inpatient episode. Children with depressive symptoms especially appeared to benefit both in the short- and longterm and this benefit extended to self-esteem.Conclusions: When analysing the benefits of an inpatient admission it is crucial to consider outcome and therefore efficacy on a long-term basis. Efficacy needs to take into account longer-term outcomes. The impact of an inpatient episode on a child's psychosocial adjustment will for some children take time. These ‘sleeper effects’ need further study.

Behavioral assessment and analysis of mechanical restraint utilization on a psychiatric, child and adolescent inpatient setting

A behavioral assessment and analysis of mechanical restraint utilization on a child and adolescent psychiatric inpatient unit was performed to identify contextual variables associated with implementation. The most frequent antecedent conditions correlated with restraint were when staff initiated physical contact towards a patient and when a patient refused to go to, or remain in, the “quiet room” when instructed. These interactions were seen as staff-initiated encounters that elicited aggressive responses from patients and increased the likelihood of restraint because the physical intervention and “quiet room” procedures were implemented in the absence of a comprehensive treatment formulation, and without reference to behavior-specific guidelines. Recommendations to reduce the use of mechanical restraint with child and adolescent inpatients by isolating functionally controlling variables are presented. © 1998 John Wiley & Sons, Ltd.

The Therapeutic Milieu and Treatment of Emotionally Disturbed Children: Clinical Application

Children, highly resistant to treatment as outpatients, can be treated in child psychiatric inpatient units where a therapeutic environment or `Therapeutic Milieu' is maintained. Using the theoretical framework described by Gunderson in 1978 (Psychiatry, 41, 327-335) case vignettes and an extended case study are used to illustrate how milieu therapy works within the context of a multidisciplinary team. Some points of difficulty in application are discussed. The key elements of milieu therapy are discussed: maintenance of a safe and containing environment, a highly structured programme, physical and emotional support, collective involvement of the child, family and staff in the unit regimen and continuous evaluation of all therapeutic interventions. Milieu therapy is contrasted with previous attempts to treat the children as outpatients. Although we now live in an era dominated by community-based treatment, the intractability of some chronic mental illness and its high cost to children and their families makes continued research and development in this area essential.

A profile of children and adolescents in a psychiatric unit: multidomain impairment and research implications.

The scientific literature has not kept pace with the evolution of child and adolescent psychiatric inpatient units, including their nature, patient profile, philosophical orientation and efficacy. This study aims to establish a comprehensive, multimodal description of the population served by an inpatient psychiatric treatment facility for children and adolescents. A multidisciplinary assessment regime including psychiatric, medical, speech and language examination, observer rating and patient self-report of psychopathology was used to assess 58 consecutive patients over a 20-month period. In addition to a prevalence of disruptive behaviour disorders of 67% and a high rate of comorbidity with other psychiatric conditions, a breadth of impairment was demonstrated in many areas. Significantly decreased measures of socialisation, communication, daily living skills, self-esteem, intelligence and physical health are reported. Moderate to severe language handicap was found in 40% of patients. The inpatient population of children and adolescents exhibited not only a high rate of disruptive behaviour disorders, frequently comorbid with other psychiatric conditions, but also high levels of physical, speech, language and living skills impairment. This finding supports the need for multimodal, multidisciplinary evaluation and treatment in this population. Outcome research evaluating treatment effectiveness must also account for the wide-ranging disabilities of these children and adolescents.

The prevalence of suicidal behavior among preadolescent children who are psychiatric inpatients.

The prevalence of suicidal behavior displayed by preadolescent children hospitalized on inpatient psychiatric units is estimated to range between 18% and 80% of the population. The current study provides an independent estimate of the prevalence of this problem. A semistructured interview was used to assess suicidal behavior displayed by 61 admissions to a child psychiatric inpatient unit between April 1988 and September 1989. According to the Pfeffer Spectrum of Suicidal Behavior Scale, 63% of the sample engaged in some form of suicidal behavior. Preadolescents and their parents reported similar rates of suicidal thoughts, threats and attempts. The dangerousness of recent suicidal behavior was not found to differ by age, sex, legal custody status or socioeconomic status.

Increased prevalence of electrophysiological abnormalities in children with psychological, physical, and sexual abuse

This retrospective study examined the association between abuse history and neurological abnormalities in 115 consecutive patients admitted to a child and adolescent psychiatric inpatient unit. Increased electrophysiological abnormalities were found in abused patients compared with non-abused patients (54.4% vs. 26.9%, P = 0.021), predominantly in the left side of the frontal, temporal, or anterior region (P = 0.036). This may support the hypothesis that early abuse alters brain development, particularly limbic structures. However, a large-scale prospective longitudinal assessment study is needed to interpret this association. Possible clinical consequences of relatively preserved right frontal function are discussed.

Evaluation of treatment integrity on a child psychiatric unit: an illustration.

The authors present a systematic evaluation of the implementation of a token economy protocol on a child psychiatric inpatient unit. Unobtrusive observations and staff responses to vignettes that depicted child behavior indicated that staff members did not always distribute tokens as scheduled and were inconsistent in their judgments about which behaviors should be rewarded. The results highlight the need for child psychiatric nurses to monitor systematically the implementation of care for which they are responsible.