Handbook Of Adolescent Inpatient Psychiatric Treatment

Harinder S. Ghuman, Richard M. Sarles, Harinder S. Ghuman, Richard M. Sarles

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134858699
• Edition: 1
• Topic: Médecine
• Subtopic: Psychiatrie et santé mentale

First published in 1994. The Sheppard and Enoch Pratt Hospital has been treating severely emotionally disturbed adolescents for a number of years. During this time, they have had the opportunity to build upon the principles and techniques of acknowledged experts and leaders, and have gained a great deal of experience and wisdom ourselves. Our treatment teams had the time to deliver intensive, in-depth treatment, which included three weekly individual psychotherapy sessions, three weekly group therapy sessions, daily activity therapy, and intensive milieu program, daily ward meetings, weekly family therapy, and a daily therapeutic school program. The knowledge and principles described in this book are not only applicable to inpatient facilities but also valuable to practitioners in day hospitals, group homes, and outpatient practice.

PART I

General Considerations

Chapter 1

INDICATIONS FOR INPATIENT TREATMENT AND TYPES OF SETTINGS

Harinder S. Ghuman and Richard M. Sarles

“Mental Hospital Chain Accused of Much Cheating on Insurance”

The New York Times, November 24, 1991.

“Bounty Hunting”

Networker, July/August 1990.

Recent criticism of adolescent inpatient hospitalization by the media, public, and some professionals has had a profound effect on hospital programs and a somber effect on the hospital staff. It is, therefore, even more imperative that the hospital staff working with adolescents clearly document the necessity for inpatient treatment, what occurred throughout the hospitalization, and what was accomplished. A look at the chain of events leading to the present state of affairs may help to put the current criticism into perspective.

It was not until the late 1970s and continuing to the mid-1980s that proliferation of inpatient adolescent settings took place. However, this was preceded by other significant and fundamental changes in health care and funding for this care. In fact, 50 years ago there were limited hospital beds, not enough physicians, and very few people covered by health insurance. The medical model of care was a two-payer system—patient and doctor.

During the 1940s and 1950s, employers began to provide health insurance to employees as part of their “benefits” for working for a particular company. A new medical model of reimbursement was introduced, a third-party payer system. American medicine witnessed a “new” resource for funding health care, making possible an increase in the number of people being able to afford health care, which led to an increase in the number of physicians and to the number of hospital beds for treatment of these “new” patients. Coincidental with these increases in health care providers, funding, and facilities was the beginning of a technological boom.

During the 1960s and 1970s, technology exploded and government and industry made an open-ended commitment to comprehensive health care. Health care became a right for most Americans. In 1965, Title 18 established Medicare Part A & B and Social Security Amendment PL 89–97 was initiated.

By the 1980s, a clear increase in the incidence of adolescent suicide, and abuse of drugs and alcohol was evident. DSM-III (American Psychiatric Association, 1980) included child and adolescent depression as a bona fide diagnosable disorder. Manic-depressive illness was diagnosed with increased frequency during the adolescent years, there was an increased number (incidence-reporting) of sexual abuse cases, and runaways, family breakdown, and adolescent aggressive behavior all seemed to be increasing.

The Diagnosis Related Grouping (DRG) prospective pricing system initiated by the Federal government in the 1980s placed greater constraints on medical-surgical hospital treatment. As hospitals were forced to downsize these areas, these beds were converted to psychiatric beds, which were still unrestricted, or unregulated by DRGs. Thus, in a regulated-restricted DRG, cost-containment climate, which reduced growth, a new market was developed and the growth industry for hospitals became psychiatric beds, especially for chemical dependency and adolescents. The number of psychiatric admissions for children and adolescents under 18 years of age rose from 10,764 in 1980 to 48,375 in 1984. In geographic areas where psychiatric beds were unrestricted or deregulated with certificate of need removed, there was an explosion in the number of new psychiatric beds and hospitals. In Florida, it was reported that 456 new beds opened, with over a million dollars spent on lobbying.

During the 1980s, for-profit national chain hospital corporations capitalized on the burgeoning child and adolescent market and opened thousands of beds in hundreds of newly constructed inpatient facilities. This enormous increase in hospitals often led to intense competition for market share. Aggressive advertising “scare” techniques were introduced, unfortunately leading to, in some instances, unnecessary hospitalizations and unreasonably long lengths of stay. Even so, some hospitals operated at only a 40% to 50% occupancy. A more egregious example of “profiteering” was the practice of offering “bounties” to school personnel and other counsellors for referral of young patients for hospitalization.

The tremendous overbedding and the outrageous abuses in some hospitals made it painfully clear that business and government could not afford to and would not continue to pay. After a brief fling at Preferred Providers Organizations (PPOs), Health Maintenance Organizations (HMOs), Independent Practitioners Associations (IPAs) and Diagnosis Related Groupings (DRGs) that proved to be ineffective in containing costs, managed care became the dominant mechanism for controlling mental health costs. At the same time, most states tried to initiate plans to control escalating mental health costs. In the state of Maryland, for example, the State Health Plan for Children, Youth and Families clearly articulated the vision of child and adolescent mental health services as home-based and community-based, with all inpatient care to be “reduced and restricted.” In 1992, Maryland had 800 children and adolescents in out-of-state residential and hospital facilities at a cost of $40 million per year. The aim of the health plan was to return these children and adolescents to Maryland and to reallocate these dollars to the least restrictive, least costly setting. The major emphasis was to restore the family unit and to “empower” families and communities to house, treat, and educate these children and adolescents in the community with the reallocation of monies from the out-of-state placements and in-state inpatient settings.

The net result of these events is that many adolescent inpatient treatment programs have been left in chaos. According to Lewis (1991, p. 165), “A combination of these forces has resulted in more beds, more empty beds, more competition among hospitals and practitioners, shorter lengths of stay, more hospitalizations, less control over treatment programming for the admitting psychiatrist, and a less secure, confident, and predictable context for inpatient psychiatric treatment of youth.”

Rinsley (1990, p. 9) wrote, “Excellent programs for severely disturbed juveniles have suffered along with purely or basically custodial ones characterized by neglect or even abuse.”

It may appear that the public, insurers, and professionals, who never appreciated the value of inpatient treatment or who may have had bad inpatient experiences, have written an “obituary” for inpatient treatment. As a result, large numbers of adolescents and families experience great difficulty in accepting the need for hospitalization now. When parents hear reports that inpatient treatment is unnecessary, not helpful, or even harmful, they are unlikely to accept inpatient treatment. The present confusion and turmoil of adolescent inpatient treatment may engender a sense of pessimism. However, it is vital for professionals working in inpatient settings to look inward and rectify any responsibility they may have for creating this negative picture. In fact, this publicity may provide an opportunity to weed out the growth of opportunistic facilities, where staff and administrators are more concerned with profit than with treatment of adolescents. Concurrently, opportunities exist for professionals to explore alternative methods of assisting adolescents by developing more creative, less restrictive treatment approaches and modalities. Lastly, a word of caution: Before discarding “older ways of treating adolescents” and starting new approaches, treatment programs and professionals must make sure these new programs are not again solely based on monetary gains from deceptive new sources of funding.

With this background and caveat, we believe it is most important to examine indications for inpatient treatment and to discuss various treatment settings.

INDICATIONS FOR INPATIENT TREATMENT

Various authors have described indications for inpatient treatment of adolescents (Potter, 1934, 1935; Petti, 1980; Harper & Geraty, 1989; Weintrob, 1975; Wardle, 1974; Kester, 1966; Barker, 1976; Silver, 1976; Rinsley, 1991). The American Psychiatric Association (1989) issued a statement regarding appropriate hospitalization for adolescents, and the American Academy of Child and Adolescent Psychiatry (1989) and the American Society for Adolescent Psychiatry (1990) have published guidelines regarding adolescent inpatient admissions. In general the indications for adolescent admission may be summarized in the following manner:

A. Dangerous Behavior

Most clinicians would agree to the hospitalization of an adolescent when his/her behavior is dangerous to self or others regardless of the diagnosis. For example:

A 16-year-old male had been intermittently threatening to kill his mother for several months. The night prior to admission, he held his mother’s head in a headlock and tried to cut her throat with a knife, but stopped at the last moment, saying that he could not do it.

A 14-year-old female took an overdose of her antidepressant medication and required treatment in the intensive care unit of a general hospital. She continued to express suicidal ideation and was involved in cutting herself after discharge from the general hospital.

A 15-year-old male with a history of truancy, and aggressive and impulsive behavior made sexual advances toward his sister. The patient’s level of intelligence was borderline. He stated that he heard voices telling him to touch his sister in “her private parts” and to have sex with her. The patient also had a history of making sexual advances towards other younger girls.

B. Disorganized Behavior Interfering in Daily Functioning

These behaviors include excessive withdrawal, agitation, rituals, disorganization in thinking and perceptual disturbances. In such cases, the adolescent may not be able to take care of basic needs or be involved in social interaction or education. Also, admission may be necessary when there is deterioration despite outpatient psychiatric interventions and/or as a result of noncompliance with treatment. For example:

A 13-year-old female required admission because she was talking to herself, hearing voices, isolating herself in her room, refusing to go to school, and refusing to eat. Her condition had deteriorated despite outpatient treatment that included the use of psychotropic medications.

A 16-year-old female who had history of obsessive/compul-sive behavior became preoccupied with her menstrual period, visited the bathroom every few minutes, and spent inordinate time cleaning herself. She was in outpatient treatment receiving moderate dosages of Anafranil and Ativan.

A 14-year-old became extremely agitated and confused, was unable to sleep, and broke household articles after inhaling glue.

C. Severe Out-of-Control Behaviors

These behaviors include frequent runaways, inappropriate sexual behaviors including promiscuity, prostitution, exhibitionism, and molestation, and frequent fighting, stealing, robbing, breaking/entering, and fire-setting. For example:

A 17-year-old female was admitted to the hospital after a three-week runaway episode. The patient’s parents were able to arrange, with the help of the police, to bring her to the hospital from the detention center. She had a history of runaways starting at age 15 and was involved in abusing various drugs and alcohol. Additionally, she was involved in severe risk-taking sexual activity with multiple males to support her drug habit.

A 16-year-old male was referred to the hospital for psychiatric evaluation and treatment by the juvenile court after having exposed himself to a female. He also had a history of stealing, breaking and entering, and drug abuse.

D. Miscellaneous Indications

These are indications which do not fit in the categories described above and may include court referrals or combinations of individual adolescent problems with severe family psychopathology. For example:

A 17-year-old female was brought to the hospital by a social service caseworker. The patient had not been out of her room for three months, except to go to the toilet, and had not left her house for one and a half years. She had a long history of school refusal, numerous somatic complaints, and various symptoms of anxiety. The patient and her family, particularly her mother, were quite enmeshed, with the patient’s mother sleeping with her at night.

It may be useful to define indicators as either absolute or relative. Of the previous indications, (A) dangerous behavior is the only absolute indication for hospitalization, whereas the rest of the indications depend upon severity and chronicity of the problem. Before an adolescent is admitted to an inpatient setting, a thorough psychiatric evaluation should be completed to ascertain if and why the adolescent requires hospitalization. The evaluation can be done on an outpatient basis or during a preadmission interview. In case of acute emergency, one may have to do the assessment in the emergency room.

Issue of Diagnosis and Inpatient Admission

The adolescent’s need for hospitalization is usually based upon the presenting behaviors, problems, and symptomatology, and not necessarily on the diagnosis. Occasionally, adolescents are referred for hospitalization so that a diagnosis may be substantiated or clarified. This should not be a valid criterion for admission unless the adolescent’s behavior/symptomatology is severe and dangerous enough that evaluation and treatment on an outpatient basis is not possible. In such instances, the advantage of admission is the opportunity for observation of the adolescent in a secure, safe environment where clarification of the diagnosis and an outline for treatment are formulated...