In-patient Child Psychiatry

Modern Practice, Research and the Future

Jonathan Green, Brian Jacobs, Jonathan Green, Brian Jacobs

• Publisher: Routledge
• Year: 2013
• Topic: Psychology
• eBook ISBN:
  9781134759880
• Subtopic: History & Theory in Psychology
• Index: Psychology

Essential Reading for clinicians, managers and researchers in child psychiatry, this authoritative book provides accessible coverage of essential theory as well as clear practical guidance to inpatient child psychiatric treatment. This method of treatment has fallen out of fashion in recent years in favour of community-based care, but remains a useful setting for treating more seriously ill patients. Bringing together contributions from across the profession, this book covers the 'state-of-the-art' in current clinical treatment, and sets a bold new agenda for the future, arguing that inpatient child psychiatric units retain great potential for creative, effective, relevant treatment.

Part I
The current context

Introduction

With a long history and tradition behind them, residential psychiatry units for children find themselves now in a period of rapid transition. Health service delivery in the UK is going through rapid change and there is a profound worldwide re-examination of methods of delivery of health care. In adapting to these changing circumstances, there will need to be a continual re-evaluation of our ideas of what residential mental health treatment for children should be like and its place in the overall pattern of mental health services. A number of intellectual and practical challenges have to be faced. Doing so will help clarify the core contribution of this kind of treatment to the mental health of children in the community. The central purpose of this book is to conduct that re-examination of the aims and approaches of child psychiatry in-patient treatment in the light of this changing context. We have aimed to produce a book that reflects the move towards evidence based medicine by emphasising the links between research and practice and, wherever possible, the evidence base for that practice. Where treatments do not have specific evidential support, we have aimed to elucidate the clinical experience behind their advocacy.

In this first section of the book we set the context. First there is a discussion of the current challenges that we believe in-patient child psychiatry faces—the challenges that led us to wish to write this book. Second, we include a review of current provision—based on a questionnaire study of in-patient units that we conducted in 1995. Third, William Parry-Jones gives an account of some aspects of the history of residential psychiatric care for children. Many readers will know that Professor Parry-Jones died tragically and suddenly, soon after delivering the final draft of his chapter to us. The great sense of loss at his death (especially for one of us, once his trainee) is linked to our appreciation that this chapter must represent one of his last pieces of academic work. William was powerfully committed to the view that the study of the history of psychiatry—especially of the waxing and waning of treatment enthusiasms—should provide sobering lessons for our current practices and enthusiasms. This could lead him at times to a pessimistic view of progress in psychiatry and certainly his chapter here has an almost elegiac tone in relation to residential treatment of children. His warnings and reminders at the end of this section act as a foil for the committed work and attitudes described elsewhere in the book.

1 Current challenges

Jonathan Green and Brian Jacobs

This book is written in the context of a number of challenges to the appropriateness and effectiveness of residential psychiatry treatment of children. The challenges come from many directions: from economic and political developments in many countries; from shifts in the social attitudes towards children and family life; from within the profession and from other professional groups. Let us begin by identifying some of the most salient.

SECULAR SHIFT IN USE OF HOSPITALS

There has been a general shift towards reduced use of in-patient treatment throughout medicine including paediatrics and adult mental health. In-patient child psychiatry has been no different and the total number of in-patient child psychiatry beds has certainly decreased over a number of years. It is not now felt to be essential for each health district to have its own in-patient facility, although all districts should have access to in-patient child psychiatry beds on a supra-district basis (Royal College of Psychiatrists 1992). A recent UK review (NHS Health Advisory Service 1995) identifies the core need for in-patient services as a ‘Tier 4’ specialist resource available in the context of tertiary referral. Thus in-patient child psychiatry has become a low volume, high cost, supra-district service with similarities to other highly specialist or intensive care facilities throughout medicine. This position within the NHS purchaser provider structure creates particular challenges for the negotiation of contracts and financing. Creative solutions involving consortium contracting and joint funding will have to be sought and these issues are discussed in detail in Part VII of this book. There is a risk that poor management of such co-ordinated contracting might result in the closure of units through default.

DEVELOPMENT OF INTENSIVE OUTREACH

In parallel with the relative decline in the use of in-patient facilities has come the growth in sophistication and application of various new forms of outpatient treatment. Intellectually, there have been arguments in favour of an increasing amount of treatment taking place within the child's natural context, and for the professional service to reach out to the child rather than have the child come into a specialised environment away from the natural setting of school and home. Such a move away from institutional care towards family care has occurred on many fronts, for instance in the social services field. Additionally, the growth of family based approaches to treatment such as family therapy has led many professionals within child mental health to question the wisdom and efficacy of separating young children from their family for the treatment process. In this context, child in-patient units can be seen as anachronistic hangovers from an ‘institutional’ past and likely to do more harm than good. There have, of course, been parallel movements within adult psychiatry, focused on the development of community care and the closure of mental hospitals.

These are persuasive arguments. Most clinicians would agree that the increase in community outreach and family based care when coherently and effectively organised with skilled personnel offers an effective and probably optimal treatment for most child mental health problems in the current community. However, it is likely that the shortcomings of a purely outreach based approach will become increasingly apparent for a core group of serious problems in the community. There may be a danger in idealising community outreach such that its overall effectiveness will be over-emphasised and insufficient attention paid to children who are unable to benefit from such work. There are also dangers, to be discussed at several places in this book, that a number of areas of serious psychopathology in children may currently be under-recognised or under-treated. This can apply to biological disorders such as undiagnosed epilepsy or developmental disorder, to psychological disorders such as unrecognised mood disorder or attention problems, and to psychosocial traumas such as undisclosed abuse or privation. The intensive residential assessment of such children can reveal problems that are not apparent in the outpatient setting, and intensive residential treatment may be able to promote change and developmental progress when outpatient treatment cannot. Naturally, it is going to be critical to provide evidence for such assertions. Much will be found throughout this book, especially in Parts V and VI. Further it is essential that future research strategies within the in-patient field concentrate on these issues and the ‘added value’ that in-patient assessment and treatment may or may not bring in certain situations (see Chapter 27).

QUESTIONING THE MILIEU

Another important challenge to traditional modes of in-patient child psychiatry treatment relates to the concept and efficacy of the so-called therapeutic ‘milieu’: that environment of care within which much of the therapeutic effect deemed distinctive to in-patient therapy is felt to take place. Some have developed attitudes hostile to any form of non-family care. These combine with pressures towards financial economy and the ‘efficiency’ of high throughput. They have led to the development of the notion, particularly in the USA, that in-patient units should provide the bare ‘minimum necessary’ intervention in order to return the child to the home environment. Children are admitted for a few days or at most a few weeks and intensive programmes are supposed to produce a proscription for services that will then be provided in the community. This model is described in detail in chapter 8. This does represent a significant challenge from within and without the profession to traditional notions of in-patient milieu therapy. From within the profession it partly stems from changes in treatment philosophy from ones based on psychodynamic principles with broad goals and an expectation of slow change, to more focused goal directed therapies such as cognitive behavioural therapy and behavioural management techniques.

We welcome many of these changes. However, shortening treatment times beyond a critical point will lead to a collapse of any proper notion of in-patient psychological treatment, and replace it by the most short term triage or superficial symptom control. Much of the re-definition of in-patient therapy that we are arguing for in this book does involve the incorporation within in-patient care of new styles of treatment delivery often initiated within the outpatient context, such as systemic, group and cognitive behavioural treatments. The challenge is to integrate these within a residential environment along with the best of what the traditional milieu has to offer, transforming them both in the context of overall shorter treatment admissions. Much of the thinking within Parts III and VI of this book is concerned with just this evolving practice. In the end, what it is that is efficacious about the complex intervention within in-patient care needs to be a matter of continuing intellectual debate and research initiatives. Such questions have proved difficult to research systematically in the past, but in Part VI we present such findings as there have been and suggest research initiatives for the future.

FAMILY CENTRED APPROACHES

The theory behind family centred treatment approaches strongly suggests that it is illogical to treat children outside the immediate context of the family. This has been another powerful challenge that has needed consideration. Most in-patient units have made great strides towards adapting their practice towards a family centred approach. Methods have been devised to keep a family focus of while admitting the child and keeping a focus from the beginning on ‘family restoration’. Parts II and III of the book consider these matters as they affect the family engaging with the unit, during admission and post discharge. The admission of whole families is a radical solution to this problem and procedures to do this have been developed in the UK particularly at the Cassel Hospital and the Park Hospital, Oxford. A flexible use of family admission during the course of a child's treatment is being increasingly contemplated by many units but there are, of course, resource implications and the effectiveness of this manoeuvre needs to be tested. The effect of a family on the unit and the effect on an admitted family of being there need careful consideration in those units where there is limited or no separate speciali...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Figures
• List of Tables
• List of Contributors
• Acknowledgements
• Preface
• Part I The current context
• Part II Treatment process
• Part III Therapeutic elements in in-patient treatment
• Part IV Team organisation and dynamics
• Part V Critical areas of management
• Part VI Research
• Part VII Management and finance
• Part VIII Other residential options
• Part IX Conclusions
• Subject index
• Name index