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Ask the Experts: Psychiatric Hospitalization

From The Child's Doctor, Spring 2004

Thomas K. Cummins, MD
Medical director, Inpatient Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago; Assistant professor of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine
Disclosure: Thomas Cummins has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for use in the context of this discussion.

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Educational objectives

At the conclusion of this activity, participants will be able to:

  • Identify indications for acute inpatient psychiatric treatment.
  • Describe alternative psychiatric treatment settings that may be appropriate for less severely ill children.

CME credit

Credit statement


Summary

This article discusses when hospitalization is indicated in the treatment of severe psychiatric illness in children and adolescents.

When is hospitalization indicated in the treatment of severe psychiatric illness in children and adolescents?

Psychiatric treatment settings available today for children and adolescents should be considered along a continuum, according to levels of treatment intensity required. A patient may transition from one level of care to another depending on changes in the condition’s severity. [1,2] A review of treatment options will help to differentiate the level of care most appropriate for the patient’s current situation.

Acute inpatient hospitalization

Inpatient hospitalization is the most intensive level of psychiatric care. It involves short-term crisis-stabilization and treatment of patients with acute psychiatric disease that is severe enough to meet stringent criteria. Hospitalized patients receive nursing care and multidisciplinary treatment under the supervision of an attending child and adolescent psychiatrist. Any of the following factors indicates a need for acute inpatient psychiatric treatment.

  • Imminent risk for self-injury: Includes patients with a recent suicide attempt; suicidal thinking with a plan for self harm and at least some degree of intent to act on that plan; severe self-mutilation; or recent very high-risk behavior occurring in conjunction with a severe psychiatric or substance abuse diagnosis.

  • Imminent risk for injury to others: Includes patients who recently have severely assaulted someone; intend to seriously harm others, have a definite plan and the means to execute that plan; or recently have engaged in physically destructive acts that indicate a high risk for future harm to others.

  • Acute and serious deterioration from a patient’s baseline functioning: Includes patients with disordered, disorganized, or bizarre behavior that would make a less intensive level of care potentially unsafe.

  • Imminent risk for acute deterioration of a medical condition due to psychological factors: Includes patients with psychological issues that affect proper treatment of a serious medical condition.

  • Severe weight loss or failure to maintain expected weight gain, which results in serious medical complications: Includes patients whose eating disorders have led to a serious medical complication due to malnutrition or binge-purge behaviors. Additionally, the presence of a serious concurrent medical condition, such as cardiac disease, may necessitate inpatient treatment.

  • Inadequate treatment response in less intensive treatment settings: Includes patients who continue to experience significant psychiatric symptoms despite receiving consistent treatment in a less intensive setting, such as an outpatient or partial hospitalization setting.

Alternatives to inpatient hospitalization

Most children who suffer from psychiatric disease will not meet the rather restrictive criteria for acute inpatient treatment outlined above. In these instances, one of the less intensive alternatives described below can be selected.

Psychiatric residential treatment: The residential setting is usually reserved for patients with sub-acute conditions who may need continuous care for weeks or months, and in some instances for a year or more. This level of care includes intensive, individualized treatment on a 24-hour-per-day basis. Often this setting is used for cases that have been refractory to multiple acute treatments. Residential treatment also provides additional time to work with patients and families if chronic highly conflicted family dynamics appear to be contributing significantly to the lack of treatment response in more acute treatment settings.

Acute partial hospitalization: If a child suffers from severe illness but does not reasonably require around-the-clock treatment, then partial hospitalization may be an excellent option. Partial hospitalization provides the added benefit of intensive treatment while the patient remains in his or her home environment where treatment gains must be maintained over the long term. Partial hospitalization may also be used as a “step-down” from acute inpatient care. At this therapeutic level, patients participate in a highly structured multimodal treatment program, 5 to 7 days a week for 4 or more hours a day, for the duration of approximately 2 weeks. This treatment generally requires intensive family involvement.

Intensive outpatient treatment: This less intensive level of care can provide a useful middle ground between partial hospitalization and general outpatient settings. Intensive outpatient treatment usually entails both individual and group therapy, meeting at least 3 times a week for a total of at least 4 hours of treatment each week. As an added advantage, patients often can continue to attend classes at their own school with minimal or no interruption of their ongoing curriculum.

General outpatient treatment: This least intensive level of care involves a traditional clinic-based setting where children and adolescents come for individual and/or family therapy. Most patients are treated by 1 or more clinicians on a weekly or biweekly basis. Patients also may be seen monthly for routine medication management, or more frequently if needed. In summary, acute inpatient treatment is appropriate only for severely ill patients who present an imminent danger to themselves or others. A range of other long-term and shortterm treatment options may be suitable for less severe situations, depending on the intensity of care a patient needs.

References

[1.] Criteria for short-term treatment of acute psychiatric illness. The American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association. 1997.
[2.] Policy Statement: Inpatient hospital treatment of children and adolescents. The American Academy of Child and Adolescent Psychiatry. 1989.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.