Kids Do Get Better: Values Driven Inpatient Care

In New York State, and across the country, the story of how mental health care began begins with inpatient care provided in large institutions located in a bucolic rural environment. This “humane treatment,” in its day, was considered a progressive avant-garde form of care. For decades this form of inpatient care was virtually the only option for those with more serious illnesses. While well intended, these environments were not without their darker sides as reflected in Ken Kesey’s “One Flew over the Cuckoo’s Nest.”

In the more modern era, inpatient care has often come to be thought of in a very negative light.  Born of historic overuse, and too often abuse, the need for inpatient care became reflective of inadequate (either poor quality or not enough) community-based care.  The cost of inpatient care has also been seen as a limiting factor in the development of community-based alternatives.

The truth is that the inpatient level of care has evolved just as mental health care in general has.  During the current emphasis in policy circles on Evidenced-Based Practices, it is often said that there is no evidence that inpatient care is effective.  “Inpatient” is a place and the term says little or nothing about what occurs there or what kinds of treatments or supports are offered.  At Four Winds Saratoga we have a great deal of empirical evidence that brief inpatient treatment can be extremely effective in stabilizing acute symptoms, interrupting negative spiraling of behavior and helping adolescents and their families get “back on track.”

For those experiencing and those witnessing the deterioration in a young person’s functioning, it can be disconcerting and, in many cases,, terrifying.  As a parent, one wonders what has gone wrong.  You may suspect illicit drug use, or even some type of abuse or trauma.  Children who are admitted to the hospital present with a variety of symptoms and issues.  Particularly during adolescence, it is important to identify and clarify symptoms. For instance, an increase in aggressive acts, volatility in your child’s mood, a noteworthy change in his or her fearfulness, withdrawal and isolation, feelings of sadness and hopelessness, or a significant focus on body image and weight issues are all worthy of attention, assessment, and often, some type of intervention.  A parent may obtain this information from their own experience or by speaking with their child’s teacher, therapist, daycare provider, coach, troop leader or any individual who has regular contact with their child and may recognize changes in functioning.  Problem solving between the parent and child may suffice or initiating outpatient counseling may be enough to help resolve these issues. In many cases, these “symptoms” will be attributed to “hormones” (i.e., How do I know what is teenage behavior and what is a mental health problem?).  Or, “she’s hanging with a different crowd” or “the media puts a lot of pressure on kids these days.” It is when the aforementioned symptoms dramatically impede functioning or become dangerous or when other interventions have proved ineffective, that inpatient care may be necessary.

For the vast majority of those admitted to the hospital, the safety of the child or those around him has been compromised.  For those not posing an imminent safety risk the impact on functioning is so profound that it affects not only the child, but family functioning as well. For instance, parents may not be able to maintain a steady work schedule due to the need for multiple appointments. Or their child’s problems in school such as poor attendance related to behavioral problems, anxiety, school phobia, or depression have become overwhelming.

The thought of inpatient hospitalization can be frightening to parents, guardians, and siblings as well as the child.  The separation alone can be cause for significant anxiety and concern.  Some parents may ask questions such as: Why can’t this be done on an outpatient basis?  Do I have to give my child up to these people/strangers? Will they just drug my child? What will she do all day in there?  How do I know this place is any good?  Will I get to have contact with my child? Can I call and visit him?  Youngsters may ask: Are they taking me from my parents?  Are my parents sending me there because I was “bad?  When will I get out?  Can I see my family?  Will I ever see my friends again?

These are the type of concerns that have been perpetuated by the stigma of psychiatric care and the artifacts of negative inpatient experiences.  It is important to remain cognizant of the fact that inpatient is NOT just a place, but rather a treatment intervention.  The role of expert inpatient care has improved just as mental health care in general has adjusted to external pressures, new treatment options, data collection and analysis, and the feedback of those receiving treatment.

As providers in an established inpatient program, Four Winds-Saratoga has found that the role of the hospital has to be multifaceted in order to meet the diverse needs of the children and adolescents we serve. A comprehensive psychiatric evaluation occurs in the context of 24-hour nursing care and skilled milieu programming. Multiple assessments are conducted including, a psychiatric evaluation, a nursing assessment, medical/physical evaluation, and a social and leisure skills assessment. A therapist is assigned to each youngster who will conduct individual and family therapy as well as actively working toward establishing a comprehensive discharge plan. The unit Medical Director (psychiatrist) provides clinical oversight and medication management, when necessary, for each child.  In addition, school services are provided which includes collaboration with the child’s home school in order to maintain as much continuity as possible. The multidisciplinary team also collaborates with the child and parents/ guardian to develop a plan for treatment and discharge.

This description may be similar to other inpatient programs.  What is it that sets one apart from the other?  How do you know what components of the program actually contribute to its positive outcome?  We believe that one of the most critical aspects of a treatment program is the intimate involvement of the child and their parent or guardian.  It is critical that parents and collateral individuals, such as extended family and outpatient providers are involved in the assessment, treatment, and discharge process throughout the hospital stay.  We believe that professionals on the treatment team need to be expert in the areas of child development and psychiatric care and that parents and their children are expert in their knowledge of their own lives, functioning, strengths, and areas of concern.

The focus of treatment is to help the child and family to identify the issues contributing to the crisis that lead to admission and most importantly, the strengths of the child and family which can be emphasized to facilitate the mitigation of problematic issues.  These strengths are idiosyncratic and vary greatly from situation to situation and family to family.  For instance, strengths may include a supportive family, above average intelligence, favorable premorbid functioning, a comprehensive outpatient plan for some, a history of medication compliance (which is often overlooked as strength), a sense of humor, readily engaging with adults, and a history of engaging in hobbies, athletics, or other extracurricular activities.  Furthermore, emphasis is placed on helping the child to identify triggers to his or her distress, which frequently relates to interpersonal issues such as teasing or bullying at school, abandonment or rejection by a significant adult in his or her life, or trauma related issues, among many others.  Simultaneously, children and family members are encouraged to recognize the early warning signs of a beginning crisis and potential deterioration in functioning – emphasis here is on “early.” Again, there are many variations to these signs.  Some examples include, subjective feelings of agitation and impatience, observable changes in facial expressions or body movements such as leg shaking or finger tapping, thoughts of self-harm, changes in the youngster’s choice in music or clothes (i.e. darker, more moribund themes relative to the typical presentation), and sleep and appetite changes among many, many others.  New coping and target skills are identified by the child and family within the treatment program and practice is encouraged.

All of these aspects of the treatment plan – triggers, early warning signs, developing and practicing new skills – are an integral aspect of programming throughout the day.  They are established in the context of the child’s chronological and developmental age and/or level of functioning and these issues are addressed throughout the hospitalization in the milieu, recreational activities, skill building modules including daily goal setting where goals for the day are established and discussed, Focus and Wrap Up meetings to discuss progress, and Dialectical Behavior Therapy interventions where target symptoms are identified, the severity is rated and progress noted daily.  A token economy system is in place on each of the respective children’s programs and adapted to the child’s age.  It is important to note that emphasis is placed on “earning” and not losing points, tickets, or privileges.  This positive perspective, the strength-based emphasis, and the comprehensive and reinforcing approach to treatment planning and interventions have been critical to quality care.  Furthermore, and most importantly, the individualized nature of the approach to care has greatly contributed to successful outcomes.

The commitment to quality care and the intensity of the involvement with children and family members is critical to the success of the treatment process. An attempt to engage the patient in treatment often begins at the time of the referral and the admission assessment by gathering as much information as possible during each interaction.  After the initial interview the child and family are oriented to the living unit, staff members and many aspects of the treatment program.  Family members are encouraged to regularly visit and speak with their child in order to maintain the connection.  Contact with the physician and therapist occurs very quickly in order to gather further data, discuss treatment options and discharge planning.  It is important to engage quickly since the treatment in the hospital is relatively brief (six to twelve days in many cases) and the intervention is one aspect of the continuum of care for children and adolescents.

At Four Winds-Saratoga we are committed to quality patient care and actively obtain and utilize empirical data obtained during the hospitalization in the form of feedback from the youngster’s experience in treatment.  We also utilize a structured patient and parent satisfaction survey in the data gathering process.  We use the Piers Harris Children’s Instrument Self–Concept scale, 2nd edition, which is a well-established tool developed by Ellen V. Piers PhD, Dale B. Harris, PhD, and David S.  Herzberg, PhD.  This instrument provides an overall view of a youngster’s (ages 7-18) self-perception.  This is a hand scored tool with test items that cover six different subscales, as well as two subscales that account for biased responding and random answering.  Items are presented as descriptive statements and the youngster answers in a “yes” or “no” fashion indicating whether or not the statement applies to himself or herself.  The subscales address the following concepts: physical appearance and attributes, freedom from anxiety, intellectual and school status behavioral adjustment, happiness and satisfaction, and popularity.  We have over a decade of data from this instrument and a response rate of over 80%.  Results consistently indicate a clear change in the youngster’s self-perception from the time of admission to the inpatient unit to the time of discharge.  Specifically, over the last year alone, a thousand children rating themselves on Piers- Harris, scores improved 30% to 40%. The individual subscales consistently showing the greatest change during hospitalization are the child’s self-perception scores related to “anxiety”, (a 55%-65% improvement) and “happiness”, (a 50%-60% increase), both of which are key to a young person’s experience of depression.

Simultaneously, youngsters and parents are asked to complete an anonymous  satisfaction survey relating to their experience in the hospital encompassing all aspects of their experiences from the admission process, financial arrangements, comfort of the physical environment to clinical interventions such as individual and family therapy, discharge planning, medication management, and direct nursing care, among others. The child and parents are also given the opportunity to provide a narrative about his or her experience during the hospitalization.  The results have been overwhelmingly positive including some surprising results from our youngsters who are asked the following question: Would you come back to Four Winds? Most, we thought, would interpret the inquiry in such a way as to discount the value of their experience and want to separate them from the setting, particularly at the time of discharge. While the rating is without exception, the lowest of the survey, the children and teenagers typically respond in a positive fashion as evidenced by the 80%-90% favorable response.

In conclusion, it is important to recognize that “inpatient” is a complex intervention and the quality and treatment approach of these programs can vary widely.   Those programs that are characterized by the following qualities would seem to be most effective:  Respecting the youngster and family members, emphasizing individualized care, maintaining a focus on strengths (and avoid the trap of a purely pathological perspective), include a trained committed group of providers in the program that is reflective of an organization whose mission is driven by quality care, compassion, and safety.  In addition, a program that is focused and places emphasis on target symptoms and coping strategies, comprehensive follow up care, and the creation and utilization of a constructive feedback loop involving both young people and their families are critical aspects of a quality program and provides the best opportunity for change.

Joseph Commisso, PhD, is Director of Adolescent Services, and David Woodlock, MS, is Chief Executive Officer at Four Winds Hospital in Saratoga, New York.

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