Pediatric Annals

Hospitalization of the Young: Rationale and Criteria

Sherman C Feinstein, MD; Victor Uribe, MD

Abstract

The decision to hospitalize a young person for psychiatric treatment demands an integration of developmental, intrapersonal, and psychosocial factors that are operative, along with current conflict and behavior that signal the presence of extreme emotional stress. The upset and breakdown of an adolescent's basic life defenses indicates serious interferences in the critical areas of object relations and self-structures and produces functional impairment in all of the basic adjustment areas, the family, the community, and school.

Hospitalizaron has strong impact upon adolescents and their families and requires careful clinical and administrative judgments. Hospital izat ion should be considered only after outpatient alternatives have been ineffective or refused, or when the psychiatric disorder is severe enough to necessitate a comprehensive inpatient program. The latter is indicated when adolescents are overtly or potentially dangerous to themselves, their families, or others; when their behaviors are self-destructive through drug or alcohol abuse or self-inflicted injuries; or when they manifest repetitive running away, violence, truancy, promiscuity, social isolation, extreme mood swings, severe psychosomatic dysfunctions, or psychotic disorder. Other indications may be impaired ego strength manifested by aggressive, sexual, or dependency actions with major difficulty in maintaining interpersonal relationships and coping with age-appropriate environmental demands.

Adolescents may or may not experience distress, recognize or deny their problems and need for help, or cooperate with their admission to a hospital program. Most commonly, family members, pediatricians, school representatives, and professional consultants are distressed by the adolescent's behavior and are forced to arrange, by a series of manipulations, admission. Those adolescents and their families who have had therapeutic involvements are usually better prepared to use hospital ization as part of an overall treatment program.

The nosological label used on admission should not be considered final. A definite diagnosis requires a comprehensive assessment of the adolescent's physical, psychological, and sociocultural systems to include: a) etiological interactions of genetic and acquired factors; b) evaluation of patterns of behavior that have characterized previous adaptations; c) the dynamic impact of biopsychosocial precipitating stresses and predisposing factors that have resulted in maladaptation; and d) specific symptoms and signs along with their onset, duration, intensity, and response to therapeutic interventions. A synthesis of these findings and considerations should provide a comprehensive treatment plan designed to protect the young person and begin the process of resolving conflicts and encouraging further growth and development. The period of hospitalization is usually one part of the whole treatment plan, rather than being the definitive therapeutic approach, and requires posthospital planning from the onset.

LENGTH OF STAY IN THE HOSPITAL

Recent studies have considered the emerging patterns in psychiatric inpatient care mediated both by changing ideology and economic restraints. A popular current atritude is rhat "shorter is better" and "out is better than in." Click and Hargreaves found that short-term treatment was no less efficacious than longterm treatment for neurosis, personality disorder, and schizophrenia with poor prehospital functioning.' Long-term treatment, however, was found more efficient for schizophrenia with good prehospital function as well as the affective disorders. The advantages of the long-term treatment approach were related to effective aftercare participation. Herz, Endicott, and Spitzer found brief hospitalization effective when linked with good continuity of care that provided day treatment and other nonhospital aftercare services.2,3 Klerman demonstrated clear evidence of the efficacy of psychopharmacologic agents in the treatment of schizophrenia and the major affective disorders.4

In a long-term study of adolescent inpatient treatment at Michael Reese Hospital, the unimproved patient remained hospitalized for less than 6 months and was minimally involved wirh other adolescents, staff, and the program.5 The markedly improved adolescent usually stayed in the hospital between 6 and 12…

The decision to hospitalize a young person for psychiatric treatment demands an integration of developmental, intrapersonal, and psychosocial factors that are operative, along with current conflict and behavior that signal the presence of extreme emotional stress. The upset and breakdown of an adolescent's basic life defenses indicates serious interferences in the critical areas of object relations and self-structures and produces functional impairment in all of the basic adjustment areas, the family, the community, and school.

Hospitalizaron has strong impact upon adolescents and their families and requires careful clinical and administrative judgments. Hospital izat ion should be considered only after outpatient alternatives have been ineffective or refused, or when the psychiatric disorder is severe enough to necessitate a comprehensive inpatient program. The latter is indicated when adolescents are overtly or potentially dangerous to themselves, their families, or others; when their behaviors are self-destructive through drug or alcohol abuse or self-inflicted injuries; or when they manifest repetitive running away, violence, truancy, promiscuity, social isolation, extreme mood swings, severe psychosomatic dysfunctions, or psychotic disorder. Other indications may be impaired ego strength manifested by aggressive, sexual, or dependency actions with major difficulty in maintaining interpersonal relationships and coping with age-appropriate environmental demands.

Adolescents may or may not experience distress, recognize or deny their problems and need for help, or cooperate with their admission to a hospital program. Most commonly, family members, pediatricians, school representatives, and professional consultants are distressed by the adolescent's behavior and are forced to arrange, by a series of manipulations, admission. Those adolescents and their families who have had therapeutic involvements are usually better prepared to use hospital ization as part of an overall treatment program.

The nosological label used on admission should not be considered final. A definite diagnosis requires a comprehensive assessment of the adolescent's physical, psychological, and sociocultural systems to include: a) etiological interactions of genetic and acquired factors; b) evaluation of patterns of behavior that have characterized previous adaptations; c) the dynamic impact of biopsychosocial precipitating stresses and predisposing factors that have resulted in maladaptation; and d) specific symptoms and signs along with their onset, duration, intensity, and response to therapeutic interventions. A synthesis of these findings and considerations should provide a comprehensive treatment plan designed to protect the young person and begin the process of resolving conflicts and encouraging further growth and development. The period of hospitalization is usually one part of the whole treatment plan, rather than being the definitive therapeutic approach, and requires posthospital planning from the onset.

LENGTH OF STAY IN THE HOSPITAL

Recent studies have considered the emerging patterns in psychiatric inpatient care mediated both by changing ideology and economic restraints. A popular current atritude is rhat "shorter is better" and "out is better than in." Click and Hargreaves found that short-term treatment was no less efficacious than longterm treatment for neurosis, personality disorder, and schizophrenia with poor prehospital functioning.' Long-term treatment, however, was found more efficient for schizophrenia with good prehospital function as well as the affective disorders. The advantages of the long-term treatment approach were related to effective aftercare participation. Herz, Endicott, and Spitzer found brief hospitalization effective when linked with good continuity of care that provided day treatment and other nonhospital aftercare services.2,3 Klerman demonstrated clear evidence of the efficacy of psychopharmacologic agents in the treatment of schizophrenia and the major affective disorders.4

In a long-term study of adolescent inpatient treatment at Michael Reese Hospital, the unimproved patient remained hospitalized for less than 6 months and was minimally involved wirh other adolescents, staff, and the program.5 The markedly improved adolescent usually stayed in the hospital between 6 and 12 months and was an active participant in therapy and the program. Gossett, Lewis, and Bamhart conclude that seven factors correlate with long-tenu outcome: severity of psychopathology; process vs. reactive onset of symptomatology; intelligence; severity of family dysfunction; a specialized adolescent treatment program; completion of recommended hospital treatment; and continuation of recommended psychotherapy after hospitalization.6 In their study, 65% to 70% of the adolescents showed significant benefits after a stay of 6 to 18 months and continuation of psychotherapy after discharge. This leads to the conclusion that continuity of care is a critical factor and short-term hospitalization is only indicated when a well -deve loped aftercare program is available and careful discharge plans are formulated from the onset.7

TYPES OF ALX)LESCENT PROGRAMS

The rationale for program selection depends on the early history of the adolescent upset, the diagnostic configuration of the pathologic response, emotional and financial resources available in the family, and resources available in the community. As the psychiatric treatment of adolescents improves through advances in research and clinical experience, a broadening range of services are being offered that allow the mental health professional real choices in quality care.

In the past 25 years, program availability has increased from a few residential and hospital programs to a cascade system of increasingly differentiated providers that offer adolescent medicine services; hospital short-term crisis intervention and diagnostic approaches; hospital medium and long-term psychotherapeutic programs; outpatient, day, and night hospital services; long-term residential treatment programs; and a variety of creative, specialized programs in therapeutic day schools, therapeutic foster homes, and special education programs in the public school system. Aftercare services include social and vocational skill training, educational and vocational guidance, as well as transitional living and treatment facilities. The wide range of choices make the proper selection increasingly difficult and demands a synthesis of the diagnostic factors present and the resources available in order to make an effective recommendation.

SHORT-TERM PROGRAMS

The concept of short-term programming depends upon the rapid reorganization of an adolescent and his family. Acute onset disorders may lend themselves to this approach if the fundamental problem is a reactive one and removal of the Stressor can be quickly accomplished. The most common interference with rapid integration is the presence of a non -recognized process disorder which only reveals the depth of psychopathology when the adolescent is separated from the family.

Basically, short-term hospitalization, for periods up to 3 months, is indicated for those acute disorders that require crisis intervention, extensive diagnostic evaluation, or placement planning. Among those disorders that respond to short-term care are anxiety disorders, acute psychotic reactions, acute affective disorders, dissociative disorders, psychosexual problems, disorders of impulse control, and toxic disorders from substance use.

The use of short-term hospitalization has been abused by some programs since, conceptually, shortterm care fits many current third party insurance plans. Presented as a definitive treatment approach, adolescents may be rapidly hospitalized with no prehospital planning, structured by behavioral approaches into giving up acting out, and rapidly discharged back to their families and special education programs, or dumped into loosely organized residential programs that depend on self-help approaches to peer programming. These patients may show evidence of superficial compliance, but frequently experience a continuance of severe pathology and prolongation of adolescent disorders into adult life.

The correct use of short-term care depends upon careful preplanning, if time is available, through diagnostic approaches to the young person and his family. Immediate thought should also he given to discharge planning and if residential or long-term hospitalization is deemed necessary, steps should be taken in those directions. The inpatient hospitalisation period should be occupied by careful study of the psychopathological process from an individual as well as a family perspective. In those cases where the child will be going home, visitation planning both in the hospital and through trial visits should he undertaken with careful supervision. In those programs that offer day hospital care, the transitional supports are built into the services available.

The use of psychopharmacologic agents along with psychotherapeutic approaches may be the main reason short-term therapy is efficacious. Affective disorders may be responsive to tricyclics, lithium carbonate, or other emerging drugs. Acute psychotic reactions can be treated with neuroleptic as well as antidepressive medications, and severe anxiety disorders may be helped by tranquilizers and use of antidepressives. It should be emphasized that the use of medication is only one part of a total approach U) the acutely disturbed patient and that psychotherapeutic measures are necessary to help the individual and family become restructured.

LONG-TERM PROGRAMS

Mediunvterm and long-term hospital programs may require a period of 4 to 12 months (or longer) to provide the structural changes necessary to correct deviant developmental processes influenced by early onset pathology. When individual psychoanalytic therapy is a key factor in the treatment program, a period of almost 3 months may be necessary to work through the resistances to separation and to form a treatment alliance with the individual and the family.

Long-term care should be considered in those young people with conduct disorders who have been chronically unresponsive to outpatient approaches; eating disorders, where restrictive dieting and bulimia with vomiting or purging is dangerous to health; psychotic disorders, where the underlying personality organization is devetopmentally borderline or schizophrenic (particularly with good prehospital function); and affective disorders with early onset or endogenous patterns that have affected developmental organization resulting in borderline personality disorder.

In order for long-term hospital treatment of adolescents to be effective, a specialized adolescent psychiatry treatment program should offer a wide range of services. In addition to core hospitalization, educational, recreational, specialized psychotherapeutic (individual and family), and discharge planning, including transitional care, are needed. Many adolescent care programs have the benefit of separate living or program facilities so that staffing procedures combine the residential treatment model, educational services, and hospital care.

As described by Rinsley, separation of an adolescent from the family conflict is usually traumatic.8 A major component of the separation process is a strong resistance phase characterized by collusive interactions reminiscent of early infantile attachments. The clinical challenge is to transform these resistances into positive motivations for the patient and family to become involved with the staff in the treatment process so that significant inner personality, group-communicative, and relationship changes can be effected.

The ensuing course of the inpatient process then assumes a profound commitment phase where fundamental changes may be made in both family and patient through a recapitulation and reworking of earlier distorted growth processes. Variously called the definitive or introjective phase,9 the engagement phase,10 and the phase of working through, this therapeutic phase usually leads to a readiness for the family to begin planning for the final termination phase and postdischarge planning.

Discharge planning, as mentioned, should be considered from the onset of hospitalization. In general, long-term hospitalization should be directed toward returning the child to the family and community, but in some cases where severe character and relationship pathology is present, the treatment approach can make transfer from hospital to residential care necessary.

RESIDENTIAL TREATMENT

The hospital treatment of a psychiatrically disturbed adolescent is rarely the definitive approach and may reveal the necessity for psychotherapeutic residential care based on findings of difficult- to-modify family dysfunction, borderline or psychotic personality organization, and severe learning defects based on organic impairment or severe perceptual difficulties. These pathological syndromes react with one another and result in complex symptom clusters that overwhelm the capacities of the family, the community, and particularly the individual.

As has been emphasized, early planning for eventual placement in an institutional setting is obligatory. The pathological attachments described by Bowlby11 must be worked through during the placement process or the therapeutic program, which may last 1 to 5 years, will be severely impaired or sabotaged. The separation process is variously handled, either through long-term prohibition of visitation, separate parent treatment, or family treatment when feasible. Recent attitudes seem to emphasize more parental involvement, but recognition should be given to those cases where extensive treatment is necessary before the family unit can be reintroduced and expected to operate as a functional group.

Residential treatment may also be seen as assuming the triphasic model mentioned. The resistance phase, the working-through phase, and the final termination phase depend on the adolescent's capacity to use a "second chance" and to be able to make enough therapeutic commitment to effect the basic structural changes needed. When a true therapeutic encounter can be undertaken, dramatic changes in life direction occur. Unfortunately, a certain skepticism remains when little change occurs because of the use of behavioral modifying programs without encouraging the basic structura) changes necessary for growth and development. The psychic impoverishment that results from poorly treated adolescents has made many professionals concerned about cost effectiveness.

CONCLUSIONS

A disturbed adolescent should be considered from a wide perspective while a treatment plan is being organized. The decision to hospitalize is a reasonable conclusion when there is functional impairment in all the life support areas (family, community, and school) and efforts to mobilize individual resources have failed.

Continuous preparation for entry into a hospital setting along with an anticipation of discharge perspectives is important from the onset. Separarionindividuation accomplishments are growth inducing and learning how to process entry, develop attachment to a program, and make commitment to a therapeutic effort are critical goals.

The decision as to whether to use short-term or long-term hospital ization depends on whether psychic reorganization can occur rapidly within the individual and the family or if process psychopathology is present. The use of specialized programming and aftercare facilities is emphasized, and true progress in an adolescent will be reflected by the formation of an adequate treatment alliance.

In those cases where hospital ization and therapeutic approaches to the family are not effective owing to extensive dysfunction, the use of a proper residential setting is indicated. Here structural changes are made only with extensive psychoanalytic psychotherapeutic efforts in both the adolescent and the family.

Adolescence should be considered a period during which extensive renegotiation of early developmental defects can still be effected. A growing range of treatment approaches are becoming available and a rationale has been suggested to improve the perspective around placement of upset young people.

REFERENCES

1. Click ID, Hargrcaves WA: PsWuoinc Hospital Treatment Fr>r Tin; J9SOs. Lexmgton. MA, Lexmgton B1KiIt. 1979.

2. Her: MI. Endicoct J. Spinet RL: Brief vs. standard hospital nation: The lam ? lies. AmJ Psyhiair, 1976; 115,795-801.

3. Hertz MI, Endicott J, Spicier RL: Brief hospital ization: A two year tblluw-up. AmJ Phychiatry 1977; 137:502-507.

4. Klcrman JL: National trends in hospital ization. Presemed at the Annual Meeting of the APA. Atlanta. Geòrgia, Mav, 1978.

5. Carrier B; Follow-Up Study of HoslMaiixed Adutescenis. New Yorfc, Bnmner/Maiel, 1972.

6. GossettJT, Lewis JM, Bamhart FD: To Find a Way: Thr Outcome of Hospuai Treatment of Disturbed Adnlescents. New York, Brunner/Mazel. 1983.

7. Feinsiein SC: Development I concepts in che quality care of adolescents. Journal of the Naaimai Association uf Private Psychiatric Hospitals- 1980; ll(3):38-42

8. Rinsley DC: BorderlincpsvchoparhofoBy: The concepts of M astersi«! and Rensley and beyond. Adeitsc Psychiatry 198h 9:259-274.

9. Rensiey DB: Intensive psychiatric hospiial treatment of adolescents: An objectrelations view. Psychaitry Q 1965; 39:405-42").

10. Masterson JF: Treatment of the Borderline Adolescent: A Oeuelojjmerttai Approach. New York, Wileylnterscience, 1972.

1 1 . Bowlby JL· Attachment Theory and Its Therapeutic Implications. Adolese Psychiatry 1978; 6:5-33.

10.3928/0090-4481-19861201-08

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