The effectiveness of child psychiatric inpatient care

Outcome evaluation of a statewide child inpatient mental health unit

OBJECTIVE

To assess the impact of inpatient intervention, provided by a child mental health unit in Victoria, Australia, on a number of key child and family variables.

METHOD

Pre-post test design with a four-month follow up was applied to assess changes across time. Twenty-nine parents, 42 teachers, and 37 referrers provided reports on a series of child, parent, and family functioning measures.

RESULTS

Significant improvements in child behaviour and functioning, parenting competency and efficacy, parenting practices, and reduced parental depression were observed over time. Changes in family functioning scores were not significant; however, univariate analysis indicated improvements in two individual subscales.

CONCLUSIONS

There is a lack of studies of the outcome of inpatient interventions of children in psychiatric settings. However, as shown in the present study, improvements in functioning can be detected and obtained with short-term interventions that focus on both children and families. Methodological shortcomings (i.e. absence of comparison groups) and lack of specificity in intervention variables, however, are difficulties yet to be overcome in evaluation research of inpatient treatment.

Risk, motives, and styles of utilization review: a cross-condition comparison

In the United States various forms of managed care have been introduced to control the use of expensive medical services. One of the most prominent involves utilization review of hospital admissions. While reviewing the appropriateness of inpatient treatment is appealing in principle, its application is made difficult by clinical uncertainty. Managed care plans develop and implement review criteria often without the guidance of clear clinical norms of treatment. Under these conditions, we suggest that utilization review organizations (UROs) can be expected to develop "styles" of review that respond to clinical uncertainty, influenced by their experience, professional orientation, and financial incentives. Two review styles are explored in this paper: standardization, where the URO reduces the variance in clinical practices by eliminating those practices that deviate from professional norms and stringency, whereby the URO shifts the distribution of clinical practice as it tries to change the professional norms of practice. Data from a 1992-1993 national survey of utilization review organizations are used to test whether UROs have review styles that systematically respond to organizational attributes, economic pressures, and clinical uncertainty associated with three medical conditions: cardiac catheterization, low back pain, and adolescent depression. UROs were found to adopt more stringent review strategies for conditions with weaker norms of appropriate treatment. Financial incentives and organizational experience are positively related to greater stringency. Standardization responds to professional orientation and organizational experience. Variation in the review styles of UROs has implications for the resulting distribution of clinical practices as well as the equity of access to medical care.

Outcome of short-term child psychiatric hospitalization: teacher evaluation at 5-month and 12-month follow-up

This prospective follow-up study reports the outcome of children and adolescents discharged from short-term inpatient treatment based on teacher evaluations with Rutter's Questionnaire. There was a significant reduction in deviant behaviour between pretreatment and 5-month follow-up assessment but not between 5-month and 1-year follow-up. However, relatively few children fell within the normal range of non-clinically referred children. The child's more impaired general functioning, more frequent individual behaviour symptoms, antisociality and disengaged family interaction were associated with less favourable outcome. Pure affective or anxiety disorder predicted functioning within normal range and improvement in behaviour problems at follow-up. Treatment variables were not found to be associated with the outcome.

Short-term child psychiatric inpatient treatment. Place of residence as one-year outcome measure

In this study, 100 patients consecutively admitted to four child psychiatric inpatient wards in Finland were prospectively followed 12 months after discharge from short-term inpatient treatment. It turned out that 50 patients were discharged back to their previous residence and to outpatient treatment, 40 patients were admitted to long-term inpatient treatment and 10 patients were placed in some institution. The child's antisocial behaviour on admission was the strongest determinant for long-term treatment or placement at the 12 month follow-up. Other predictors of long-term treatment or placement in an institution included a high total score in teacher's behaviour ratings, being referred by a psychiatric agency and living in a semi-rural area. No statistically significant relationship was found in the child's age, gender, parents' education level or occupation, family characteristics, total life events, parent's ratings of total behaviour, total life events, parent's ratings of total behaviour, CGAS ratings by a clinician or a wide range of treatment variables.

Child psychiatric short-term inpatient treatment: CGAS as follow-up measure

The present study reports the outcome and follow-up data of 50 children and pre-adolescents consecutively admitted to a short-term child psychiatric inpatient treatment programme. Children were evaluated with the CGAS on admission, at discharge, and at 5-month and one-year follow-up after discharge.

Parent and teacher reports of problem behaviors in child psychiatric inpatients: cross-informant correlations on admission and at 5-month follow-up

The present study compared parent and teacher evaluations of behavioral problems in a sample of school-age child psychiatric inpatients on admission and at 5-month follow-up. Both parents and teachers viewed changes in children's emotional/behavioral problems over the course of the follow-up period rather similarly. In general, parents and teachers viewed children's behavior as significantly improved relative to pretreatment.

Adult criminality among formerly hospitalized child psychiatric patients

Among 170 preadolescent children (138 males, 32 females) admitted to the University of Iowa Psychiatric Hospital between 1970 and 1983, 23 males (17%), had adult prison records at follow-up in 1990. Assaultive behavior in childhood predicted adult imprisonment (odds ratio = 4.96, 95% confidence interval 1.8-13.8, p = 0.002), as did criminality in a biological parent (odds ratio = 4.0, 95% confidence interval 1.3-12.4, p = 0.015). Diagnosis, including conduct disorder, was not correlated with outcome. Among these young children, male gender, violence, and parental criminality identified persons at high risk for adult imprisonment. Psychiatric hospitalization in childhood is a risk for adult disturbance, including sociopathy.

Patients' characteristics and consumer satisfaction on an inpatient child psychiatric unit

This paper reports the results of a chart review and consumer satisfaction evaluation of referrals to a tertiary care child psychiatric inpatient unit. The evaluation involved an examination of the types of child and family difficulties treated during the period of the study; the nature and extent of assessment, treatment and follow-up; treatment outcome and parental perception of factors related to treatment outcome; and the satisfaction of both the parents and referral sources. Results indicated that children admitted for treatment were a heterogeneous group with severe difficulties from families with a number of problems. Most parents and referring therapists were very satisfied with the treatment, recommendations and follow-up provided. Significant correlations were observed between the parents' and referring therapist's satisfaction with the service and the extent to which home based problems were addressed during the child's stay in hospital. In addition, some suggestions are given for strategies to improve services. The findings are discussed with special reference to the value of program evaluations for inpatient child psychiatric services.

Parental substance abuse and suspected child abuse/maltreatment predict outcome in children's inpatient treatment

There has been relatively little empirical study of outcome for school aged children treated in psychiatric hospitals. In earlier studies, four preadmission variables were operationally defined and studied as hypothesized predictors of poor outcome in psychiatric day treatment by the criterion of recommended in-home or out-of-home placements on discharge. The preadmission variables are recent histories of severe aggression and suicidal ideation/behavior in the child and histories of parental substance abuse and reported suspicions of child abuse/maltreatment. In this study, the work has been extended to determine if these four preadmission factors relate to outcome of children treated in inpatient hospitalization. The findings indicate that the parent/family related variables, and not the child variables (nor child diagnosis), are significantly related to out-of-home recommended placements.

The effectiveness of a child psychiatric unit: a follow-up study

This follow-up study to determine the effectiveness of a child psychiatric unit found evidence to support a program emphasizing a predetermined period of hospitalization. Most measures of family satisfaction, behaviour and social function improved significantly. The unit appears to treat older children as well as those less than 9, children from fighting families as well as those with less fighting, and sexually abused children as well as physically abused children. The program includes: 2 weeks of preadmission evaluations, 5 weeks hospitalization and 5 weeks of follow-up, placement decisions made before admission, primary responsibility for front line staff and treatment programs composed of various combinations of techniques from a list of 65 possible techniques.