The Environmental Effects of Children’s Psychiatric Inpatient Hospitalization Stays
Eric Johnson, PhD
Background: Children have been shown to have a positive treatment effect from psychiatric inpatient stays. Objective: The purpose of this study was to determine why the treatment effect occurs. Hypothesis: The hypothesis was that if the children do demonstrate a change in behavior, the behavior will be in response to the inpatient environment and that after a two week period, no significant change would occur. Results: No significant difference from combined two week post admission scores to combined two week prior discharge scores was found (t(13) = .119, p.>.05). Conclusion: If change did occur, it occurred within the first two weeks as a response to a change in the environment. Before inpatient is considered, children should be referred to family therapists who focus on environmental changes that can be made in the home.
Keywords: children, inpatient, therapy, medication, primary care physician
In a study conducted by Goodwin, Gould, Blanco, and Olfson (2001), they identified that 84.4% of psychotropic medication prescribed to children and adolescents are done so by general practitioners or pediatricians. Goodwin et al, 2001 referred to primary care physicians as the gatekeepers to mental health. When clients are not making progress with medication management they are often referred by general practitioners to therapists. Studies demonstrate that medication management combined with therapy is more effective than medication management alone (Clarking, Carpenter, Hull, Wilner, & Glick, 1998; Craske et al., 2005; Feeney, Connor, Young, Tucker & McPherson, 2006; Mitchell, 1999; Safren et al., 2005).
Combined medication management and psychotherapy may not always be enough either. When outpatient therapy and medication management fails, physicians often look toward inpatient facilities. When using pre-admission and post-discharge data, inpatient facilities have been found to have a positive treatment effect with children (Garralda, Rose, & Dawson, 2008; Gavidia-Payne, Littlefield, Hallgren, Jenkins, & Coventry, 2003; Mayes, Calhoun, Krecko, Vesell, & Hu, 2001; Sourander & Piha, 1997).
Although some studies have identified variables that predict stability after discharge, it is not yet known why inpatient facilities, for children, have a treatment effect (Dean et al., 1995; Gavida-Payne et al., 2003; Sourander & Piha, 1997; Garralda, Rose, & Dawson, 2008). The aim of this study is to determine why the treatment effect of inpatient stays, for children, actually occurs.
Children have shown the ability to decrease or increase behavior quickly in response to changes in their environment (Moore & Boniecki, 2003; Moore, Tingstrom, Doggett, & Carlyon, 2001; Higgins, Williams, & McLaughlin, 2001). My hypothesis is that if there is a behavior change, the change in the child’s behavior will occur within two weeks after admission in response to the new environment of the hospital and that although the child will exhibit small increases and decreases in behavior, there will not be a significant change in behavior following the first two weeks of admission.
Setting and Participants
The setting was an inpatient psychiatric hospital for children. The unit holds up to 16 children. Acute and sub-acute stays are conducted on the same unit. I examined the behavior of the sub-acute (or long term residential) children only. All children received a diagnosis prior to admission. Each sub-acute child was receiving outpatient therapy and medication management prior to admission. As a requirement for admission, it was determined by a mental health professional that outpatient services had failed. I explored the data collected from the behavior of 45 children ages five to twelve. There were 11 females and 34 males.
The combined mean of the first and last month two week scores of all of the sub-acute children that were admitted and discharged in 2006 through 2009 was compared using a paired measures t-test. Only clean data was utilized. Data that contained missing information resulted in the children’s data being thrown out. The children were sometimes given passes into their homes. The days on which passes occurred, were not counted as a day spent in the residential center, and data was not collected from the day the child was in the home.
In this study, I utilized scores that were recorded on a form the facility uses to track child’s behavior. The behavior was recorded by PsychTechs who are have been trained by the nursing supervisor on how to fill out the form. Prior to filling out the form by themselves they were also required to observe seasoned PsychTechs fill out the form for an eight hour period on an average of 4-8 children, during the regular shift hours.
The forms were used to record the child’s behavior and points for each activity that are conducted on the unit. There were 20 activities that behaviors were recorded for. The behaviors that were recorded are: aggression, destruction of property, not flowing directions/unit rules, non-compliance, non-participation, stealing, disrespectful/inappropriate behavior, bullying peers, and instigating or lying. If a behavior was recorded within the activity slot, the child did not receive a point for that period. If no behaviors were recorded, a point was received. It is the daily total points that was used to measure child’s progress in this study.
An interrater reliability assessment was conducted with three spate sets of staff members. Two sets compared the ratings of two separate therapeutic recreational therapists to the ratings of two separate PsychTechs. One set compared the ratings of the charge nurse to a separate recreational therapist. The interrater reliability score (.76) was moderate.
A paired-samples t test was calculated to compare the combined mean of the first two weeks post admission scores to the last two weeks prior discharge scores. The mean on the combined admission scores was 747.36 (sd = 14.15) and the mean of the combined discharge scores was 735.36 (sd = 18.63). No significant difference from admission scores to discharge scores was found (t(13) = .119, p.>.05).
My hypothesis was that if there was a behavior change, the change in the child’s behavior would occur within two weeks after admission in response to the new environment of the hospital and that although the child would exhibit small increases and decreases in behavior, there would not be a significant change in behavior following the first month of admission. Children did exhibit small increases and decreases in behavior, but there was no significant change in behavior following the first two weeks of admission when compared with the last two weeks of discharge.
Overall, if a change did occur, it occurred immediately after a change in the environment. This indicates that behavioral changes may occur very quickly with environmental changes. It further indicates that once a child’s behavior has changed to fit the new environment, there is very little influence that continued residential stay will have on continued change.
There is no way of reliably using the same form that was used to collect data in inpatient, to collect pre-admission data about the child’s behavior in the home. For this reason, this study does not purpose to establish that inpatient treatment does indeed have a treatment effect. Rather, this study intends to identify that if an effect did occur, the reason for the effect would be the child’s adaptation to a new environment. Since failing outpatient medication management and therapy is a pre-requisite to admission, it is a reasonable conclusion to assume that more of the same would not influence the child to exhibit an increase of positive behavior. This appeared to be confirmed by the results.
In conjunction with medication management, primary care physicians should consider referring children to family therapists. Family therapists focus on environmental changes as opposed to processing issues. Changes in the child’s environment may lead to a change in the child’s behavior. A referral to a family therapist that focuses on environment should be considered before a child is admitted to a residential treatment facility.
The concept of children needing to stay at residential facilities for a period of several months needs to be examined by the mental health community. If no significant differences in overall scores exist over time, then there is not a need to keep the children for several months at a time. Future studies examining inpatient residential stays need to focus on quantitatively measuring recorded behaviors instead of perceived behaviors. This will increase the accuracy of the measurement and decrease response bias.
If children are admitted into psychiatric facilities, careful monitoring of their behavior with objective measures should be used to avoid unnecessary length in stays. If the child does not show progress or demonstrates a decline in progress within over a period of weeks, then it should be considered if the child has received maximum benefit from the residential stay.
Feeney, F. X. G., Connor P. J., Young, M. R., Tucker, J., & McPherson, A. (2006). Combined acamprosate and naltrexone, with cognitive behavioral therapy is superior to either medication alone for alcohol abstinence: A single centers experience with pharmacotherapy. Alcohol and Alcoholsim, 41(3), 321-327.
Gavidia-Payne, S. Littlefield, L. Hallgren, M., Jenkins, P., & Coventry N. (2003). Outcome evaluation of state wide child inpatient mental health unit. Australia and New Zealand Journal of Psychiatry, 37(2), 204-211.
Garralda, E. M., Rose, G., & Dawson, R. (2008). Measuring outcomes in a child psychiatry inpatient unit. Journal of Children’s Services, 3(3), 6-16.
Goodwin, R., Gould, S. M., Blanco, C., & Olson, M. (2001) Prescription of psychotropic medications to youths in office-based practice. Psychiatric Services, 52(8), 1081-1087.
Higgins, W. J., Williams, L. R., & McLaughlin, F. T. (2001). The effects of a token economy employing instructional consequences for a third-grade student with learning disabilities: A data-based case study. Education and Treatment of Children, 24(1), 99-106.
Mayes, S. D., Calhoun, S. L., Krecko, V. F., Vessell, H. P., & Hu, J. (2001). Outcome following child psychiatric hospitalization. Journal of Behavioral Health Service and Research, 28(1), 96-103.
Mitchell, G. C. (1999). Treating anxiety in a managed care setting: A controlled comparison of medication alone versus medication plus cognitive-behavioral group therapy. Research on Social Work Practice, 9(2), 188-200.
Moore, S., & Boniecki, K. A. (2003). Breaking the silence: using a token economy to reinforce classroom participation. Teaching Psychology, 30(3), 224-229.
Moore, W. J., Tingstrom, H. D., Doggett, A. R., & Carlyon, D. W. (2001). Restructuring an existing token economy in a psychiatric facility for children, 23(3), 51-57.
Clarkin, F. J., Carpenter, D., Hull, J. Wilner, P., & Glick, I. (1998). Effects of psychoeducational intervention for married patients with bipolar disorder and their spouses. Psychiatric Services, 49, 531-533.
Craske, G. M., Golinelli, D., Stein, B. M., Roy-Byrne, P., Bystritsky, A., & Sherbourne, C. (2005). Does the addiction of cognitive behavioral therapy improve panic disorder treatment outcome relative to medication
alone in the primary-care setting? Psychological Medicine, 35(11), 1645-1654.
Dean, X. P., Cohen, R. Nemil, M., Best, M. Al, Cassell, S. & Dyson. F. (1995). Children and Adolescents Discharged from Public Psychiatric Hospitals: Evaluation of Outcome in a Continuum of Care. Journal of Child and Family Studies, 4(1), 43-55.
Safren, A. S, Otto, W. M., Sprich, S., Winett, L. C., Wilens, E. T., & Biederman, J. (2005). Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behavior Research and Therapy, 43, 831-842.
Sourander, A., & Piha, J. (1997). Three-year follow-up of child psychiatric inpatient treatment. European Child and Adolescent Psychiatry, 7(3), 153-162.