Approved by Council, June 1989
To be reviewed
The American Academy of Child and Adolescent Psychiatry supports the use of inpatient psychiatric treatment in a hospital setting when the psychiatric needs of a child or adolescent, as assessed by a properly qualified psychiatrist, warrant such treatment and when the treatment provided is of high quality.
- A "qualified psychiatrist" is a fully trained child and adolescent psychiatrist. For patients 14 years of age and older, a general psychiatrist with documented specialized training, supervised experience and demonstrated competence in work with adolescents, may be considered qualified.
- Recognizing that inpatient hospital treatment may have both desirable and undesirable effects and requires the commitment of costly resources, the decision for admission and continued treatment must be very carefully considered.
Essentials include the diagnosis of a psychiatric disorder as defined by both the criteria of the American Psychiatric Association's DSM-III-R and the criteria for inpatient psychiatric hospitalization described in Chapter 4 of the American Academy of Child and Adolescent Psychiatry's Guidelines for Treatment Resources, Quality Assurance, Peer Review and Reimbursement. Among many others, these guidelines include as requirements:
- The psychiatric disorder must be of such severity as to cause significant impairment of daily functioning in at least two important areas of the child and adolescent's life such as school performance, social interactions, or family relationships.
- The treatment proposed mush be relevant to the problems diagnosed and adjudged likely to benefit the patient.
- Other available less restrictive treatment resources must have been considered and determined to be not available or not appropriate to the patient's's needs or have been attempted and proven unsuccessful. Examples of less restrictive treatment resources would include, but not be limited to, residential treatment, day treatment, or intensive outpatient care.
The decision to admit a child or adolescent younger than 16 years of age to a psychiatric hospital should be made by a qualified psychiatrist as defined in I.A., unless there is no such qualified psychiatrist available, in which case a general psychiatrist is required.
- This decision must be based either on an examination conducted personally by the admitting child psychiatrist or on the basis of an evaluation at the time of admission by the admitting psychiatrist of the findings of an appropriate clinician.
- In every case the admitting decision must be confirmed within twenty-four hours of admission on the basis of a personal examination by a qualified psychiatrist.
Inpatient treatment should be conducted in a facility approved by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and meeting its criteria for inpatient hospital-based psychiatric treatment programs for children and adolescents.
- Unless there are compelling clinical reasons to the contrary, or serious limitations in availability, children and adolescents younger than 14 years of age should be admitted only to programs that are designed for children and adolescents and physically distinct from programs for adult psychiatric patients.
- Adolescents 16 and older may be admitted to adult units for valid clinical reasons, but should be treated in a program specifically designed for hospitalized adolescent patients.
The patient's treatment program should be under the direction of a qualified psychiatrist, as defined in I.A.
- The treatment should include an individualized treatment plan based on an assessment of the patient's's biological, psychological and social needs.
- The plan should address the patient's's developmental needs including those for education and age-appropriate social interaction.
The child or adolescent should be encourage to participate voluntarily in the decision for admission, in the process of ongoing treatment, and in discharge planning.
Every effort should be made to keep parents as fully informed participants through the course of a child or adolescent's hospitalization.
- Prior to admission, parents should receive an explanation of why inpatient treatment is being recommended, what benefits may be expected from it, and what, if any, appropriate alternative treatment options are available.
- Parents should be told what their child's treatment program will include, how school progress will be maintained, and the roles of treatment team members, including the overall responsibility for treatment of the attending psychiatrist.
- Parents should understand the expectation for their involvement in their child's treatment and in discharge and aftercare planning.
- Before admission, parents should also be fully informed of their financial obligations for treatment and how financial issues may impact the length of their child's hospitalization.
The goals of the treatment plan and the length of time expected to achieve these goals should be discussed with the parents. They should understand that hospitalization will be one phase in the treatment process and that their active involvement in the treatment is expected to continue.
The Academy fully supports external review of admission and treatment decisions to ensure clinical appropriateness, evaluation of length of stay and quality of care, recognizing the need to help contain costs of expensive hospital resources.
- Such review should emphasize clinical issues as its major concern and priority.
- Review should be conducted through a peer review mechanism involving a qualified psychiatrist with experience in the inpatient hospital treatment of children and adolescents.
- The Academy encourages its members to be actively involved in the process of peer review and quality assurance in order to make quality, comprehensive psychiatric treatment accessible to all children and adolescents in need.
The following behavior are considered inappropriate and/or unethical:
- Participation in any program which offers to any party financial or other rewards in exchange for admissions to the program.
- Participation in any program which does not require admission decisions be made by a qualified psychiatrists.
- Participation in a program which uses misleading, guilt-provoking, or unduly alarming advertising to promote self-referrals and admissions.
With the application of these principles, inpatient psychiatric hospital treatment will be used only when necessary and avoided when other, more appropriate alternative treatments are available. Those who plan, provide, and finance psychiatric treatment for children and adolescents will need to make consistent and concerted efforts to ensure the availability of such alternative services.