Kim Masters M.D. and Vida McMinn, R.N.
Have you ever been consulted about admitting “out of control“ children or adolescents? These calls often come to our facility from local mental health centers, their homes, and regional emergency rooms. Upon arrival at our hospital, these patients often again became aggressive, frequently requiring restraint, seclusion, or medication.
Did you sometimes wonder if the referring staff were describing behavior that the child could control if he/she were less angry, fearful, or confused? Did you think that maybe the crisis environment was provoking the aggression? We wanted to find out.
We asked the intake staff at Focus by the Sea, a private psychiatric hospital on St. Simons Island, Georgia, where we work, to talk to angry and distressed children and adolescents at the time of referral to see if it would establish their trust in our treatment and thus decrease the number of admission “codes”— calls for restraint—in our lobby. Initially, emergency room staff and some practitioners refused to let us. They thought that the patients were not in enough control to talk to us and that it was “unprofessional” to let these phone calls interfere with communication between professionals or parents and referral sources. We were able to overcome this resistance with our explanation about this project.
Surprisingly, we found that almost all patients were willing to talk to us. The conversations were brief, no more than 5-10 minutes. They followed an outline that required the intake staff to introduce themselves and ask if the child/adolescent knew anything about the hospital youth program to which he/she was being referred. The staff gave a description of the program, emphasizing the following elements:
- Purpose: teaching better coping skills;
- Requirements: that all patients cooperate in learning to control their anger through safe methods that we taught;
- Involvement of Family Members: that family members be included in family sessions and daily visitations;
- Length of Stay: up to 10 days.
Children and adolescents were asked if they had any questions, about the program. The conversation ended with the intake staff asking if they wanted to come to the program and if they wanted to learn the unit’s non violent anger management strategies. Whenever possible, the intake staff who talked to the patients also met them on arrival at our hospital to further the treatment alliance.
Almost all the children we talked with have agreed to come willingly to our child and adolescent program and there have been no “codes” in the lobby from these referrals. Why? Many children and adolescents think that a psychiatric hospital stay is akin to a jail sentence: restrictive, punitive, and without freedom and autonomy. By consulting with them before admission we are able to offer a different picture of the experience: educational, supportive, collaborative, and impossible without their consent. This is empowering and enables treatment.
Another type of hospital crisis occurs when parents bring children or adolescents for a psychiatric admission under false pretenses, such as: “seeing the doctor,” “having an outpatient consultation,” or “visiting a friend.“ In essence, the guardians are handing the facility a “loaded bomb.“ These explanations are often offered: “That is the only way I could get him here,“ or “She would have jumped out of the car if she knew we wanted her admitted.”
Our approach has been to suggest to the child or adolescent that his innate intelligence has already told him that a hospital stay is likely, so it is not necessary to act as if this is a surprise. When this is acknowledged, the intake person can then stress the collaborative nature of treatment, and differentiate it from a prison sentence. Making this point successfully allows a frightened or angry child/adolescent to work in collaboration with the hospital staff in treatment. For some patients, particularly those who are especially wary or fearful, suggesting that they work out a reward with their parents for successfully completing the psychiatric program also helps to improve the therapeutic alliance between the patient, family and hospital staff.
Sometimes hospital lobby crises are exacerbated by verbal interchanges between the child or adolescent and his parents. In these cases, we often talk with the child by him/herself, and divert the parents to another room where they can sign the admission papers. Sometimes this promotes autonomy skills, allowing the patient to go to the psychiatric unit with the intake worker, to be introduced to unit staff, and to be admitted on his own. The parents visit once the child has settled in.
These strategies also work well with children with separation anxiety who present to our hospital because of their inability to go to school. Often they are prepared to replay in our lobby, past “horror scenes” in which they were forcibly peeled away from their parents’ cars by school staff amidst yells and screams. The use of a reward for participation in treatment and separation from parents during the intake session, permits a different more collegial relationship to develop with hospital staff which undercuts the anxiety and panicky behavior.
Decreasing the need for seclusion and restraint means making treatment alliances between hospital staff and the children and adolescents with whom they work. Why not start this process before admission?
Dr. Masters is Medical Director of Focus by the Sea, a private psychiatric hospital on St. Simons Island, Georgia. He is also co-author of AACAP’s Practice Parameter on the Prevention of Aggressive Behavior. Ms. McMinn is Director of Needs Assessment at Focus by the Sea.