Reasons for admission to an adolescent unit

Journal ofAdolescence 1989, 12, 187-195

Reasons for admission to an adolescent unit TONY

JAFFA

AND ANNA MARIA DEZSERY

Three years admissions to a regional adolescent unit are analyzed to obtain information on the referral, the adolescent and family, and the behaviours leading to admission. The findings are discussed with particular relevance to the N.H.S. Health Advisory Service report on services for disturbed adolescents. Possible implications of the report which are not described by the H.A.S. are described. INTRODUCTION

N.H.S. Health Advisory Service Report

In I 986 the N . H . S . Health Advisory Service published its report on services for disturbed adolescents entitled Bridges Over Troubled Waters. It recommends uniform admission policies and more eclectic methods to widen the range of disorders treated. Also that adolescents not be excluded from services on the grounds of “mental handicap, sensory handicap, acquired brain damage, chronic physical illness and autism”. The report has had a mixed reception. It has been suggested that implementation of the recommendations may result in a set of adolescent units which attempt to cater for all but satisfactorily cater for few or none (Wells, 1986). Adolescent Units Adolescent units vary widely in their admission criteria and their models of working (N.H.S. Health Advisory Service, 1986). Framrose (1975) describes a period of outpatient treatment and a negotiated admission. Wells (1978) emphasizes the motivation of both adolescent and family. Steinberg (1981, 1983) differentiates admission of adolescents with a clearly defined psychiatric condition from that of those presenting in a social crisis. Ainsworth’s admission criteria include a willingness of the carers to co-operate with treatment, and the belief of the unit staff that there is a need for observation and investigation, or scope for therapeutic intervention (Ainsworth, 1984). Reprintrequeststo Tony Jaffa, Senior Registrar in Child&Adolescent Clinic, Tavistock

Centre, 120 Be&e

014~‘97’189/020’87 + 09 903.00l0

Psychiatry, The Tavistock

Lane, London NW3 gBA, U.K.

0 1989The

Association for the Psychiatric Study of Adolescents

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T. JAFFA

AND A. M. DEZSERY

This study was carried out at Hill End Adolescent Unit. It is the unit for younger adolescents (under 16) in the North West Thames Health Region. It is a short stay unit with rapid response to referrals and no waiting list. The criterion for admission is that the person or persons with legal parental authority state that they cannot cope with the adolescent and specify the behaviour that cannot be coped with. The focus of the work is to achieve the minimum change needed for those responsible for the adolescent to discharge them. There are no apparent exclusion criteria for admission. Adolescents are not excluded from the service on the grounds of physical or mental disorder or behaviour disturbance. The unit policies (Bruggen and O’Brian, 1987) are made clear to those with parental authority, and they will make the decision to admit or not. The policies are also made clear to the referrers who may influence this decision and who may or may not refer subsequent cases. This study This retrospective study of the admissions to Hill End Adolescent Unit in the years 1983, 1984 and 1985 was undertaken to describe characteristics of the adolescents and to relate these to the admission policy. Most papers look at the diagnoses. Working in a unit which focuses on problem behaviour, we decided to look not at diagnosis but at the behaviour not coped with by those in the community. METHOD The admission register was used to obtain a list of all admissions in the three years 1983, 1984, 1985. Inspection of names and dates of birth allowed exclusion of second and subsequent admissions for any adolescent, leaving a list of all first admissions in the study period. For each of these, the admission form, case notes and discharge summary were used to collect information on the referral, the adolescent and family, and on the behaviours leading to admission. RESULTS The total number of first admissions in the three years 1983-1985 was 139. In two cases there was insufficient information on the admission form, leaving 137 cases for further analysis. Age and Sex 73 cases (53 per cent) were boys and 64 cases (47 per cent) were girls; 15and r4-year-olds each made up 33 per cent of cases and 13-, 12- and I I-year-olds made up 27 per cent, 14 per cent and 4 per cent, respectively.

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Refening agencies Analysis of referrals by professions of referrers gave the information shown in Table I.

Table 1. Prvfession of referrers

Social Workers Psychiatrists General Practitioners Teachers Psychotherapists Other (Ed. Psych., Nurse, Other)

No.

%

86 27

62

IO

7 4 4 3

5 5 4

20

The largest group of referrers was social workers. Of the 86 social workers, 43 referred from Social Services Area Offices, 31 from Child and Family Psychiatric Clinics, seven from General Hospitals and five from Residential Social Services Establishments. Analysis of referrals by place of work of referrers gave the information shown in Table 2. Table 2. Place of work of referrer

Child and Family Psychiatric Clinic Social Services Office General Hospital General Practice School Social Services Residential Establishment Psychiatric Hospital

No.

%

49 43

37 3’

20

'5

IO

7 4 4

6 6 3

2

Of the 4g referrals from Child and Family Psychiatric Clinics, 31 were from social workers, 12 from psychiatrists, four from psychotherapists, and one each from a nurse and an educational psychologist.

The adolescents-site

of parental authority and place of residence

Analysis of family and living circumstances information shown in Tables 3 and 4.

of the adolescents

gave the

T. JAFFA

r9o

AND A. M. DEZSERY

Table 3. Person(s) legally responsible for the adolescent

Both natural parents Natural mother Natural father Adoptive parents Local authority Other

No.

%

39 4’

29 30

;

z

40

29

2

I

Table 4. Residence at the time of admission

Home with both natural parents Home with natural mother only Home with natural mother and her partner Home with natural father with or without his partner Home with adoptive parent(s) Home with foster parents Local authority residential establishment Residential school Other

No.

%

32 27 I8

24

4 : 30 j:

20

‘3

: 4 22

f;

Of the 30 adolescents who were living in Local Authority (L.A.) residential establishments, 27 were in the care of their L.A., two in the care of their mother and one was a ward of court. Of these 30,24 were referred to the unit by social workers, four by psychiatrists and one by a psychotherapist and a G.P. each.

Reasons for admission We did not record all disturbing behaviour, but only behaviours that those with legal parental authority felt unable to cope with. These were the behaviours which resulted in admission and are listed in Table 5. The table shows the number of cases for which each behaviour was recorded as an intolerable problem. As in many cases more than one behaviour appeared, the total number of behaviours is higher than the number of admissions. There was a mean of 2-5 behaviours given as the reason for admission; 21 cases had a mean of 4 or more. Most of the behaviours are self-explanatory. Physical violence included violence towards people, animals and objects. Sexual behaviour was given as

REASONS FOR ADMISSION TO AN ADOLESCENT

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Table 5. Pmblem behavioun

No. of cases Physical violence Verbal abuse, disobedience, lying Staying out late, running away Substance abuse Self-harm threatened or attempted Not going to school Theft Mood swings Bizarre behaviour Sexual behaviour Untidyness/dirtyness Withdrawal Fire raising Not staying at school Refusing to eat Sleep problems Bedwetting Overeating/obesity Soiling Suspension from school Refuse to separate from mother Physical complaints with no cause found Victim of violence Vomiting

69 68 33 20

a3 21 20 12

8 8 5 5 4 4 3 3 2 2

2 2 I I I

I

a reason for admission in five girls and three boys. For the boys, it included sexual advances to younger children and self-exposure. Substances abused included solvents, alcohol and other drugs. In 14 cases there was solvent abuse, in five alcohol abuse, and in five abuse of other drugs. There were four cases of multiple substance abuse. The category “bizarre behaviour ” included hearing voices; smearing of food and faeces; complaining of the skin being too tight, the eyes falling down, of being different, e.g. of being “dragged from an abortion basket”, chanting and wandering; and “gruesome tales”. There was an association with violence in five cases, with verbal abuse and with self-harm in three cases. DISCUSSION This study showed a slight excess of male admissions. A previous study of Hill End Adolescent Unit (Bruggen, Byng-Hall and Pitt-Aikens, 1973)

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found a slight excess of girls, as do the studies of other units (Ainsworth, 1984; Framrose, 1975; Wells, Morris, Jones and Allen, 1978). Our finding, that two-thirds of the admitted adolescents were 14- and IS-years-old, is consistent with other published figures (Ainsworth, 1984; Bruggen et al., 1973; Wells et al., 1978). The predominance of referrals by social workers (62 per cent of admissions) was markedly different from the accounts of other adolescent units which had the majority of referrals from doctors (Framrose, 1975; Wells et al., 1978), or even insisted that doctors make all referrals (Ainsworth, 1984). The relatively high proportion of social worker referrals to Hill End Adolescent Unit might reflect the policy of accepting and encouraging referrals from all professionals working with children. It is also possible that social workers feel more comfortable with the unit’s emphasis on behaviour rather than diagnosis. Where psychiatrists and social workers work together this might lead to the social worker rather than the psychiatrist being chosen to make the referral. Compared with Ainsworth’s (1984) figures this study shows a considerably lower percentage of adolescents living with both natural parents, and a higher percentage in the care of the Local Authority. The numbers living with a single mother and with mother and stepfather on the other hand, are similar. The higher proportions of Hill End Adolescent Unit admissions in Local Authority care may be related to the finding (discussed above) that Hill End Adolescent Unit is used more by social workers and less by doctors. Violence as a factor

in admission

Intolerable physical violence was a reason for admission for about 50 per cent of the adolescents. This was the case irrespective of the profession of the referrer and of the sex or home circumstances of the adolescent. Therefore the high incidence of violence is not related to the high proportion of social work referrals or to the high proportion of adolescents admitted from local authority care. Perhaps it is related to the fact that Hill End does not discourage or refuse the admission of violent adolescents. Implications

of violent adolescents

for the running of Hill End Adolescent Unit

The adolescent unit is highly structured with close supervision and an expectation that adolescents behave well and observe the rules of the unit. If they break the rules, staff react promptly, calling meetings to clarify rules and/or discuss the incident. Safety of staff and patients is seen as of paramount importance, and is stressed in the regular staff training events which include sessions on techniques of physical restraint.

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Implications of HiIl End Adolescent Unit’s Admission Policy The emphasis on presenting problem rather than diagnosis, and on decisions about admission and discharge being made by those with legal parental authority rather than by doctors, raises several questions. Can such a unit provide a service for the psychiatrically disturbed adolescents of the region? Is the work of such a unit, psychiatry, or is it residential social work? It may be that potential referrers are deterred by their understanding of the unit policies and so do not refer some of the “psychiatrically ill” adolescents. This possibility could be explored by further research. The impression of Hill End unit staff, based on experience and perhaps prejudice, is that the unit policies are appropriate for meeting the needs of most of the psychiatrically ill adolescents who are referred. Steinberg (1983) makes the point “that the crucial distinction between an inpatient unit and every alternative (including day patient care) is quite simply having trained psychiatric nurses available and awake at night with a duty psychiatrist available if necessary”. Many psychiatrically ill adolescents, according to the thinking of Sternberg and the Hill End policies, are best managed outside the hospital setting. Where admission of these psychiatrically disturbed adolescents is appropriate it is often on the ground that they cannot be coped with elsewhere, and this falls within the reasons for admission to the Hill End Adolescent Unit. The group of autistic, schizophrenic and retarded patients who, in the experience of Steinberg (1g83), “remain dependent on residential psychiatric care for a long time” are admitted to Hill End on the grounds that no one else can cope with them and remain there for the same reason, sometimes until the unfortunate young people become too old for the unit and are transferred to another hospital. There are occasions when the unit admission and discharge policies are seen not to be appropriate for psychiatrically ill adolescents, and it has been found necessary temporarily to abandon them for the good of a particular patient. The parents of a Is-year-old admitted her on the grounds that they could not cope with her obsessional behaviour. This included ritual touching and repeating words aloud. She had been refusing to touch food until two hours of rituals had been completed. A minimum change was agreed with great difficulty, not least because staff perceived this girl to be very disturbed and found it difficult to press the parents with confidence. The change required was that she sit upright at meal-times. After an initial period in which she hardly spoke, ate or drank very little, and began to appear dehydrated, staff met to review progress. Lack of response to the unit regime and the apparent suffering of the girl and her parents convinced staff that it was no longer justifiable to manage her in this way. It was agreed with her parents that she would be started on a drug. This change carried the obvious implication that

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she was being treated as psychiatrically ill. The emphasis of treatment shifted away from notions of her changing her behaviour so that she could be coped with at home, and she was started on oral clomipramine. Is the work of Hill End Adolescent Unit appropriately done by psychiatric services, or would it be more appropriately done by social service departments? After all, is not a reason for children being placed in the care of social services, that parents cannot cope with and therefore meet the various needs of their children? One might argue that those childen not being coped with for psychiatric reasons should be in the province of psychiatry, and that those not being coped with for social reasons should be in the province of social service departments. A substantial proportion of child psychiatric patients and their families have psychological and social problems. A multidisciplinary approach enables attention to psychological, social and medical needs in a way that would be more difficult in a social service residential home. When it is apparent that the problems of an adolescent are mainly social, then such an adolescent would be admitted only if admission to a social service institution was not possible, or more commonly, where this had been tried but the residential social workers had been unable to cope. A period in the adolescent unit with the psychological therapies (mostly group and family) which are a part of the regime, may result in changes which allow the adolescent to be managed in the residential home, or in some cases, back in the family home. This seems an appropriate use of psychiatric resources, and is arguably no less so because the adolescents do not have a formal psychiatric diagnosis. Implications

of the Health Advisory

Service

report

If influential, the H.A.S. report is likely to cause pressure for change in adolescent units. This would encourage the development of uniform units covering defined catchment areas. Each unit would offer a service for all the disturbed adolescents of its area. Such a change might avoid disturbed and disturbing adolescents falling between idiosyncratic services and remaining in the community. But is it possible? How many units can provide equally well for all disturbed adolescents, irrespective of such factors as diagnosis, intellect, behaviour? A policy designed to serve one group of adolescent, or diagnoses, of problems, may act to exclude another group. At the extreme, a unit which relies on verbal therapy may be used less for the deaf mute. A unit which relies on sign language may be used less for those of normal hearing. Although Hill End Adolescent Unit has no apparent exclusion criteria for admissions, it is our impression that the very explanation of the unit’s policies may act as an exclusion process for certain adolescents and those responsible for them. It may be that a prospective referrer or person with parental

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authority for an adolescent will be put off by a visit to the unit in which they are exposed to the violent, the psychotic or the deaf mute. Some units exclude certain adolescents as a matter of policy. Hill End Adolescent Unit, which tries to have policies which do not exclude any adolescents, may in fact be excluding adolescents by these very policies. We are aware of the following cases: parents who refused to admit a boy to the unit because it had a time-out room; a mother who decided not to admit her depressed r4-year-old son when she realized that he might be with delinquent adolescents; parents who discharged their 13-year-old daughter when she described the disturbed behaviour of an older boy. We suggest that the H.A.S. assesses the working of those units which claim to do what it recommends, namely not to exclude adolescents on the grounds of physical or sensory handicap, brain damage, physical illness or autism. This might give further information on the effect of these policies, and either provide support for the H.A.S. recommendations or suggest the need for their review. Thanks to John Rose for his work on organizing the data. REFERENCES Ainsworth, P. (1984). The first IOOadmissions to a regional general purpose adolescent unit. Journal of Adolescence 7, 337-348. Bruggen, P., Byng-Hall, J. and Pitt-Aikens, T. (1973). The reason for admission as a focus of work in an adolescent unit. British Journal of Psychiatry 122, 319-329. Bruggen, P. and O’Brian, C. (1987). Helping Families: Systems, Residential and Agency Responsibility. London: Faber and Faber. Framrose, R. (1975). The first 70 admissions to an adolescent unit in Edinburgh; general characteristics and treatment outcome. British Journal of Psychiatry 126, 38~9. N.H.S. Health Advisory Service (1986). Report on Semites for Disturbed Adolescents. Bridges Ower Troubled Waters. London: H.M.S.O. Steinberg, D. (1983). The Clinical Psychiatry of Adolescence. Chichester: John Wiley. Steinberg, D., Galhenage, D. P. C. and Robinson, S. C. (1981). Two years’referrals to a regional adolescent unit: mrne implications for psychiatric services. Social Science and Medicine 15, 113-122. Wells, P. G., Morris, A., Jones, R. M. and Allen, D. J. (1978). An adolescent unit assessed: a consumer survey. British Journal of Psychiatry 132, 3oc-8. Wells, P. (1986). Cut price adolescent units that meet all needs and none? Bulletin of the Royal College of Psychiatrists 10, 9, rj1-q2.