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Hospitalized Children Benefit When Included in Care Decisions

Encouraging children to take an active role in treatment planning and goal setting while hospitalized on a psychiatric unit may make the experience easier and more productive for all concerned.

How well do children understand their own psychiatric problems and the treatment they receive as inpatients? How well does the staff understand the children's views and take them into account when making clinical decisions?

"There hasn't been much research on this issue," said child psychiatrist Francis Sparrow, M.D., medical director of Philhaven Behavioral Healthcare Services in Mt. Gretna, Pa., in an interview. "Children often feel abandoned and uncertain about why they are in the hospital."

At his own facility, in the farmland east of Harrisburg, the staff tries to clarify to children which elements of the hospitalization they can be responsible for and how the stay fits into what the family, school, or community can do.

"How much they understand depends on the age and cognitive level of functioning," said Sparrow. "The burden is on the treatment team and care providers to put it in terms they can comprehend. For instance, after the first day or so, when we have a working diagnosis and treatment plan, we try to explain to the patient and the family about behavioral health in general, about the diagnosis and treatment, the role of each provider, and how all this fits together to help them."

Now a small, qualitative study of children admitted to a psychiatric inpatient unit in London has looked in detail at how children's perceptions of their hospitalization changes during their stay.

Children with a passive view of their treatment at admission took a more active one by discharge, but they still felt excluded from setting treatment goals, wrote Felicity Hepper, M.Sc., Tim Weaver, Ph.D., and Gillian Rose in the winter issue of Clinical Child Psychology and Psychiatry.

The researchers conducted semistructured interviews of 18 children just after admission and shortly before discharge. The 11 boys and seven girls, aged 8 to 13, were referred from area mental health centers. Diagnoses included attention-deficit/hyperactivity disorder (5 children), high-functioning autism (4), obsessive-compulsive disorder (3), depression (2), learning disability (1), psychotic episode (1), and atypical autism (1).

The postadmission interviews asked the children for their view of their problems and why they were coming to the unit, their treatment expectations, and what they thought their role in treatment would be. The predischarge interview asked if the stay had been helpful, how well they were involved in treatment decisions, and what their peers thought of the child's admission.

Generally, the children said they had come to the unit because they were unable to control themselves, wrote the authors. Eleven of the 18 children were there to deal with "temper problems," while others cited "worries" or "depression."

Upon arrival, most of the children thought that treatment would help them but that the staff would take the lead in their care.

By discharge, however, their explanations of treatment were more complex, and they had a more engaged view of their roles. They had learned to talk to the staff to gain their attention rather than acting out. Their newly developed ability to manage anger or anxiety helped them feel more in control of themselves and increased their self-esteem. Some described the insight into their own lives they had gained from watching other children's negative behavior.

They also developed insight into the workings of the institution. Before admission, children had a poor understanding of the therapeutic work conducted on the unit. They saw treatment goals created and managed by others only as a means to gain rewards when completed successfully. At discharge, they wished they had been involved more in the process: "Maybe just to be asked," said one child. While children appreciated the containment offered by the institution, they also felt that staff supervision meant a lack of privacy and autonomy.

"This study speaks to the role children can have in their hospitalization," said Sparrow. "You have to have the child at the table to explain what you're doing and why. If their role in their care is passive, their level of engagement in the treatment process is going to be diminished, and I think the outcome of their care is going to be diminished."

Children like to master skills, he said. The skill components of cognitive-behavioral therapies allow them to deal with symptoms of anger, anxiety, or depression and help them modify how they feel and behave. Ultimately, they gain a sense of power over their behavior.

Hepper and colleagues didn't merely survey the students at their London hospital; they fed the results back to the hospital staff, who in turn adapted their strategies to increase children's participation in their treatment.

Now, weekly goals are discussed with each child to gain the child's ideas about the goal. Children from the unit also collaborated on a booklet and video to explain to prospective patients what the unit does and how it works.

"Children's Understanding of a Psychiatric Inpatient Admission" is posted at <http://ccp.sagepub.com/cgi/reprint/10/4/557>.

Clinical Child Psychology and Psychiatry 2005 10 557[Abstract]

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