Ultrashort Stays and a Focus on Recovery

To the Editor: The Open Forum by Dr. Glick and colleagues (1) raises important concerns and offers a valuable treatment model for child and adolescent psychiatry. The concerns these authors describe are also issues in providing care to youths (2): ultrashort stays similar to those for adults; a single criterion—dangerousness—for admission decisions; limited availability at hospital admission of information from previous therapies; infrequent psychological and medical evaluations; lack of attention to collaborative care that meets the physiological and safety elements of Maslow's hierarchies (3); few treatment objectives other than safety; lack of evidence-based psychosocial programming; inadequate family involvement; administrative barriers to evaluating interventions, such as out-of-hospital passes; and restricting the options of the treating child psychiatrist to evaluation, treatment of behavioral crises, medical management, and dealing with abrupt discharges when the managed care company denies further treatment.

The three-phase treatment mode—assessment, implementation, and resolution—proposed by Dr. Glick and coauthors can address many of these issues, but I would like to highlight several that I feel are particularly important.

The role of the child psychiatrist should return to being that of a comprehensive deliverer and director of all aspects of treatment, so that coherent psychosocial diagnosis and individual, group, and family treatment can occur. This would be a time-intensive effort that could result in the development of child psychiatry hospitalists. In addition, treatment authorization must be based on psychosocial and diagnostic issues. Treatment goals for the child and family should be clarified at admission, a process that must include asking about perceptions of hospitalization, which may be based on films such as Sucker Punch or Girl, Interrupted. Also, viable individual safety plans (4) should be developed at admission for children who are prone to behavioral crises and harm to themselves or others.

Furthermore, admission screening questionnaires should be routinely used, including a children's depression inventory, a trauma assessment inventory, a substance abuse screen, and an incomplete-sentence form. Children may be willing to disclose their concerns on written forms rather than to an unknown professional. Screening for medical illnesses must also be routine and under the direction of a pediatrician who works closely with the child psychiatrist to identify chronic conditions, such as hepatitis, anemia, hyperglycemia, and obesity. In addition, a structured collaborative teaching and treatment environment should be created for the delivery of care. “A CBT Approach to Inpatient Psychiatric Hospitalization” (5) describes an effort developed to achieve these goals. Designed for stays of five to 12 days, the program is compatible with managed care treatment limits.