The types of adolescent inpatient services

Different services provide specialisation but within typically broad strata of age, clinical need and level of security. In England and Wales, of the currently available beds, 727 are in general adolescent units (GAUs), 248 are eating disorder beds and there are 59 beds for children (<13 years of age) and 6 for deaf children and young people. In regard to beds that offer higher levels of security, there are 124 psychiatric intensive care unit (PICU) beds, 104 low secure unit (LSU) beds and 44 medium secure unit (MSU) beds.4 PICUs provide short-term (6–8 week) admission for young people with acute mental disorder associated with significant risk, and LSUs provide a similar level of security over a longer timescale. MSUs offer a higher level of security and are largely, but not exclusively, for young people whose mental disorder has brought them into contact with the criminal justice system. In addition, there are 56 learning disability beds in total, split between general, LSU and MSU beds. The Royal College of Psychiatrists proposed, in its most recent recommendations,11 that 24–40 mental health beds per 1 000 000 population up to the age of 18 years were required, also taking into account the availability of services designed to provide an alternative to admission.

The most common type of adolescent units, GAUs, are not a homogenous entity; significant variation exists in terms of the nature of the service provided, and this is reflected in disparities in issues such as staffing levels and lengths of stay. Taking the estate as a whole, the mean length of stay for GAU admissions, including eating disorders, ending in 2019/2020, was 85 days but with some young people having considerably longer admission: 32% over 90 days and 2% in excess of 1 year.4 This represents a reduction in average length of stay, from 114 days in 2014,5 which is reflective of changes in practice. Not all children and young people admitted to hospital for a mental disorder are in an age-appropriate mental health setting. Six per cent of general paediatric beds are occupied by children and young people who have mental disorder as their primary clinical need,12 and ‘overriding’ or ‘atypical’ situations do not prevent the admission of children and young people to adult mental health services, which occurred for 246 individuals over an accumulated total of 3289 bed days in 2017–2018.13 These figures largely predate the pandemic, which has had a significant impact on children and young people’s mental health, and utilisation of a broad range of services14

Mental health difficulties in young people requiring inpatient care

There is no diagnosis that would mandate inpatient treatment, although some conditions may be more likely to require a period of time spent in a mental health hospital. As a result, all diagnoses are represented in inpatient settings. The largest single group comprises patients with eating disorders (20%), followed by neurotic, stress-related and somatoform disorders (10%), mood disorders (8%), behavioural and emotional disorders (8%), schizophrenia, schizotypal and delusional disorders (4%), disorders of psychological development (4%), ‘other’ disorders (4%) and disorders of adult personality (3%). It is concerning that the largest group (38%) have no attributed diagnosis, and some other groups are heterogeneous and poorly defined.4 While the complexity of diagnosis in early onset severe mental disorders is acknowledged, this is reflective of long-standing concerns in regard to accurate information being available about a number of aspects of adolescent inpatient care.7

From a clinical perspective, there are some elements of an admission that are harder to replicate in outpatient care, and therefore, young people with certain clinical characteristics are more likely to be considered for such an option. In the case of previously well-functioning young people who experience acute deterioration in their mental state incorporating impaired reality testing, aggressive behaviours or suicidality, associated risks may be hard to contain in the community and a period of inpatient stabilisation may be necessary. Young people with early-onset bipolar disorder or psychosis are also likely to require inpatient care at some point during their treatment15 16 Similarly, young people with very strong self-harm or suicidal tendencies who have engaged in potentially lethal attempts may be difficult to manage in the community without constant supervision and support. Although lengthy inpatient care for eating disorders is generally not indicated, it is recognised that in individual cases some inpatient input may be necessary,17 18 and this is clearly the case in clinical practice. The necessity for admission is also related to the resources available to manage young people with mental health difficulties outside of a hospital setting.

Legal framework

Broadly speaking, and specifically with reference to the legal framework in England and Wales, the provision of healthcare is typically based on a collaborative and negotiated relationship between the provider and the recipient of that care. In regard to the provision of mental healthcare for children and young people, although this should be the starting point, there are circumstances where that may not be possible. If a child or young person lacks decisional ability, either by virtue of age or because of the presence of mental disorder, it may be possible to rely on substituted parental consent to authorise care and treatment, especially for younger children. However, this is dependent on the validity of that consent, and the nature of the interventions, and specifically whether they amounted to a deprivation of liberty, which would engage a child or young person’s rights under the Human Rights Act 1998. Where a child or young person has decisional ability and is refusing care and treatment, or lacks decisional ability and care and treatment is beyond what it is reasonable for those with parental responsibility to consent to, that is, it is outside the ‘scope of parental responsibility’,19 then the Mental Health Act 1983 (MHA) can authorise admission and treatment if the criteria for detention under the Act are met, as could the court, if the criteria were not met.

Although some caution is required due to incomplete data, in 2019–2020, 1172 detentions under the MHA were recorded in those 17 years and under,20 which is a lower rate than for all adult age groups. On a specific day in 2020, over half (544 out of 944) of young people in adolescent inpatient units were formally detained. Approximately 1/3, 294, were informal or voluntary patients, but the status of 104 was not recorded.4 Although there can be complexity in regard to the medico legal context for the care and treatment of children and young people, this is a source of concern, as is the fact that this figure diverges from that held by the National Health Service dataset for the same day, which indicated 469 young people were detained under the MHA.4 ,20

Benefits and risks of inpatient mental health admissions

In general, a mental health admission to an inpatient adolescent unit is rarely the treatment of first choice from the perspective of young people, families or mental health professionals. It is normally pursued when other avenues to address the clinical needs of the young person have been exhausted, and the clinical scenario is characterised by some combination of severity, complexity, persistence and risk. Although studies are limited, they generally report positive outcomes from inpatient admission.21 An admission involves a more restrictive alternative to outpatient care and, as such, careful consideration should be given to confirm its inevitability. If undertaken, it should only be employed for the shortest time possible and with parallel active exploration of robust community care to allow for its safe and timely termination.

There are several potential benefits from an inpatient admission for young people with mental disorders who need it. These may include a more comprehensive assessment of their clinical presentation, more robust monitoring and containment of risks, towards themselves or others associated with mental disorder, the initiation of treatments that they are not adherent to in the community and the evaluation of their response to that treatment and its potential side effects. In hospital, the group milieu can have a positive effect. Young people have described having experienced feeling criticised and judged in the community but feeling understood and validated by the staff and their peers in hospital.22 Brief and time limited crisis admissions can also offer opportunities to break a cycle of increasing risk and can offer support for the family and wider network.23 Such admissions can provide space away from the perpetuating factors of poor mental health such as a challenging home dynamic24 and negative peer relationships, even if core psychopathology persists. Given the chronicity of some forms of disorder, risk and symptom management may be the goal of the inpatient care, rather than the complete resolution of symptoms, and minimum effective change to allow care to continue in a less restrictive community setting should be the expectation.

However, these potential benefits need to be weighed against risks and drawbacks that can be associated with inpatient admissions. There are risks associated with removing a young person from their normal environment and support structures, both professional and informal, and admitting them to an environment, especially if at a significant distance from home that can be challenging or expose them to a novel range of stressors. Some young people may find the boundaries of the admission uncomfortable, especially if it precludes access to coping strategies that, even if maladaptive, had previously been employed. As a result, their behaviour may escalate, and more restrictive measures including physical holding, restraint and seclusion may be needed25 to manage risk. These restrictions and interventions may impact on the young person’s sense of autonomy and self-esteem. Some young people have described their experiences in restrictive mental health settings as negative and associated with feelings of stigma and alienation26 or of rejection, punishment,27 disempowerment and terror.28 The effect of coercive measures can also affect the future therapeutic alliance and adherence to care plans.29 Restrictions in inpatient environments may lead to feelings of confinement and rigidity30 and a sense of powerlessness and lack of control.22 Attempts to circumvent the boundaries of admission can also have a negative impact on the therapeutic engagement.31 Although staff support is objectively a benefit, some young people have described the 24-hour support as too intense, with little space for themselves.22 In a hospital setting, young people may be exposed to a wider range of psychopathology, become familiar with more elaborate or dangerous self-harming behaviours and get to know other young people with additional risk factors, like substance misuse, who may influence their behaviour (‘contagion’). Some of these risks are not possible to avoid, so the clinical presentation and potential vulnerabilities of each young person considered for an inpatient admission should be carefully scrutinised by their professional network and family. This process can lead to interdisciplinary or interprofessional disagreement about the right course of action, with inpatient services being reluctant to admit in the context of concern about exacerbating rather than ameliorating problems and other members of the network advocating for admission from a variety of positions ranging from therapeutic optimism to the lack of an alternative.

In order to maximise the benefits and minimise the risks associated with inpatient mental health admissions, working collaboratively with the young person and their family during this time is crucial. It is essential in ensuring that the admission is appropriate, progresses efficiently and the young person is benefiting from it as much as possible. It also facilitates discharge to the community without delays and with an appropriate care package. Discharge from an inpatient mental health setting can be a worrying time for young people. Some report that being in hospital is not representative of the outside world and a ‘culture shock’ is experienced once the intensive support available in hospital is lost. Young people may prematurely disengage to mitigate these difficulties when the time for discharge comes.22 Careful planning through regular multiagency meetings and active involvement of the young person and their family from the beginning of their admission is helpful in facilitating discharge.

Parallel input during an inpatient mental health admission

An important consideration in discussions about the necessity and relative benefits of hospital admissions for young people is the availability of community services that can meet the young person’s needs, because the benefits of the admission would inevitably be compared with other available interventions. If young people need to come into hospital, it is unusual that all their needs can be addressed by medical intervention, and engagement is required from all agencies with responsibility to support young people and their families, including social care and education. This may be even more relevant in the case of young people with neurodevelopmental disorders and learning needs, or for ‘Looked After Children’ under the care of the local authority, who are both probably over-represented in inpatient care.32 33 Care, education and treatment reviews34 are currently implemented for all young people with autism spectrum disorder and/or learning disability, aimed at preventing inpatient admissions or reducing their duration. There have been recent developments in the greater availability of assertive community treatment as a cost-effective alternative to inpatient care, as otherwise the gulf between outpatient clinic-based and hospital care is broad.9 These teams actively participate in the planning of postdischarge arrangements throughout a young person’s admission, thus facilitating timely discharge as soon as their needs can be met in the community.9 22 35