Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Services Interventions
Treatment Interventions
Inpatient Treatment
Inpatient hospitalization is the most restrictive type of care in the continuum
of mental health services for children and adolescents. Questions about
excessive and inappropriate use of hospitals were raised in the early 1980s (Knitzer,
1982) and clearly documented thereafter in rising admission rates from the 1980s
into the mid-1990s, without evidence of increased social or clinical need for
such treatment (Weller et al., 1995). Inpatient care consumes about half of
child mental health resources, based on the latest estimate available (Burns,
1991), but it is the clinical intervention with the weakest research support.
Nevertheless, because some children with severe disorders do require a highly
restrictive treatment environment, hospitals are expected to remain an integral
component of mental health care (Singh et al., 1994). More concerted attention
to the risks and benefits of hospital use is critical, however, along with
development of community-based alternative services.
Research on inpatient treatment mostly consists of uncontrolled studies (Curry,
1991). Factors that are likely to predict benefit have been identified from such
studies. Beneficial factors were found to include higher child intelligence; the
quality of family functioning and family involvement in treatment; specific
characteristics of treatment (e.g., completion of treatment program and planned
discharge); and the use of aftercare services. Neither age nor gender affected
prognosis after hospitalization. The prognosis was poor for several clinical
characteristics, including children with a psychotic diagnosis and antisocial
features with conduct disorder (Kutash & Rivera, 1996).
Only three controlled studies evaluated the effectiveness of inpatient
treatment: one that randomized antisocial children to specific interventions on
an inpatient unit (Kazdin et al., 1987a, 1987b) and two older clinical trials (Flomenhaft,
1974; Winsberg et al., 1980). All three studies demonstrated that community care
was at least as effective as inpatient treatment.
More recently there have been preliminary favorable findings from a randomized
trial of inpatient treatment versus multisystemic therapy (MST), an intensive
home-based intervention. For example, MST was more effective than psychiatric
hospitalization in reducing antisocial behavior, improving family structure and
cohesion, improving social relationships, and keeping children in school and out
of institutions (after the initial period when the control group was in the
hospital). Hospitalized youth reported improved self-esteem, and youth in both
treatment conditions showed comparable decreases in emotional distress (Henggeler
et al., 1998). A great deal more research is needed on inpatient
hospitalization, as it is by far the costliest and most restrictive form of
care. Recent changes in health care management have resulted in short lengths of
stay for children and adolescents. Preliminary results from the study of MST
indicate that intensive home-based services may be a viable alternative to
hospitalization. However, even when such services are available, there may be a
need for brief 24-hour stabilization units for handling crises (see Crisis
Services).
Back to the Mental Health: The Surgeon General's Report Table of Contents