Hospitalization: When? Where? How?

When you have a child with serious mental illness, hospitalization is something that comes up frequently. The first time hospitalization was mentioned to us, it felt like a slap in the face. It was frightening. No one wants to think of their child in the hospital at all, and being in a psychiatric ward just felt so much worse. But after the first time Little Man was hospitalized, we realized that we would probably be doing this again, and not just once. It was time to make a plan. Mostly because plans make me feel better and, also, it’s a pretty good idea. Here are my tips for thinking about and preparing for hospitalization.

1. Set your plan in advance.

Do NOT decide in the moment what your criteria for hospitalization is, if at all possible. Our criteria for admission is extremely high, because hospitalization sucks. We consider hospitalization when Little Man has had 3-5 consecutive days that include hours of aggressive and/or self-injurious behavior that has a high risk of injury and is not able to be managed through therapeutic parenting and/or PRN medication. Your admissions criteria will depend a lot on what your family needs, what your family can handle, and what services are available in your area. General red flags to consider: self-harm (especially new), suicidal ideation, risk of injury to others, homicidal ideation, hallucinations / psychosis (especially new, or considerably more severe than previous instances).

2. Know the nearest psychiatric hospitals & their admissions criteria.

What hospitals are within a 2 hour distance? What age do they accept? What are the philosophies of their medical team? What supports do they offer via hospitalization? What are the visitation policies? Most importantly, what is the admissions criteria? You usually MUST be a danger to yourself or others. Unfortunately, what you think is a danger may not be to the psychiatric ER doctor, especially if they don’t have beds. Write down the crisis phone numbers to all the hospitals where you would be willing to admit your child; all hospitals that take children within 2 hours are programmed into my phone. Call in advance when you can, because it stinks to drive several hours, wait in an ER, and then find that there are no beds. (When that happens, you will either need to wait for even more hours, go home, or be transferred elsewhere. What will you do?)

3. Know which ER feeds to which hospital system.

Not every hospital has a psychiatric emergency room, and emergency room is usually your best bet for admittance. (Ask for a psych eval when you enter.) If you prefer XYZ hospital, know which emergency room will get you there.

4. Know your options for getting to the hospital.

If you can get there under your own steam, do that. Do it. Police escorts and ambulance rides are not fun for anyone in the family, and there’s no guarantee that the people who arrive at your home will have any training in supporting people with mental illness. If you do need to call 911 for one of these things, be sure to say that you are calling in regards to a psychiatric emergency for someone with a documented mental illness.

5. Find out if your county has mobile crisis services.

Many counties do have mobile crisis type services but do not advertise it. Mobile crisis usually means that a social worker will be at your home within a certain amount of time to provide support. These people can sometimes help refer you to services in the community. Call your county’s mental health department and ask about it. Put their phone number in your list. In most areas of Virginia, there’s also a service called CrisisOne. It provides 8 hours daily, maybe more, of crisis intervention services to prevent out-of-home placements. We’ve found their supervisor to be very receptive to feedback as well.

6. Spend your money on a quality psychiatrist (if possible).

I know psychiatry is expensive. If you can, at all, pay for one who is more than just a prescription pusher. Shop around; interview them. Ask the psychiatrist what the availability and plan is for after-hours psychiatric emergencies. Do they have an on-call psychiatrist? Are they willing to give out their home/cell phone numbers for true emergencies? How often are they willing to see you? Our psychiatrist sees Little Man every week during psychiatric emergencies, and never goes more than 3 weeks in between appointments. For a child with serious mental illness, a 15 minute appointment every 2-3 months is not going to suffice. Bonus: A good psychiatrist may be able to get you admitted to the psychiatric hospital while avoiding the emergency room. They usually have to be willing to spend quite a bit of time on paperwork and the phone. It’s worth it. I know that’s not feasible for everyone, but it makes a huge difference to both avoiding hospitalization & getting admitted more effectively.

7. Talk to your doctor about PRN medication. 

With your pediatrician or psychiatrist’s consent, consider carrying a PRN medication with you. Benadryl can be more effective as a PRN for some of our kids than prescription PRN medication (usually antipsychotics or benzos). Have a plan for when a PRN will be used, and document its use. Note that this is not medical advice, and you should make no medical decisions without speaking to a medical professional who knows you & your child.

8. Make safety plans for every situation you can imagine.

A safety plan is exactly what it sounds like — a plan to keep everyone safe in a situation. When you have a child with serious mental illness, you need safety plans for road trips, for being at home with siblings, for being at home without siblings, for being at home with one parent, for being at home with both parents, for shopping trips, for restaurants, and so on. Some safety plans are all about prevention. Little Man is never allowed to have unsupervised time with animals, and his supervised time with animals is strictly limited. We have a safe room with loads of cat toys & furniture for our animals when he is in the home and awake. We have all sharps and medication locked at all times, even kid scissors. Other safety plans are “what to do in the moment”. For example, when Little Man begins to engage in property destruction, we immediately remove his sister to our bedroom & lock the door. When you can, go with prevention over reaction, clearly. Don’t just think these through in your head — discuss it with any other caregivers for your child.

9. Know who you can call for help.

Do you have family or friends that you can call? Will they assist with the child in crisis or with the child’s siblings? Do you have therapists that would be able to speak to your child on the phone and/or come to the house to help in a crisis? What order will you call them in? Do all caregivers for your child have those phone numbers? Are they posted around the house?

10. Be prepared for the hospital.

There are some simple things that you can do to help ensure the process goes a little bit smoother, like having your child’s insurance cards on you. Keep a list of your child’s current medications & supplements in your purse, along with a printed list of medical providers or therapists. The hospital will want all this information, and it’s way easier if you can just hand it to them. If you have time, pack 2-3 outfits. That’s usually all your child will be able to bring. When the doctor asks you about what happened, do not sugar coat, not one bit. They need to know the real deal in order to help your child & your family. If you cannot take the child back home safely, then you need to be clear about that with the medical team. Maintain this firm stance throughout treatment, and do not let insurance dictate your discharge date. Fight back. And, please — tell your child where you are going and why. Do not let the hospital become this surprise thing that happens when the kid is “bad”. That’s not going to build any trust in you, medical teams, or medication, all of which our kids need.

11. Remember the strengths and limitations of inpatient treatment.

Acute inpatient treatment is honestly not that therapeutic or structured, especially compared to quality therapeutic interventions that exist in the home or at the best residential treatment centers. They have a revolving door of patients, as well as high turnover of staff. Your child will often be seen by a variety of residents, rather than one psychiatrist who has known them for X number of years. They will be around children who are also in varying states of psychiatric distress. Do not expect the hospital to do much other than provide basic crisis stabilization services and medication management. Medication management is probably the strongest reason for hospitalization, as they are able to make rapid changes due to the 24/7 psychiatric nursing supervision, instant lab access, and so on. (Hospitals are often pretty honest that this is what they do — at least the good ones are.) It’s also a very sterile environment, which means that your child is not likely to be able to hurt themselves or someone else. And that’s a huge relief, when you have a child for whom you are very, very afraid.

Feel free to leave additional tips & suggestions in the comments! I would love to hear what has helped you avoid the hospital and/or make it a better experience. I’ll have to make another post about how to make hospitalization more effective for your child (and less scary for the whole family), coming soon.

 

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