Children as Inpatients: Why the Increase?

Article excerpt

In a recent, soon-to-be published analysis of National Hospital Discharge Survey data, Joseph C. Blader, Ph.D., and his colleague, Dr. Gabrielle A. Carlson, found that the rate of psychiatric hospitalization of children increased 53% and the rate for adolescents increased 58% between 1996 and 2004.

During the same time period, psychiatric hospitalizations of adults increased only 3%.

In addition, this analysis indicated a large increase among children and adolescents in the rates with which bipolar disorder was the discharge diagnosis. It also reports a corresponding decrease in the diagnoses of attention-deficit/hyperactivity disorder (ADHD) with a disruptive disorder among inpatient youth. The study is slated for publication in the July 15 issue of Biological Psychiatry.

This month, CLINICAL PSYCHIATRY NEWS explores the implications of these findings with Dr. Blader.

CLINICAL PSYCHIATRY NEWS: What prompted you to review the National Hospital Discharge Data for inpatient hospitalization of children and adolescents, and were you surprised by what you found?

Dr. Blader: I had completed a study that followed up children who were discharged from a single children's inpatient psychiatric unit at 3, 6, and 12 months after they left the hospital, and some of the findings provoked additional questions that a larger study could address. But because mental health services over the last 10 years had, appropriately, emphasized the importance of alternatives to inpatient care to treat children with severe psychiatric illnesses, I first needed to see if the admission of children to acute-care units had declined to the point that there might not be much value in conducting the research.

When I looked at trends from the annual National Hospital Discharge Survey, the rates of children admitted to acute inpatient care had increased significantly. This was somewhat surprising in view of well-publicized projects aimed at buttressing community-based mental health services for children.

What is not clear is whether these services are not yet widely available to affect hospitalization rates, or whether they do not always avoid acute inpatient admissions. Lengths of stay had also become shorter for all age groups.

CPN: The largest increases in inpatient discharges were for patients diagnosed with bipolar disorder. Could this represent upcoding aimed at getting patients admitted to the hospital in an era with tighter insurance restrictions on psychiatric admissions?

Dr. Blader: I certainly don't think that physicians are being disingenuous in their diagnoses for administrative reasons. However, doctors are hearing all the time that the children with the volatile, impulsive, explosive, erratic behavior who have been the mainstay of the child psychiatric inpatient population for many years have some form of bipolar disorder.

For some reason, the diagnoses that accentuate the impulse-control and behavior problem, such as ADHD oppositional defiant and conduct disorders, carry a connotation as being less serious.

It bears emphasizing that these chronic difficulties are major neuropsychiatric problems in their own right. They greatly increase the risk for much impairment that can lead to personal, familial, and social tragedy. It's debatable now in child psychiatry whether a broad conception of bipolar disorder that could include these children is more appropriate than a narrow one.

Discussion about diagnostic boundaries should not obscure the fact that these children suffer from a serious neuropsychiatric condition.

CPN: Are most of the admissions done to start a patient on medication? And is the hospital the best place for these children?

Dr. Blader: Adolescents are more likely than children to have a precipitous onset of major personality or behavior change. …