Admission rates of children and adolescents to psychiatric hospitals have been increasing since 1920 and have increased rapidly in recent years. Weithorn (1988) analyzed data from the National Institute of Mental Health (NIMH) that showed a 15 percent increase in admissions during the 1970s. Darnton (1989) found that between 1980 and 1986 psychiatric admissions of people younger than 18 increased by more than 36 percent.
Privately owned psychiatric hospitals have accounted for the most recent increases in admissions of children and adolescents. Public hospitals, in contrast, have had declining admissions. During the 1970s, private hospital admissions of children and adolescents increased from 37 percent of the total admissions to 61 percent (Weithorn, 1988). Between 1980 and 1986 admissions of children and youths to private psychiatric hospitals increased 60 percent (Darnton, 1989).
Is the increased use of private institutions consistent with current theory and research about what constitutes the most appropriate mental health treatment for children and youths? Are these accelerating admissions justified by the admitting diagnoses? Are they effective in terms of treatment outcome and cost?
This article discusses reasons for continued high rates of institutionalization of children and adolescents, including changes in juvenile justice law, insurance practices, lack of legal protection for children and youths, inappropriate government policies, and the increase in for-profit hospitals.
Evaluation of Increased Use of Psychiatric Hospitals
Appropriateness for Youths
Current theory and empirical research stress that the problems of children and youths reflect the interactions between intrapsychic difficulties and the child's environment, including family, school, home, and community. Multiple government and advocacy group investigations into the mental health treatment of children and adolescents have come to similar conclusions. If children and youths are to be treated effectively, their problems must be dealt with in a coordinated way within a variety of community-based settings (Inouye, 1988; Saxe, Cross, & Silverman, 1988; Tuma, 1989).
The increased use of psychiatric hospitalization as a form of mental health treatment for children and adolescents is not consistent with these conclusions. Hospitalization removes the child from his or her environment, identifies the child as the patient, and in most instances focuses treatment on the child or adolescent. Hospitalization inherently makes it difficult to deal effectively with the individual's problems within the variety of systems in which the child or adolescent must interact and, in most cases, to which the child will ultimately return.
During the past two decades inpatient facilities for children and adolescents have placed more emphasis on incorporating the family and other social systems into the patient's treatment plan. Formerly, many family therapists were reluctant to even legitimize hospital treatment for families as constituting "family therapy" because of the separation and designation of a family member as the patient (Hanrahan, 1986). Today, most authorities on the psychiatric hospitalization of children agree that some type of collaborative work with families is necessary for successful treatment, and there is some empirical evidence to support this (Jemerin & Philips, 1988). In addition to family therapy, approaches involving the family within the hospital setting have included individual therapy with each family member, intensive collateral work, hospitalization of the mother or the entire family along with the child (Jemerin & Philips, 1988), parent training programs, and parent support groups (Dalton, Muller, & Forman, 1988).
The treatment perspective of the transactional risk model advocated by Woolston (1989) is perhaps the most consistent with the current view on child and adolescent mental health problems. …