New initiatives: A psychiatric inpatient facility for older adolescents in India.

CONTEXT: Almost 1/5th of the adolescent population suffers from mental morbidity. In older adolescents, clinical challenges are accompanied by unique psychosocial and developmental needs. Recent legislations in India - the Mental Health Care Act, 2017 and the Juvenile Justice Act, 2015 - mandate specific arrangements and provisions for evaluation and treatment of children and adolescents. A separate inpatient Adolescent Psychiatry Center (APC) was started at National Institute of Mental Health and Neurosciences, Bangalore, in 2016. AIMS: (a) The aim of this study is to present the need for, development, infrastructure and workforce at APC; (b) to describe clinical profile of adolescents admitted to APC and (c) to identify clinical and psychosocial challenges in the management of older adolescents. SETTING AND
DESIGN: The paper covers consecutive inpatient admissions over the first 7 months of APC.
MATERIALS AND METHODS: Data were gathered from a review of hospital records, staff meetings, and case files. STATISTICAL ANALYSIS: Qualitative data, such as clinical management challenges, are summarized under major emergent themes. Quantitative data are summarized as means with standard deviations and frequencies with percentages.
RESULTS: Males, from urban, nuclear family background constituted the majority admissions. Family stressors and risk behaviors were prevalent. Unique clinical challenges included - risk behaviors, issues related to autonomy, conflict with family and conflict with the legal system.
CONCLUSIONS: Older adolescents need to be treated in an environment appropriate to their age and developmental stage. Restructuring of spaces, routines, and creative inputs to interventions strategies must be made for healing environments for youngsters. APC could be a model for the development of other similar centers.

INTRODUCTION

The World Mental Health Survey showed that about half of all lifetime psychiatric disorders start by mid-adolescence.[12] Mental health problems affect almost 20% adolescents, worldwide.[3] In India, estimates of psychiatric morbidity among adolescents range between 7%[4] and 16.5%,[5] while 16%–25% adolescents report “psychological stress.”[6] These statistics reiterate the need for (re) organization and improvement of mental healthcare services for children and adolescents. While the larger proportion of mental morbidity in adolescents is amenable to community-based interventions, hospital admission becomes a necessity in circumstances such as self-harm, aggression, and severe family dysfunction. Inpatient care for children and adolescents with mental health problems started around 1920s, focused primarily on custodial care.[7] In the last few decades, hospital admissions for treatment and intervention have become routine practice.[8]

The United Nations Convention on the Rights of the Child (UNCRC) defines a child as anyone under the age of 18.[9] The tenets of the convention emphasize child rights, best interests of the child, child protection, and life, survival, and development. In keeping with these tenets, treatment in child and adolescent psychiatry has to be tailored not only to the diagnosable behavioral problem but also to the developmental and psychosocial needs of the individual. Developmental needs of children change with age; needs of older adolescents, particularly, are different from younger children, as they are in the crucial transition from childhood to adulthood. Biological changes combined with greater environmental exposure and an emerging sense of independence pose unique risks for adolescents.[10]

The National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore started the first independent Department of Child and Adolescent Psychiatry in India. The department runs 6-days/week outpatient services. On an average 45–50 patients visit the first-contact services and 90–110 patients visit the follow-up services every day. The department has been providing inpatient care in a 40-bedded Child Psychiatry Center (CPC). With the aim of comprehensive short-term care and long-term care planning, the child is admitted with family members; this innovative and novel feature contrasts with similar units in the western world, where children are admitted alone.[11] The indications for admission are broad and flexible ranging from management of acute behavioral problems, chronic psychiatric illnesses, to education and training of parents and alleviating caregiver stress.[12] In July 2016, a separate inpatient facility, the Adolescent Psychiatry Center (APC) was started for adolescents in the age range of 16–18 years.

Need for and development of an Adolescent Psychiatry Center

NIMHANS has had an inpatient facility for children and adolescents, below the age of 16 years, since 1967. In 2012, the Department of Child and Adolescent Psychiatry proposed, under the 12th 5-year plan, that the upper age limit for the clientele be increased from 16 to 18 years, keeping with the UNCRC.[9] The proposal received impetus also in view of the new legislation for mental health in India, the Mental Health Care Act, 2017[13] that mandates creation of separate facilities for “minors” i.e., individuals below the age of 18 years. A group of experts from administrative and technical echelons of the institute and representatives from the Government of India examined the department's proposal and a decision was made to start a separate inpatient facility for older adolescents (16–18 years). In the outpatient services, too, all individuals between 16 and 18 years of age were shifted from adult to child and adolescent psychiatry. Further, it was decided to extend the philosophy of admitting children with their family members, to this facility for older adolescents as well.

Setting up of the APC is pertinent in view of the Juvenile Justice (Care and Protection of Children) Act, 2015.[14] The act has a new provision that if an adolescent is alleged to have committed a heinous offense and is more than 16 years of age, the Juvenile Justice Board may pass an order for the child to be tried as an adult. To facilitate this decision-making process the legal system consults psychosocial experts. A developmental and nuanced understanding of the predicament and circumstances of these older adolescents is critical in this decision. Brain maturation goes on well into the third decade.[15] While adolescents may be “aware” of their actions and the consequences thereof, imminent life skills such as emotional regulation, decision-making, and interpersonal skills may not be fully developed. Moreover, children who come in conflict with the law are often from dysfunctional family and psychosocial backgrounds with history of abuse, violence, and neglect. The background further hinders psychological and cognitive development in the adolescent. Thus, engagement of mental health professionals with the legal system is imperative for rehabilitative and restorative justice.[16]

Infrastructure and manpower at the Adolescent Psychiatry Center

APC started functioning in July 2016. It is situated in an exclusive, spacious, multi-storied building directly opposite the existing CPC at NIMHANS. APC is a 24-bedded inpatient facility. Outpatient services for 16– 18-year-olds are run in the common OPD building at NIMHANS, along with services for younger adolescents and children. APC has shared, semi-private and private wards. The shared wards include male and female general wards with 4 beds each. Partitions/curtains ensure privacy in the shared accommodations. A four-bedded High Intensity Care Unit is tactically located on the ground floor, adjacent to the nursing station. Other than the wards, APC has three main sections – (a) nursing section comprising the nursing station and interview rooms, (b) family sections that include common areas (including play areas for indoor games, a gymnasium, a common kitchen), where adolescents and their families can mix around in their leisure time, (c) guidance and training sections for group and individual psychotherapy and supervised activities including behavior modification interventions. The guidance and training sections also include a library, study rooms and a model classroom with audio-visual aids. There is a quiet room that is well lit and ventilated. This is where adolescents can have a “quiet, reflective” time, and practice interventions such as relaxation techniques.

Security and safety

The facility is constantly under CCTV surveillance with cameras placed in all the corridors, common areas and staircases. Security personnel monitor movement of adolescents in and out of APC. Adolescents are free to go out to other areas within the hospital but have to be accompanied by their parents/guardians.

Ward staff and ward routines

In view of the diverse needs of adolescents between 16 and 18 years of age, the paramedical staff at APC (staff: patient ratio 1:2) are trained to handle developmental issues characteristic in this age group; especially striking a balance between the adolescent's desire for autonomy, and ward rules for abiding by a daily schedule. The faculty of the Department of Child and Adolescent Psychiatry organize periodic training and feedback sessions for staff on effective limit setting, monitoring peer interactions, sensitivity to gender issues, and managing provocation and agitation. Both adolescents and parents follow a structured routine to ensure a sense of normalization and uniformity, as well as to give opportunities to parents to improve quality of their interaction with adolescents and learn effective communication and management strategies in a supportive and supervised environment. A typical day in the ward starts with a physical exercise and meditation session in the morning. Thereafter, a classroom teaching session, supervised by special educators, focuses on developmental themes (such as life skills and sexuality) and strategic group activities. The latter involves parental engagement, recreation tasks, and organized games. The day ends with a get together in a common room and light-hearted narratives by parents and adolescents on the events of the day followed by a consensus on plans for the next day. Child Psychiatrists, Clinical Psychologists and Psychiatric Social Workers involved in clinical and psychosocial care of an adolescent visit the ward in the evening for individual and/or family-based interventions. The Psychiatric Social Work faculty and students also organize weekly group sessions with parents and adolescents. These sessions generally focus on education about mental health and various mental illnesses.

Treating team and intervention module

APC follows the philosophy of integrated patient care under one roof. The treating team is multi-disciplinary with faculty, staff, and students from Child and Adolescent Psychiatry, Clinical Psychology and Psychiatric Social Work. Other professionals, including speech therapists, physiotherapists, special educators, and occupational therapists, are regularly involved in clinical care. Senior Residents, pursuing their DM or Post-Doctoral Fellowship in Child and Adolescent Psychiatry, are primarily involved in clinical care of the patients, supervised by the faculty. Postgraduate students from psychiatry, clinical psychology, and psychiatric social work are also posted in the department and work closely with the Senior Residents. Treatment is based on an eclectic case formulation to ensure that adolescent's psychopathology, contextual factors of hospitalization, caregiver motivation, and adolescent's expectations are all comprehensively addressed.

We strongly advocate normalization of routines and experiences. This aids in recovery and rehabilitation and from a practical standpoint prevents the adolescent from losing out on curricular requirements. To this end, activity scheduling and monitoring become an essential intervention early in the treatment course. While we do not as yet have an operational formal schooling support system for older adolescents, the building houses study rooms where the adolescents are encouraged to utilize time in the afternoon for curricular work. In a few instances, we have also accommodated local school attendance during inpatient stay, especially for children with anxiety disorders and school refusal at presentation. Adolescents, who come in for elective admissions, are encouraged to bring their schoolbooks so the emphasis on normative activities is made right at the beginning.

Indications for hospitalization

Indications for hospitalization at APC are broad and flexible and consider both clinical and logistic issues. Adolescents can be admitted through the outpatient or emergency services. Acute hospitalization is for patients for whom the clinical condition warrants inpatient admission– risk of self-harm, agitation, severe aggression, acute psychoses, eating disorders requiring supervised feeding, treatment nonadherence, to name a few. Nonacute hospitalization is also referred to as planned inpatient care. Pharmacological rationalization, education and developmental training inputs, family therapeutic work, and other psychosocial interventions are the primary focus here. Logistic issues, such as school terms, occupational/social obligations of parents, affordability, families from distant places, are taken into consideration when planning inpatient care. In view of the variable indications of hospitalization of adolescents and varying manifestations and severity of psychopathology, every effort is made at APC to keep a uniform and adolescent-friendly climate in the ward. There are plenty of open spaces and common areas, adequate ventilation and brightness, acoustic dampening equipment, wall hangings and motivational posters. There is no dress code for patients. Adolescents are made to feel as part of a restorative community that enhances cooperation for treatment. Strategic placement of APC near the Child Psychiatric Center (CPC) gives a sense of “similitude and continuity of environment.”

The first several months of the functioning of APC were a challenging and learning experience. The objective of the current paper is three-fold: First, to describe the need for, development of, and the infrastructure and workforce at the APC; second, to look at the clinical profile of patients admitted at the APC; and third, to discuss the clinical and psychosocial challenges in management of inpatient adolescent psychiatric admissions. The first objective has been covered under introduction. The next part of the paper will focus on clinical data and management challenges.

MATERIALS AND METHODS

A mixed method was adopted to gather clinical data. We conducted a file review of all inpatients, admitted from July 1, 2016, to January 31, 2017. Sociodemographic, diagnostic, psychosocial, treatment, and outcome information was obtained from the inpatient charts. Two authors (ASY and RKM) collected the quantitative data. Any discrepancies in data collection were crosschecked and resolved by consensus between them. We were also interested in identifying major themes in clinical and psychosocial management. These themes were identified from patient file notes, and case management difficulties brought up repeatedly during routinely scheduled staff meetings at APC. The issues identified were intensely discussed with all stakeholders – junior and senior residents, consultants, nursing staff, other staff involved in inpatient care of adolescents, as well as the parent and adolescent – and appropriate responses determined. The Institutional Ethics Committee approved the study.

RESULTS

Clinical profile of patients admitted at Adolescent Psychiatry Center

A total of 107 adolescents were admitted at APC over the first 7 months of its functioning. Table 1 depicts sociodemographic details of these adolescents. Patients had a mean age of 16.1 ± 0.96 years. As seen in Table 1, inpatient admissions largely constituted of males from urban backgrounds and nuclear families. This is in keeping with the typical help-seeking population in an urban health facility in India.

Table 1

Sociodemographic profile of adolescents admitted at the Adolescent Psychiatry center at National Institute of Mental Health and Neurosciences over the first 7 months of its functioning

Nearly half the adolescents were admitted with an affective illness [Figure 1]. The next major group was those with other behavioral and emotional disorders (oppositional defiant disorder, conduct disorder, emotional disorder), followed by nonaffective psychoses. There were only three children admitted with neurodevelopmental conditions. This is in contrast to admissions of younger children in CPC, where almost one-third admissions have neurodevelopmental disorders. It is notable that in a majority of cases the illness had an insidious onset; the course spanned over several months before admission, and had a high severity rating on the Clinical Global Impression-Severity scale[17] [Table 2].

Figure 1

Diagnostic distribution among adolescents admitted at the Adolescent Psychiatry Center at National Institute of Mental Health and Neurosciences over first seven months of its functioning

Table 2

Clinical profile of adolescents admitted at the Adolescent Psychiatry Center at National Institute of Mental Health and Neurosciences over the first 7 months of its functioning

Most admissions lasted between 2 and 4 weeks [Table 3]. Figure 2 outlines the major processes during inpatient stay in APC, illustrative for average 3 weeks duration of stay. Alongside a comprehensive process of evaluation over the first few days, the main focus is acute symptom control using a combination of pharmacotherapeutic and psychotherapeutic interventions. Psychotherapeutic interventions are individual and family based. Supportive, cognitive-behavioral, crisis-intervention, and psychoeducational techniques are commonly used with adolescents. Continuous availability of parent(s) with the adolescent gives a unique opportunity to the treating team. The contribution of on-going familial stressors to psychopathology, which is high as noted previously, are addressed, and parents given a detailed understanding about the nature of problems and their role in long-term care of the adolescent. Family intervention is typically multi-modal with both nonformal activities through the day for enhancing parent-adolescent communication and positive interaction, and more structured targeted interventions.

Table 3

Stay characteristics at the Adolescent Psychiatry Center at National Institute of Mental Health and Neurosciences over the first 7 months of its functioning

Figure 2

Flowchart depicting processes during inpatient stay at the Adolescent Psychiatry Center, National Institute of Mental Health and Neurosciences. *The timeline in this flowchart is for an average duration of 3 weeks of inpatient stay, considering the average duration of inpatient stay seen in the study sample

It is notable that among adolescents admitted during the first 7 months of the functioning of the APC, almost 1/3rd did not have significant improvement at the time of discharge [Table 3]. It is important to fathom the underlying processes here. In a few cases (n = 8), the adolescent had to be prematurely discharged from inpatient care due to other engagements of the parent(s), and thus the treatment process was left incomplete. In other adolescents, however, there was inadequate reduction in symptoms despite recommended pharmacotherapeutic and psychotherapeutic interventions. Often, mental health problems in children and adolescents are slow to respond to treatment. Further, adequate coverage of the multi-factorial causality may not be possible in a single inpatient admission. It is our usual practice to discuss and follow through on care postdischarge from inpatient setting. In the outpatient setting, the same team continues to see the child to provide continued support, and address persisting or new symptoms/psychosocial issues. Referral letters to local mental health professionals, and schools, etc., are also given to ensure continuity of care in the place of residence.

Clinical and psychosocial challenges in management

Risk behaviors, specifically aggression and self-harm, were present in more than 50% adolescents. Familial stressors, which may contribute to the adolescent's distress, were reported in 68.2% cases, and a positive history of psychiatric illness in the family was present in 52.3% cases. This, in a way, validates our philosophy of admitting the adolescent with their family members. Over the first 7 months, there were five admissions where the adolescent had been in conflict with the law. Due to the sensitive nature of issues and confidentiality concerns, we are refraining from discussing any further details about these cases.

DISCUSSION

The present manuscript revolves around the setting up of an APC, a special inpatient facility for older adolescents (16–18 years). The inpatient admissions over the first 7 months of operation were largely male, from urban, nuclear families. The most common presentations, nearly half, were with mood disorders, followed by other emotional and behavioral disorders and nonaffective psychotic disorders. Family-related stressors were present in almost 70% of the adolescents, and a family history of mental illness in nearly 50%. More than 1/3rd of the adolescents manifested risk behaviors in the form of aggression or self-harm. Alongside pharmacological treatment, psychotherapeutic management was needed in nearly all patients. These data reiterate the biopsychosocial framework of psychiatric disorder causality and the need for multi-pronged assessments and interventions.

Consumer reports support the establishment of separate facilities for older adolescents. Besides symptom control and ensuring safety and security, adolescents desire opportunities for socialization with peers, place to safely express their views, involvement in treatment decisions, and to be treated more like a person than a patient. Interventions for adolescents should address their developmental needs, family relationships and help in strengthening the self.[18] Several reports comment on how emerging sexuality, aggression, and larger physical size could intimidate young children, especially if older adolescents have sexual or physical acting out behavior.[19] A review on inpatient facilities, largely from the western world, which was unable to synthesize evidence for the indications of hospitalizations and the best model of care due to small sample sizes and heterogeneity across studies, did identify elements common to effective models of care – individualized age-appropriate care, multimodal family-based treatment and the involvement of a multi-disciplinary team.[20] APC embraces these common elements. At some centers, in other parts of the world,[21] simultaneous presence of other medical specialties, such as pediatrics, are advantageous for clinical care, especially for comorbid medical or neuropsychiatric conditions. At APC, we liaise with Neurology and Neurosurgery departments present on campus. For other medical specialties, we have to rely on referrals to other hospitals.

Inpatient adolescent facilities across medical specialties come with inherent challenges. Crowd control, sexual acting out, substance use have been reported earlier.[22] We have faced similar management and logistic challenges while working with older adolescents in an inpatient setting. We discuss below the major themes that emerged.

Risk behaviors

The most common risk behavior noted among the adolescents was aggression. While aggression arising out of impaired judgment and insight in psychotic illnesses is treated primarily pharmacotherapeutically, this option becomes second choice when largely psychosocial circumstances contribute to aggression. In the context of familial stress, therapeutic engagement of both the adolescent and parent(s) becomes critical and challenging as the key conflict is often in the parent-adolescent relationship. We address this with parallel interventions for the adolescent and parent(s) by separate therapists, in separate and combined sessions. It is extremely important to value the adolescent's point of view and understanding of the conflict, to affect any real change in the scenario. Directive interventions are less useful. It helps to track the dynamic interplay of parent-adolescent relationship during inpatient care to gain insights and plan strategic interventions.

Older adolescents are in a phase of developing increasingly stable views and opinions. At the same time, there is a persisting childlike curiosity and need to experiment. Novelty seeking and risk-taking behaviors, which could be moderated by psychopathology, are prominent. Adolescents expressing sexual interests and behaviors, substance use, and peer contagion (e.g., imitated self-harm behaviors, aggression) pose significant management challenges. In a treatment setting, these issues can be tricky. From a developmental lens, sexual interest and peer affiliation may be normative; however, for a child dealing with mental health issues, they could result in indiscriminate exposures with possibly long-lasting detrimental consequences. Such issues cannot and should not be ignored just because they do not form part of the primary reason for consultation. In fact, guiding adolescents through these “real” experiences may go a long way in preserving and protecting their mental health as well. We have adopted an open, non-judgmental stance to such occurrences. Once we get behind the apparent “problem behavior” and understand the determinants of it, we can give corrective inputs. In this context, life-skills-training forms a key component of our interventions. The World Health Organization has listed ten life skills– self-awareness, decision-making, problem-solving, creative thinking, critical thinking, effective communication, interpersonal relationships, empathy, coping with stress and emotions, and resilience. Taking the life skills approach is effective in reducing “undesirable” behavior; moreover, it makes more sense to adolescents than a “do's” and “don’ts” approach.

Autonomy and conflict with the family

In the Indian education system, class 10 (age ~ 16 years) and 12 (age ~ 18 years) are major milestones. In many adolescents presenting with school refusal, dissociative symptoms, emotional and conduct problems, academic (non) performance is the main stress. There might be discordance between parental expectations and the adolescent's aptitude or attitude towards academic achievement. The conflict is usually complex in this particular scenario as adolescents may be internally conflicted about their academic abilities, which are then further compounded by parental control and expectations. As an institution, we come from a child's rights perspective. Very often in our work, we have supported and guided the adolescent and family to draw common grounds where the adolescent's academic/career aspirations are given primacy, the adolescent's strengths are supported, and a trusting and friendly relationship between the parent and adolescent is fostered, instead of an authoritarian one. The intention is to take off negative stress that further compromises performance. The Indian society is undergoing dynamic structural and social changes. Adolescents are much more exposed to the outside world, given the access to technology and social media. The obvious “generation gap” results in increasingly autonomous, independent adolescents with conservative parents. The conflicts are multi-faceted with boundary issues and social, educational, professional, cultural, and even religious themes. Family environments remain the first and most significant social context within which adolescents grow and develop. Hence, families contribute to predisposing, precipitating, perpetuating and prognostic factors. Thus, involving and addressing family-related variables have long-lasting implications for adolescent mental health.[2324]

Children in conflict with the law

Children who come in conflict with the law are usually older adolescents. Within the first few months of APC, we had five adolescent inpatients who had been in conflict with the law. We got referrals from the Juvenile Justice Board (JJB) for assessment of youngsters allegedly accused of crimes, including heinous crimes. It was no surprise to us when we discovered the harsh backgrounds these adolescents came from. Significantly, there appears to be a biopsychosocial causality behind the offense. Just as an illustrative example, a 16-year-old was accused of a sexual offense under the Protection of Children from Sexual Offenses Act (POCSO, 2012).[25] This child belonged to a socio-economically deprived family with 6 members and had come away from home to find work and support his family. During his stay in a big city, he came in contact with a group of boys who persuaded him for homosexual activity. His engaging a younger child in homosexual activity constituted the alleged offense. When the adolescent was evaluated at APC, we found he had subaverage intellectual functioning (borderline intelligence), poor decision-making, and critical thinking abilities. The same were communicated as part of our assessment report to the JJB. The need for the adolescent to be supervised and guided in social judgment was stressed. This information could be crucial for legal decision-making.

Adolescents in conflict with the law need the circumstances that led up to the alleged crime to be understood from a bio-psycho-socio-legal lens, and not just a culpability lens. The assessment, treatment (if there is a psychiatric illness) and reporting, needs to take into consideration current problems, and long-term care and rehabilitation including psychosocial rehabilitation. The JJ Act considers three main aspects in determining culpability – the mental and physical capacity to commit the offense, the circumstances in which the offense was committed and whether the accused understands the consequences of committing the alleged offense. The circumstances need to be understood longitudinally. In our experience, children who come in conflict with the law are in need of care and protection for a long time before their fateful associations with legal conflicts.

CONCLUSIONS

The need for older adolescents to be treated in an environment appropriate to their age and developmental stage is evident by the pattern of illnesses and psychosocial contexts they present with. APC at NIMHANS, Bangalore is a one of its kind inpatient facility for 16– 18-year-olds with a unique focus on family interventions alongside individual intervention. Our work at the APC over its initial months has been both insightful and rewarding. Restructuring of spaces, routines, and creative inputs to interventions strategies are constantly being made to make this facility a friendly, healing environment for the youngsters who come here. This could be a model for development of similar centers in the rest of the country. The field of Child and Adolescent Psychiatry is expanding in the country with the initiation of DM courses at other centers, and a huge impetus to the setting up of Institutes of National Importance. Alongside these developments, it would be wise to have a developmental lens in setting up of child and adolescent psychiatry services, and plan for separate facilities for older adolescents.

The APC, a unique clinical facility, apart from serving clinical needs also provides a novel training environment for nurturing future mental health professionals. We anticipate that the exclusive experiences in dealing with adolescent-specific developmental themes, the conflicts with family and the legal system, will better shape the students’ clinical repertoire. Finally, this facility also provides scope for a systematic framework to transition care from adolescent to adult psychiatric services using continuous and collaborative engagement.

Note: Further details about the Adolescent Psychiatry Center facility, including grant/budgetary details, are available for interested readers on request from the Head of Department of Child and Adolescent Psychiatry, NIMHANS, Bangalore (please send an E-mail to: capnimhans@gmail.com).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest