While parents all hope their children will never be hospitalized, under certain situations, it may be necessary. For children with autism, a hospitalization may be even scarier. Kids on the spectrum may become emotionally dysregulated when taken out of their routine. If it is necessary to hospitalize a child on the Inpatient Psychiatric Unit (IPU) at Seattle Children’s Hospital (SCH), there are many things a parent should know and can do to help in the transition to the hospital. The purpose of this blog is to give some background on why a child might be admitted and what to expect during a hospital stay.
I recently talked with Kelly Schloredt, PhD, Clinical Director, Inpatient Psychiatry Unit. Dr. Schloredt is a Clinical Associate Professor at the University of Washington and a researcher at the Center for Clinical and Translational Research. Dr. Schloredt shared her insights about what parents can expect if their child is admitted to the IPU and what might ease the transition for their child.
Wendi Gardner: Tell me about the IPU.
Kelly Schloredt: The Inpatient Psychiatric Unit (IPU) at Seattle Children’s Hospital (SCH) is a 20-bed acute care crisis stabilization unit. Most typically, we treat children between the ages of 4 and 18, but under special circumstances this age range is flexible. We pride ourselves on caring for all children who are in need of acute psychiatric care, regardless of developmental level and diagnostic status. Five of our 20 beds are designated med-psych beds, and although they are not always used for this purpose, having those five beds allows us the opportunity to serve children with significant medical problems in conjunction with their psychiatric concerns, as well as children who have a primary medical concern but whose behavior might be difficult to manage on the medical floor.
WG: For what reason would a child with autism be admitted to the IPU?
KS: The most common scenario under which a child with autism would be admitted is behavior that has escalated to the point that it has become unsafe or unmanageable in the home or community setting. Such behavioral “storms” represent a major change in the child’s functioning and often require a hospitalization for stabilization. Second, children are often admitted so that medication changes can be made in the confines of a controlled setting and safe environment. We typically do this in coordination with the child’s outpatient provider in a “planned admission” where there are concerns that the change in medication would result in significant behavioral changes needing close supervision. Due to limitations in length of hospital stay, it is most often not possible to do a “medication wash-out” where a child is gradually taken off all medications.
WG: What kinds of behaviors might specifically warrant an IPU admission?
KS: Behaviors that would most commonly warrant an admission would include aggression, self-injury, or some other type of unsafe behavior. Related to this, children may be admitted in the context of a major shift in their baseline functioning If a child’s outpatient team and family are struggling to figure out what is going on, this may be a reason to for admission.
WG: When a child is admitted to the IPU, what can a parent expect?
KS: The average length of stay for an acute care admission is relatively short and usually somewhere between 7 to 10 days. While providers and families sometimes wish it could be longer, , the length of stay for all children, regardless of diagnosis, comes down to “medical necessity” and whether the child continues to meet medical necessity requirements for an ongoing acute care hospitalization.
In general, it is our strong preference to plan admissions as much as possible for children with autism. Past experience has led us to believe that when such admissions are planned, they tend to go much smoother from start to finish. The reasoning behind this is that hospitalizations represent major transitions for all children, but particularly children with autism. Preplanning allows us to minimize the impact of the transition to the best of our ability, allowing us to learn about the child’s preferences so that we can attempt to set up our environment in a way that will best suit their needs.
WG: Do you do diagnostic evaluations for autism in the IPU?
KS: Because the IPU is an acute care, stabilization unit, we do not perform diagnostic evaluations or “work-ups” for autism spectrum disorders. Instead, our focus is on the specific crisis that brought the child to the hospital. .
WG: If a child is receiving outpatient behavioral intervention or has an ABA program at home, is that something the IPU staff could implement or work into the program?
KS: While we make our best efforts to carry forward programming that occurs in a child’s home setting, we cannot always manage the intricacies of this in the hospital and our ability to do so comes down to an issue of the particular needs of the child and the extent of the behavioral program. For example, if a child comes with a specialized communication device, we can do our best to effectively incorporate the communication device into our daily routine. At the same time, it is unfortunately not possible for our staff to become experts in the implementation of more involved and intricate behavioral interventions (such as ABA programs) in such a short period of time. Thus, beyond standard interventions for youth with autism (e.g., use of picture schedules, standard routines, the use of “first-then” language and sequencing, etc.), we are often not able to implement specific programs designed for home or school.
WG: Do children have their own room?
KS: While most of the patient rooms on the IPU are single rooms, we do have a few double rooms. Decisions about who will and will not have a roommate are based on a range of variables that are reevaluated on a daily basis according to our patient mix. Roommate decisions are dependent on the needs of all of our patients on the IPU. With very few exceptions, we cannot guarantee that any child will not have a roommate at some point during their stay.
WG: Are parents able to stay with their child on the IPU?
KS: Yes, parents are welcome on our unit 24 hours a day, 7 days a week. All patient rooms have couches that fold down into a bed for parents to sleep if they wish to stay with their child. .
WG: How involved are parents in their child’s care?
KS: As we firmly believe that parents are the best “experts” regarding their children, we view parents as critical members of our treatment team and really appreciate their ongoing feedback and input with regard to their child’s care. There are many opportunities for parents to participate throughout the day. While we appreciate parent’s availability to sit down and meet with us at various points during the hospitalization, we especially appreciate their daily involvement in treatment team rounds (Monday through Friday). Although daily rounds is a short meeting, it offers the entire team, including parents, an opportunity to sit in the same room at the same time and get an update on the child’s status, treatment plan and medications.
Parents should know that they are assigned a case manager upon admission, and this person really serves as the conduit between the family and the treatment team. Parents can contact their case manager at any time with questions or concerns and request a meeting with their child’s team or care providers and case managers will set it up. In addition to hearing the concerns parents have, I should also mention that we like to hear what we might be doing right—feedback, whether positive or negative, is extraordinarily beneficial in helping us learn how to best serve all families. As one of our many goals is to put “patients and families first”, we appreciate any feedback that helps us understand if we are achieving this goal.
WG: How do you manage “out of control” behavior?
KS: This is an interesting question, as “out of control” behavior means different things to different people. In general, we define out of control behavior as behavior that represents “a danger to self, others, or property.” Our management of such behavior follows what we call “continuum of care interventions.” In general, our behavioral management philosophy is based on a system of natural and logical consequences, and unlike other psychiatric units, we pride ourselves on running a “seclusion and restraint free environment.”
This means that we are committed to using the least restrictive intervention possible in managing behavior that is “out of control.” Seclusion and restraint are the most restrictive actions staff can take and are reserved as safety interventions of last resort. Research tells us that such interventions are not therapeutic for children and because of this, we steer away from using them. I can assure parents that our staff are highly trained and follow the “continuum of care” with the goal of using the least restrictive intervention possible.
WG: What type of providers work with children on the IPU?
KS: We have a multidisciplinary team of mental health providers including psychiatrists, psychologists, advanced registered nurse practitioners, psychology and psychiatry residents and fellows , mental health therapists, registered nurses, educators, case managers, and pediatric mental health specialists. All providers on the unit have a unique niche and aspect of care in which they specialize. Over the course of an average day, a child’s activities of daily living is managed and supported by registered nurses and pediatric mental health specialists, while other providers are more specifically focused on the bigger picture issues of what brought the child into the hospital.
If need be, the IPU team can request consultation from a group of speciality providers within the medical center, including nutrition, pediatrics, neurology, adolescent medicine and many others. Such consultation is sought and utilized in accordance with the acute nature of the IPU hospital stay.
WG: Are their specific treatments on the IPU related to children with autism?
KS: The treatment needs of each child with autism admitted to the IPU are evaluated in the context of a range of factors including the reason for admission and the child’s developmental level. Treatment plans are then developed accordingly. Because children with autism are so unique in their needs, we do not use a “one size fits all” approach and instead focus our approach on individual needs..
WG: Can you follow special diet plans?
KS: Although we are able to accommodate diets specific to a medical condition, such as diabetes, we are not able to accommodate highly specialized “autism diets”. We do our best to work with families to accommodate a child’s food preferences. Families may bring in food but should know that we do not have the ability to store special foods, particularly foods that require refrigeration.
WG: Does the IPU communicate with my child’s school?
KS: With the written consent of parents, our IPU Educators can contact the child’s teacher or counselor to obtain work, discuss the child’s challenges at school, and offer any recommendations related to school that might come out of the hospitalization. Because of the short nature of the stay, we are not able to recreate the school program, but we will assist the child in completing work that is sent to us. It should be noted that while we can offer general recommendations for classroom strategies, we are not in a position of being able to recommend significant changes in school programming (e.g., obtaining 1:1 para-educators, changing schools or classrooms, etc.), as such issues cannot be formally assessed during an acute care stay and never constitute the reason for admission. These are all activities that must go through the formal school IEP process.
WG: What would you like parents to know about the IPU and what to expect?
KS: The focus of an acute inpatient stay centers on the crisis that precipitated the admission. Our goal is to help parents and caregivers manage the crisis, and to this end, significant participation by parents and caregivers is needed. IPU admissions are short in length and are not intended as respite care, day treatment, or a place to get all medical needs met at one time. Children may not leave the IPU looking a lot different than when they came in, short of the fact that the crisis that precipitated the admission will have passed.