Psychiatric hospitalisation of children and adolescents should be a last resort and only recommended when intensive outpatient treatment is inaccessible or insufficient, and when the capacity of parental care is overwhelmed by the severity of the child’s mental illness.

In a paper published in the Australian & New Zealand Journal of Psychiatry (ANZJP), the authors outline the criteria that would lead to the decision to hospitalise children or adolescents with mental illnesses.

UNSW Sydney’s Dr Iain Perkes, who was lead author on the paper, says it is important for GPs, other clinicians, and parents to be clear on what the indications for hospitalisation are.

“It’s crucial to weigh up whether children and young people can be safely treated in the community with appropriate services and support, because hospitalisation carries risks.”

Such risks, as indicated in the paper, include the trauma of separation from family by hospitalisation, as well as the adoption of maladaptive behaviours observed in others, regression, dependence and stigmatisation.

Dr Perkes, a UNSW Senior Lecturer in Child and Adolescent Psychiatry, says there are three conditions that may support hospitalisation ahead of using community services where available.


Dr Iain Perkes, UNSW School of Psychiatry. Picture: UNSW

“First, hospitalisation is sometimes necessary to enable 24-hour observations for diagnostic clarification,” Dr Perkes says.

“Secondly, hospitalisation should be opted for as a containment of risk of harm, either to self or to others, especially if there have been recurring episodes of self-harm with increasing lethality.

“And the third reason for hospitalisation would be for a non-psychiatric medical intervention to a young person with a mental illness or disability, such as an EEG or a sleep study in some children with a medical history of, for example, autism or an intellectual disability.”

Dr Perkes says that according to recent figures collected in 2017, more than 4000 children and young people were hospitalised that year in NSW because of self-harm. “And that’s an upward trend. My own impression is that there are probably more children receiving treatment in hospital emergency departments and at inpatient services rather than suitably resourced community-based care.”

Dr Perkes says it’s unclear whether that is because of the upwards trend meaning more potential hospitalisations, or whether younger people are being over-hospitalised. He and his authors say that while rates of mental illness are fairly constant geographically, the access to services between urban and rural Australia could be the difference that risks more young people hospitalised in non-urban areas.

“What is different is how services are organised. Whether there is a responsive referral pathway and intensive community-based care in mental health services, and welfare agencies to support families and alleviate some of the burden of illness that comes with severe and complex mental health issues — these are the things that determine who is able to look after that child: either his or her own family with support from the community, or a hospital team of doctors, nurses and support staff.”

Dr Perkes says there is no doubt that young people with mental illnesses are best served when there's intensive community based care, even where hospitalisation is recommended.

“Those community-based services can be instrumental in organising and referring for admissions. So they provide a pathway into hospital, but crucially, they can also provide a pathway out of hospitals.”

“So there's that community based treatment for the child and their families to come out of hospital sooner rather than later, thereby shortening the length of admission.”

Dr Perkes will be exploring the theme of equity in access and pathways to care for children and adolescents with mental illness at the Faculty of Child and Adolescent Psychiatry conference which will be held in Newcastle in October.


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