Hospitalization How-To (When You Have To)

One of my kids was in the psychiatric hospital, or the “phosp” as we short hand it in the Facebook Support Group, last week. It doesn’t matter which one. Even though each of my kids with mental health concerns has, of course, their own distinctly different issues, the experience of being hospitalized, working on those issue, formulating a plan for aftercare, and discharge is generally the same. At least for us parents. Someone pointed out to me that, unbelievably, I’ve never written a post about what to do when your child is hospitalized. As this is the 14th time I’ve had a child admitted to the phsop – not a badge of honor, I can assure you – I guess there’s no time like the present.

The Awareness

The first time Tim went inpatient, we were told by his therapist that it was necessary. The next 10 times, we waited until he was a psychotic, raging, melting mess and we had to call police and paramedics to get him to go. The last time (so far, knock wood) we decided that he was showing signs of decompensating to the point of being dangerous to himself / the rest of the family and worked with his doctor to check him in. The first 11 stays were more than 20 days each. The last was 4. You might say that we’re slow learners ( you wouldn’t be the first), but we finally realized that waiting until he was a puddle of goo and beyond unhinged wasn’t healthy for him or anyone else in the house. If you feel your child is decompensating, call your pdoc or therapist. Start the discussion. You know when it’s just an off day and when it’s becoming a trend. That way you and your doctor can decide when a hospital stay can help stabilize your kiddo without having to wait until you find yourself, like I found myself, more than once, screaming, “That’s it! You’re going to the hospital!”

Getting There

There’s only three ways – you drive, the police drive, or an ambulance drives. There are pluses and minuses to all three options. Police can help calm an escalated situation and can call an ambulance for transport if that is what is needed to get your child to the hospital safely. But it takes time. The police have to come. They have to assess. Same with EMT. And then there’s the extreme visibility to the neighborhood if police and/or an ambulance show up in your driveway which can distress you and your child later. But if it’s between you possibly getting brained in the car by flying objects or your child bailing out of a moving car or dealing with nosy neighbors later, please always opt for the choice that keeps everyone safe.

One additional note about calling the police. Before you have a crisis, call your local police / sheriff non-emergency number and ask if they have CIT trained officers or a mental health registry program. If they do, register your phone number and address as the home of a person with a mental illness. Then, if you must call for help, you can tell the 911 operator, “I need a CIT trained officer, as I have a child in a mental health crisis.” You will have a more positive experience with law enforcement and emergency personnel if you make plans in advance.

The Wait

The vast majority of psychiatric admissions are through the ER, whether your child arrives by ambulance or you drive him/her there. ER staff are used to dealing with crisis, but most are woefully unprepared / untrained to deal with a child in a psychiatric crisis. If you arrive by ambulance at least you’ll get a room right away. If you walk into an ER, you will likely try and keep your kid from coming unglued in the waiting room for an hour or more before you even see a triage nurse. And, as great as triage nurses are, they will likely have a difficult time understanding why you are in an ER for a kid who’s having a “tantrum” or a “meltdown”. Once you get into a room you wait for a psych consult. And you wait. And wait. If you’re lucky, you can, again, keep your kid from becoming unglued. If you’re unlucky – like happened to us once – your kid will scream and rage and spit and tell the staff that you’re trying to kill him, which will bring a social worker to see you WAY faster than it will bring the psych consult.

Once you get the psych consult, there’s only one reason they will consider admission for your kid. He/she has to be an IMMEDIATE DANGER TO HIM/HERSELF AND/OR OTHERS. Just because your kid is so manic that he hasn’t slept in a week and has broken every dish and door in the house isn’t good enough. Just because she talked about suicide in vague terms every day for the past two weeks isn’t good enough. The danger has to be imminent (just ask Adrienne). Even if they do believe your child needs to be admitted, the wait continues while they try and find a bed. Or another facility. Or somewhere other than the ER. I’ve had the wait be three hours. I’ve heard it taking as long as FOUR DAYS. Yep – you read that right. I’ve had more than one mom tell me about being stuck in the ER, sitting next to her child for days waiting for a bed to become available, while the ER staff did nothing to help her son – didn’t even give him his regular meds.

If you have a good pdoc and he/she can get you a direct admit, all the better. Then you can avoid the ER nightmare. Our psychiatric hospital has a walk in assessment team so we can skip the ER. It’s a godsend.

The Admission

Once you get a bed, then there’s the paperwork. Be prepared to fill out a complete medical history, including an assessment of your child’s current mental state. Bring his/her current meds with you so you know the dosages. Your child will likely have to answer questions about his/her mood as well, and as hard as it is to help our kids by answering for them when they are unstable, do your best to let your child answer. You might find out that your child is more aware of his/her symptoms than you realize. I know I did.

They will ask you what method you prefer they use to subdue your child, should your child become a danger to him/herself or others while in the hospital. The choices are usually these three:

Use of a quiet room / seclusion
Use of rescue medication (oral and/ or injectible)
Restraint by personnel, mechanical restraints, or both

I tell them that is my preference – that order. They will tell you that they will make “best effort” to follow that, and make you sign a waiver that says you understand they can use any or all of them as they see fit, and you don’t really have a choice. But know this, and be sure THEY know you know this – they can’t give your child rescue meds or use restraint without telling you. If you show up for a visit and your child tells you they got an injection or were in a hold, and they didn’t call to tell you, raise holy hell. Call the case worker ASAP.

You will likely have to sign several releases for your child’s school, psychiatrist, pediatrician, and therapist to receive information about your child’s condition and status while in the hospital. My rule of thumb is all info to the doctors is fine, but school only needs to know that your child is in the hospital so his or her IEP and schoolwork can be sent to the hospital. They don’t need to know anything else. HIPAA law aside, in my experience, schools are the least reliable at actually following privacy law.

You will get information on what your child is allowed to have and what he/she is not. Draw strings in clothing, belts, shoe laces, under wire bras, spiral notebooks, or anything that can be used to self harm are generally not allowed. Our hospital doesn’t allow stuffed animals or outside blankets either, which can be hard on younger children. Your child will be strip searched. It will be traumatic for your child and for you. You will get information on how to call your child and what the visiting hours are. Some hospitals have strict phone and visitation times, some do not, so be sure you know before you leave.

In some states, if your child is over the age of 14, your child must consent to his or her admission.

Here’s a little known fact: Psychiatric hospitals are not allowed to change your child’s medication without getting your consent before they change it.

Be sure they give you a schedule of the program. You should know what your child is doing. Also be sure they give you a telephone number to your child’s caseworker. Each child should have a care coordinator or case worker and you need to know how to contact him or her. Know the name of the doctor assigned to your child, and his or her office phone number.

During Inpatient

If you’ve ever had a child inpatient, you know that the one thing all psychiatric hospitals suck at is communication.

Don’t let them get away with it.

Call your child’s case worker or care coordinator the day after admission and let him or her know your expectations as far as communication goes. I expect a call daily. I ask if meds have been changed. I ask if my child is participating in the program or is being allowed to sleep through it (which is a big warning sign that the hospital may not be so good at actually treating patients). I ask if my child has seen the psychiatrist, and when the first staffing is scheduled. I ask to schedule the first family session, during that first call. I ask the case worker’s hours because if I call my kid’s case worker and I don’t get a return call in two hours, I start calling every 30 minutes until I do get a call. It’s amazing how well that little trick works. Yes, I know I can be an annoying bitch when my child’s welfare is involved. Tough noogies.

After the first staffing, I expect the case worker and the doctor to give me data, and lots of it, answering these types of questions:

What is my child’s working diagnosis? Is it different than a diagnosis he/she had before admission?
In what type of groups and/or therapy sessions is my child participating? General group therapy? Play therapy? Self-injury? What is the goal of the therapy sessions?
Do you have any plans to adjust my child’s medication? Why?
Have you been in contact with my child’s primary psychiatrist? If not, why not?
How is my child adjusting to the routine of the ward?
Has the school sent over my child’s schoolwork? Is my child working on it? If not, why not?
Do you have thoughts about the aftercare plan we can discuss now?

Visitation and Calls

Tim always had a distinct pattern when it came to phone calls home and visits while inpatient. The first day or two inpatient, he would call us, say three words, and hang up on us. The first visitation time, he would refuse to see us. I still think it was his way of showing us he was in charge of the situation, even if he was in the hospital. So be prepared for your kid to be pissed off or out of sorts or not ready to talk to you right away, even if he/she knew inpatient was needed. Admitting you need to be hospitalized is as demoralizing and scary and embarrassing for our kids as it is for us. Don’t take it personally, even if he’s screaming, “I hate you!” at 120 decibels into the phone.

On the flip side, try not to puddle when your child cries and wants to come home. They know how to tug our heart strings, and they’ll do it. They will beg. They will promise to be better. They will try and rationalize that they aren’t getting anything out of the program, or the program is stupid, or the staff are incompetent. Be sympathetic but firm. If the program is sub-standard, you’ll know it. But unless the place isn’t safe or the program is horrid, there is no reason to take your kid out AMA. Trust me – your insurance will take care of that soon enough.

Oh – speaking of getting your kid discharged AMA, be advised – most states have some law that allows the phosp to take anywhere from seven to fourteen days – not including weekends or holidays – to discharge a patient from a psychiatric hospital AMA. Yeah, no joke. Be sure you know what your state’s law is. I didn’t know and when I wanted to get Tim discharged once from a really, really horrible hospital, I was told it would take up to five days. I sat outside the door to his ward for over five hours until they go tired of me sitting there staring at them through the door. Sort of my own little protest.

Discharge and After Care

Aftercare is by far the most important part of any inpatient hospitalization. Sure – your child has been stabilized by a hospital stay, but often the stay is short because your insurance will only cover until your child is no longer in imminent danger, whatever that REALLY means. Your child will likely need follow up care. It can take one of many forms:

Partial hospitalization / day hospitalization: Very similar to the day portion of an inpatient program. Your child would be in the hospital school-type hours, and work on the same goals he/she had inpatient.
Intensive outpatient: more like a condensed day hospitalization. Typically this isn’t offered for kids, but could be an option for older teens.
Residential treatment: If you child needs longer term treatment, residential may be recommended. Kids in residential typically aren’t acute (meaning, not in imminent danger) but are still far from stable. Residential can be anywhere from three weeks to, in Tim’s case, three years. It depends on the severity of your child’s symptoms and the structure they require to work towards stabilization.
Individual therapy: In some cases, your child may be treated in a classical outpatient setting as follow up.

In any of these cases, the after care plan should be agreed upon by you, the case manager, the treating psychiatrist, and your child’s primary psychiatrist if that doctor is different from the inpatient treating pdoc. And, always, call your insurance company to be sure the after care plan is covered. If it isn’t or you need help in getting after care services, call your county department of mental health services or the Federation of Families, who specialize in helping families of children with mental illness.

I know that many of you are experts at this too. Please share your tips in the comments!