Spsychiatrists Heat Up War on Children///DDD > Disruptive disorders-conduct disorder!

[Sir Arthur C.B.E. Wholeflaffers A.S.A.]

Psychiatrists Heat Up War on Children

>Psychiatric News June 21, 2002
>Volume 37 Number 12
>) 2002 American Psychiatric Association

>State Puzzled By Increase in Child Hospitalization Rate
>by Mark Moran

>As hospitalization rates for children and adolescents with mental illness
>set new records in the state of Washington, experts try to understand why.

>Mental illness is now the leading cause of hospitalization among children
>and adolescents in Washington state, according to a recent study of
>admission figures by researchers at the University of Washington.

>While overall hospitalization rates declined by 34 percent for children and
>teens in Washington in the 1990s, hospitalization rates for mental illness
>remained steady for adolescents and increased by 20 percent among children
>aged 5 to 14. During 1998-99, mental illness accounted for 12 percent of
>hospital admissions for children in that age group and 20 percent of the
>admissions for adolescents, according to Michelle Garrison, M.P.H., an
>epidemiologist at the University of Washington Child Health Institute.

>An additional 3 percent of children aged 5 to 14 and 6 percent of
>adolescents hospitalized in 1998-99 had a secondary diagnosis of a
>psychiatric disorder, Garrison reported at the 2002 meeting of the Pediatric
>Academic Societies.

>In an interview with Psychiatric News, Garrison said the causes of the
>surprise findings are not known and will be the subject of further
>investigation.

>"There are several different possible explanations," she said. "It could be
>that the prevalence of these disorders is increasing, or the severity is
>increasing. Or it could be that treatment patterns are changing. It may be
>that there are now more options for inpatient treatment or decreased
>resources for outpatient care, so that you have more kids reaching a crisis
>point."

>Depressive disorders accounted for 39 percent of primary psychiatric
>diagnoses among hospitalized school-aged children aged 5 to 14, and 54
>percent of diagnoses for adolescents. Disruptive disordersconduct disorder,
>oppositional defiant disorder, and attention-deficit/hyperactivity
>disorderaccounted for 37 percent of primary psychiatric diagnoses among
>hospitalized children aged 5 to 14, and 7 percent of diagnoses for
>adolescents.

>Garrison noted that hospitalization for bipolar disorder has increased
>markedly in Washington in the last decade. The diagnosis accounted for 4
>percent of primary psychiatric diagnoses among hospitalized children aged 5
>to 14 and 10 percent among adolescents.

>Importantly, Garrison noted that her study found that the mean length of
>stay for hospitalized school-aged children had dropped by 58 percent since
>1990, from 30.5 days to 12.7 days in 1999.

>Experts who commented on the study agreed the results could be variously
>interpreted. David Fassler, M.D., chair of APAs Council on Child and
>Adolescent Psychiatry, said one positive explanation for the findings is
>that primary care physicians may be much more willing to diagnose depression
>in children.

>"We are getting better at recognizing the signs and symptoms of depression,"
>Fassler said. "Ten years ago, pediatricians almost never wrote [a diagnosis]
>of depression. They are much more likely to do so today."

>But noting that "studies like these typically raise more questions than they
>answer," Fassler said it was unclear who was admitting
>childrenpediatricians, primary care physicians, or psychiatristsand to
>what kind of inpatient programs they were being admitted.

>"One of our concerns is that many inpatient psychiatric services are
>closing," Fassler said. "There is literally a crisis in terms of lack of
>access to appropriate child and adolescent inpatient psychiatric programs.
>Could part of what we are seeing be the result of children being
>hospitalized on pediatric services? What kind of treatment is being
>provided, and who is providing the treatment?"

>It is also possible, Fassler said, that the Washington state figures reflect
>a breakdown in services for children that could represent the tip of a
>national trend.

>"If there is a comprehensive continuum in place that is well funded with
>consistent clinical oversight, there is less need to use hospital-based
>resources," he said. "When the continuum starts to break down, or when
>funding gets cut back, we will see more and more kids referred to hospitals.
>If a community loses funding for crisis services or its local emergency
>program, for instance, kids will wind up in the hospital."

>Further, Fassler said that decreasing lengths of stay could also mean
>increasing admissions. "One of the things we know is that if length of stay
>gets too short, the number of hospitalizations will increase," he said.

>Whether the Washington state figures represent a trend or an anomaly is
>unclear, and Garrison said there were few other studies looking at childhood
>hospitalization for mental illness. At least one other study in another part
>of the country, however, indicated that many of the children who visit the
>emergency department are at high risk for mental illness (see box).

>Garrison said her study was prompted when an initial review of childhood
>hospitalization in the state by the Washington "Kids Count Project" produced
>eyebrow-raising results. "We were looking for the main causes of childhood
>hospitalization and expecting to see all the usual suspectsinjuries,
>asthma, and appendicitis," Garrison said. "Instead we saw mental illness
>really shooting to the top of the charts."

>In her study, Garrison used the Washington State Comprehensive Hospital
>Abstract Reporting System (CHARS) data for the years 1990-99.
>Pregnancy-related hospitalizations were excluded from the analysis, as were
>repeat hospitalizations for the same cause in an individual during a given
>year. An admission was considered to be a mental-illness hospitalization if
>the ICD-9 code for the primary diagnosis was for a psychiatric disorder.

>For both school-aged children (5-14 years) and adolescents (15-19 years),
>the rate of mental-illness hospitalizations was calculated, as was the
>proportion of admissions and hospital days due to mental illness. Secondary
>analyses examined hospitalizations for self-injury or substance/alcohol
>abuse, and the proportion of hospitalized children and adolescents who were
>discharged with any psychiatric diagnoses (including nonprimary diagnostic
>codes).