Child and Adolescent Mental Health Services: inpatient report

A4.6 Admissions to different types of ward - overview

This data is for all 'submissions', i.e. different parts of an admission, such as when a patient was transferred between units within an admission, are separately counted.

Admissions to different types of ward – summary of statistics

Highest rates of admission were to adult mental health wards, followed by YPUs and adult LD wards.

Few patients in the survey were admitted to learning disability child or young person's mental health inpatient unit, autism spectrum disorder mental health inpatient units, pediatric wards and the National Child Psychiatry Inpatient Unit.

Patients with increasing levels of learning disability were more likely to be admitted to adult LD wards, but only 2/3 of those even with severe/profound learning disability were admitted to a learning disability specific ward, with ½ of these being an age-appropriate facility.

The most common age for those admitted to adult MH, adult LD, YPU and LD CAMHS (including secure) wards was 16-17 years. Those remaining at home or admitted to non-hospital placements tended to be younger teenagers.

Rates of autism spectrum disorder varied according to the type of ward admitted to.

A4.6.1 Type of ward admitted to for all admissions

Note that admissions to Secure Adolescent ('Secure YPU') and to Autism units (including Autism secure units) are omitted from the above graph as there were less than 5 admissions to each of these types of units. ' AMH' refers to adult mental health.

A4.6.2 (i) Level of learning disability

There was variation as to which wards children and young people were most likely to be admitted to according to their level of learning disability:

No learning disability AMH (61%) YPU (16%) ALD (0%)

Mild learning disability AMH (39%) YPU (21%) ALD (21%)

Moderate learning disability AMH (17%) YPU (28%) ALD (24%)

Severe/profound learning disability AMH (0%) YPU (0%) ALD (36%)

LD CAMHS (29%)

Note: AMH = adult mental health; ALD = adult LD

For each level of learning disability, the % of children and young people admitted to age-appropriate mental health units (including YPUs, the National Child Psychiatry Inpatient Unit, LD CAMH and autism spectrum disorder-specific provision) were as follows:

No learning disability: 27%

Mild learning disability: 36%

Moderate learning disability: 33%

Severe/profound learning disability: 43%

For the main types of ward that patients in the study were admitted to, levels of learning disability varied as per the following table (numbers are for admissions or parts of admissions where transfers occurred).

Type of ward admitted to by level of learning disability

Level of learning disability → Type of ward ↓	None	Mild	Moderate	Severe/ profound
Adult mental health	30	17	8	<5
Adult LD	0	9	11	5
YPU	8	9	13	0

Numbers admitted to other types of ward were too small to provide meaningful/non-identifiable breakdowns of levels of learning disability.

A4.6.2 (ii) Age at admission

The age of patients admitted to the various types of units varied. The most common age-groups for patients admitted to each type of units were as follows:

Adult mental health: 16-17 (78%) 14-15 (20%)

Adult LD: 16-17 (68%) 14-15 (28%)

YPU: 16-17 (63%) 14-15 (30%)

The following had small numbers but trends are given:

• Paediatrics: mostly aged 13 and under
• Non-hospital placement: mostly aged 14-15
• Stayed at home: mostly aged 14-17
• National Child Psychiatry Inpatient Unit: all under 12 by definition
• Secure YPU: all aged 14 and over
• Autism unit (including secure): all aged 14 and over
• LD CAMHS (including secure): ranged across all age groups but most commonly 16-17 years

A4.6.2 (iii) Autism spectrum disorder diagnosis

High rates of autism spectrum disorder diagnoses were found amongst children and young people admitted to all types of units in the survey. All of those admitted to specialist units in England had autism spectrum disorder. Ratios of autism spectrum disorder to no autism spectrum disorder, in the 3 main types of units admitted to, were as follows:

• Adult mental health: 4:1
• Adult LD: 2.25:1
• YPU: 1.5:1

A4.6.3 Summary of issues and outcomes to currently available Scottish units

Some positive experiences and good outcomes were reported by clinicians and families for patients and families from admissions to all types of existing Scottish mental health wards. However, these were often the results of 'cobbled-together' arrangements, with huge support and input from community clinicians, with detrimental effects on other patient care. Outcomes for those with more than mild level of learning disability and/or with high levels of challenging behaviour or forensic needs were much less good. The following tables summarise issues and outcomes for patients admitted to Scottish units from the survey from sections 4.8-4.13 of the results.

Summary of issues on adult LD and mental health wards

Positive experiences and outcomes

Issues common to adult LD and adult mental health wards related to keeping children and young people local, allowing family contact, continuity with local multiagency professionals, facilitating discharge planning and transition to adult services

Adult LD wards only:

• Good staff knowledge and experience of learning disability and autism spectrum disorder.
• Took in children and young people with highly challenging behaviour when no other wards able to.
• Services flexible in adapting physical environment and staffing.
• Successful multidisciplinary assessment, diagnosis and management of mental and physical health conditions and challenging behaviour for some children and young people.
• Sometimes reduced medication, restraints, and use of seclusion, greater access to community and development of self-care skills .

Difficulties and poor outcomes

Issues common to adult LD and adult mental health wards:

• Difficulties keeping separate from adult patients: Some children and young people therefore felt unhappy, anxious and intimidated, with exposure to aggressive or sexualized behaviour from adult patients. Children and young people with milder learning disability and less supervision were socially and sexually vulnerable.
• Difficulty providing robust, 'autism friendly' physical environment and consistent staff team for those with highly challenging behaviour. Staff struggled to manage high levels of aggression and some children and young people had to be nursed in very restrictive settings, leading to isolation and risk adverse practice.
• Lack of a specialist age-appropriate multidisciplinary team: staff lacked confidence and expertise in learning disability and/or autism spectrum disorder; had difficulty recognising atypical presentations of mental illness and had insufficient understanding of family expertise, dynamics and systems, attachment and the impact of puberty.
• Lack of access to education, appropriate peer group, play and activity, including fresh air and physical exercise.
• These issues could combine to result in escalation of behaviour, with high use of medication and restraint. Medication side effects and lack of exercise led to weight gain, including metabolic syndrome.
• Some patients were discharged too quickly due to concern about being in an adult setting, with inadequate assessment and treatment. Others were transferred precipitously to other hospitals after breakdown of care.

Adult LD wards only:

• Lack of progress over months or years, remaining in extremely restricted ward environment for some, with missed opportunities for education and development.
• 'Delayed discharge' of some patients due to lack of suitable care and/or education placements.
• Significant impact on other adult patients, e.g. adults at risk from their aggressive and destructive behaviour, or distressed by noise and disturbance; beds/ward space closed to adult patients for long periods; ward staff had less time available for adult patients who also had reduced access to activities.

Adult mental health wards only:

• Disproportionately difficult for children and young people with learning disability and/or autism spectrum disorder, due to them being developmentally younger, with poorer communication skills. Harder to provide developmentally appropriate activities.
• Parents especially concerned and anxious about lack of staff expertise regarding learning disability and autism spectrum disorder on these wards.
• CAMHS struggled to support when no specialist LD CAMHS to advise.
• Repeated admissions to inappropriate AMH wards in crises contributed to escalation of difficulties for some patients.

Summary of issues on child and adolescent wards

Positive experiences and outcomes:

Common to YPUs and the National Child Psychiatry Inpatient Unit:

• A number of families gained a greater understanding of their children's needs.

YPU wards:

• One YPU managed a number of children and young people with moderate learning disability with training and support from the local LD CAMH team, also employing learning disability trained staff which improved staff confidence and expertise.
• Able to manage majority of children and young people with autism spectrum disorder but no learning disability/mild learning disability .

National Child Psychiatry Inpatient Unit:

• Personalised assessment, diagnosis, treatment and management of children with highly complex mental and physical health needs. Close links with Paediatrics helpful for physical co-morbidities.
• Staff experienced in neurodevelopmental disorders .
• Families learned practical strategies to support their children.
• Good pre-admission and follow-up support to local services .

Paediatric wards:

• Provided respite for some families.
• Medical investigations carried out.
• Sometimes a degree of assessment by CAMHS of the child and their family situation was possible, as was medication monitoring and change .

Difficulties and poor outcomes

YPU wards:

• Unable to manage those with forensic/secure needs .
• Patients with highly challenging behaviours generally not admitted.
• Mixed reports of staff expertise and confidence about autism spectrum disorder.
• Lack of access to specialist education for autism spectrum disorder and learning disability needs.
• Unequal access as support from LD CAMH teams unavailable for admissions of children and young people from outside the Health Board in which the YPU is located.

National Child Psychiatry Inpatient Unit:

• Some children with severe learning disability and autism spectrum disorder only manageable as day patients and ultimately requiring specialist LD CAMHS unit admission.
• Practical and financial difficulties for families from remote parts of Scotland having to travel to national or regional unit.

Paediatric wards:

• Ward staff lacked confidence and skills in dealing with mental health problems and acute behavioural disturbance.
• Families generally had to give 24 hour care to their children in hospital, which was stressful, sometimes feeling unsupported by ward staff.
• In some cases described as 'holding place' pending transfer, or as ineffective due to distress of child in that setting.
• Very time consuming for pediatricians .

Summary of other issues

Positive experiences and outcomes

Common to adult LD, YPU and adult mental health wards: included managing acute risks and medication in a safe environment, providing relief for families, identifying care needs and supporting discharge.

Common to adult mental health and YPU wards: better outcomes for patients with no/ mild learning disability with good communication skills and typical mental illness presentations. Also cases where treatment commenced, or behaviour/situation stabilised, pending move to a specialist unit.

Difficulties and poor outcomes

Common to adult LD, YPU and adult mental health wards: included lack of age-appropriate learning disability/autism spectrum disorder specific assessment, no change ('holding place' pending transfer), children and young people remaining unwell for prolonged periods, and families very unhappy about admissions, with long-term consequences on future engagement.

Common to adult mental health and YPU wards:

• Struggled to manage those with moderate/severe/profound learning disability - problems understanding implications and impact of learning disability (and in some cases autism spectrum disorder), the relevance of symptoms, using appropriate communication and managing behaviour.
• Significant treatable difficulties persisted after discharge due to lack of thorough learning disability-specific multidisciplinary assessment/treatment.