Child and Adolescent Mental Health Services: inpatient report

A4.10 Admissions to adult mental health wards, including intensive psychiatric care units ( IPCUs)

Summary of characteristics of patients admitted to adult mental health wards:

• Level of learning disability: 30 no learning disability, 17 mild learning disability, 8 moderate LD, <5 severe/profound learning disability
• Autism spectrum disorder: no autism spectrum disorder ratio: 4:1
• Age: 78% were 16-17 years, 20% were 14-15 years

Due to distances involved and bed availability, young people with or without learning disability and/or autism spectrum disorder often had to be admitted in crisis to their local adult mental health units, with subsequent assessment by their CAMH psychiatrist and transfer when possible to their regional YPU. This could be a difficult process for any young person; however, it was particularly difficult for those with learning disability and/or autism spectrum disorder.

Admissions to adult mental health inpatient units were often helpful in the short term to manage immediate risks and medication. Young people and others were kept safe in crisis situations and there was containment of anxiety. However, lack of ability to carry out overall needs-assessment, multidisciplinary treatment and management meant that often little progress was made in terms of longer-term outcomes. As for those with learning disability and/or autism spectrum disorder admitted to YPUs, admissions were most helpful for those with no or mild learning disability, good communication skills and more typical mental illness presentations. Some admissions to adult mental health wards, including several to IPCUs (intensive psychiatric care units) were extremely challenging. Some serious staff injuries were reported.

Being close to home was an advantage, allowing continuity with local clinicians and facilitating discharge planning. For some of those very close to 18 and with mild/no learning disability and autism spectrum disorder, who were about to move on into mainstream adult mental health services, it was felt little would have been gained by admission to the more distant regional YPU. This was similarly the case for brief admissions to local adult mental health wards for those with autism spectrum disorder (but no learning disability) where crisis management was all that was required.

Clinicians were aware that some young people did not like being on an adult ward and felt anxious there. One young man with moderate learning disability was extremely unhappy on an adult mental health ward and made allegations of aggressive behaviour against him by a nurse.

An admission for a young person with moderate learning disability and autism spectrum disorder went well due to 'luck and circumstance', as a new IPCU was available which happened to be quiet. Adult LD nursing staff were brought in, nursing him separately from adult patients and were able to bring behaviour under control. Had either appropriate staff or the amount of space in the ICPU not been available, this patient's behaviour could have escalated and he could have become stuck in hospital for a prolonged period.

A4.10.1 Patient safety

The vast majority of young people admitted to adult mental health wards were nursed 1:1, often in their own room, according to protocols designed to keep them safe, e.g. from exploitation by adult patients. Some clinicians commented that this also gave them more attention than the adult patients and perhaps gave them greater access to activities and recreation to keep them occupied. However, if inexperienced or unconfident staff were responsible for the 1:1 observations then it could feel counterproductive.

A number of those with mild learning disability and/or autism spectrum disorder were felt to be particularly sexually vulnerable due to immaturity, social naivety and in some cases disinhibition. Risks were mitigated by the 1:1 observations but it could be difficult, e.g. on a small IPCU, to keep young people entirely away from adult patients. Others with mild learning disability, whose presentation could not justify constant observations, made connections with young adults on the ward and were vulnerable to their influence, e.g. going out of ward with them and coming back drunk.

A lack of appropriate environment and expertise also put young people at risk of high use of psychotropic medication. Weight gain and metabolic syndrome were a problem for some, exacerbated by inactivity due to lack of access to fresh air and space for exercise.

A young person with mild learning disability who was severely mentally unwell required a secure LD CAMH hospital due to high risk of violence to others. The LD CAMH team responsible for his care for nearly 2 months on a local AMH unit were completely unable to adequately assess and manage his symptoms in that environment. The risk levels meant it was too dangerous to attempt medication change so the patient remained very distressed and unwell while awaiting transfer.

A4.10.2 Parental concerns/relationships with services

Quite a number of families were reported by clinicians to have been happy with care provided on adult mental health wards, including one on an IPCU. There was relief at admission as things were so difficult at home, but also worry about their children being in an adult environment. Families were concerned that staff lacked confidence and experience not only with young people, but particularly with those with learning disability.

Several families were reported by clinicians to have been very negative about admission and developed very difficult relationships with medical staff. Families had concerns about various aspects of management, including restraint. Unhappiness about admissions had an impact on families' ongoing relationships with services.

A4.10.3 Lack of age-appropriate environment and interventions

There was a lack of access to education and structured and purposeful activity for young people on adult mental health wards and the issues here were very similar to those described above for young people admitted to adult LD wards.

A4.10.4 Staff expertise and experience

In addition to the lack of experience of nursing staff with children and young people, there was a lack of access to age-appropriate allied health professionals, in particular occupational therapists and speech and language therapists. Advice and input from CAMH psychiatrists and nurses was often provided.

For those with no learning disability but with autism spectrum disorder, a lack of understanding of autism spectrum disorder by staff was a problem, for example understanding of communication needs; understanding the need of one patient to pace (leading to overuse of medication). Ward staff reportedly did not understand that a young person was reverting to younger behaviour due to stress, and they were not thought to be as nurturing and understanding as an YPU would have been. There were difficult diagnostic challenges regarding one patient's presentation and either a specialist autism spectrum disorder unit or advice from multidisciplinary experts would have been helpful.

For those with mild learning disability with or without autism spectrum disorder, it was reportedly difficult for staff to engage with some patients; therefore assessment of their needs, including level of understanding, was not possible. Ward staff lacked experience in understanding developmental issues in general. Where there was CAMHS rather than LD CAMHS in-reach, CAMH staff also felt under-skilled in one case and not confident in treatment decisions. They lacked familiarity with the presentation of psychosis in a young person with learning disability. Essentially they 'held' the situation pending transfer to an adult LD ward. In another case, ward staff felt 'out of their depth', not only managing a young person rather than an adult, but one whose learning disability made them developmentally much younger still.

For those with moderate and severe learning disability, very variable attitudes and levels of understanding were reported amongst staff on adult MH wards. Staff who lacked confidence could become very anxious about their ability to manage patients with high levels of complexity and challenging behaviour who were so different from their usual patient group. Constant support was required from CAMHS staff. It was also difficult for hospital staff to understand family dynamics and issues and impact of puberty on young people's presentation.

A young person with severe learning disability, admitted in crisis to an adult MH ward showed very high levels of aggression which the ward struggled to manage. A local review of service provision was required and Mental Welfare Commission involvement.

A patient who had autism spectrum disorder but no learning disability and required medium security was admitted to an IPCU. The very repeated aggression to IPCU staff meant the patient had to be isolated in one room and the whole admission was treated as a critical incident.

A4.10.5 The physical ward environment

The main 'adaptation' required for those young people with autism spectrum disorder without learning disability who were admitted to adult mental health units, whilst needing YPUs, was the need for them to be in a single room (1 specified near to the nursing station) due to their vulnerability in an adult environment. One was given the exclusive use of a 4 bedded area during the day, but was able to share the sleeping area at night. Another required a hoist and other specialist equipment due to physical immobility and health problems.

Six of the young people admitted to adult mental health units who needed an LD CAMH inpatient unit were noted as needing special physical adaptations to the ward. All of these had mild or moderate learning disability and the majority had additional autism spectrum disorder. Some of these ideally required secure LD CAMHS settings.

A patient was isolated in a segregated part of an adult mental health IPCU (Intensive Psychiatric Care Unit).

A young person was nursed on a bare mattress with no furniture, to reduce aggression and destructiveness.

The environment for a patient was adapted to make it more 'autism-friendly', taking into account the individual's sensory hypersensitivities and obsessions with/destructiveness of electrical items.

The environment was not suitable for the admission of one young person with severe learning disability. The patient required higher staffing nursing ratios and consistent care, rather than from a big team of staff. Staff struggled as the patient could not cope with others being around him and showed extremely high levels of aggression and self-injury.