inpatient units in imh regional waimh conference acre, israel 8-10.9.2009
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Inpatient units in IMH Inpatient units in IMH Regional WAIMH ConferenceRegional WAIMH Conference
Acre, Israel 8-10.9.2009Acre, Israel 8-10.9.2009 Kaija Puura, MD, PhD Kaija Puura, MD, PhD Adjunct ProfessorAdjunct ProfessorTampere University and University Hospital, Tampere University and University Hospital, Department of Child PsychiatryDepartment of Child Psychiatry
Correspondence: kaija.puura@pshp.fiCorrespondence: kaija.puura@pshp.fi
K. Puura 10.9.2009K. Puura 10.9.2009
IntroductionIntroduction
Parents are sensitised to meet the needs Parents are sensitised to meet the needs of their offspringof their offspring Genetic background for parenting behaviour Genetic background for parenting behaviour
in various species (including beetles…)in various species (including beetles…) Cultural aspects of parenting: what is Cultural aspects of parenting: what is
considered as good parenting – changes considered as good parenting – changes with timewith time
K. Puura 10.9.2009K. Puura 10.9.2009
IntroductionIntroduction
Things can go awry because ofThings can go awry because of Environmental threatsEnvironmental threats Parental illness, somatic or mentalParental illness, somatic or mental Parental distressParental distress Child characteristics making parenting Child characteristics making parenting
demandingdemanding Problems with regulating physiological and Problems with regulating physiological and
emotional statesemotional states Chronic or recurrent illness, or disabilityChronic or recurrent illness, or disability
K. Puura 10.9.2009K. Puura 10.9.2009
Inpatient units in infant mental Inpatient units in infant mental healthhealth
In adult psychiatric unitsIn adult psychiatric units
In paediatric unitsIn paediatric units
In child psychiatric units In child psychiatric units
K. Puura 10.9.2009K. Puura 10.9.2009
Parent-infant dyads in adult Parent-infant dyads in adult inpatient unitsinpatient units
Since 1950sSince 1950s Infant hospitalised with the parent Infant hospitalised with the parent
(mother) in connection with parental (mother) in connection with parental mental illnessmental illness Postpartum depressionPostpartum depression Postpartum psychosisPostpartum psychosis Other type of psychotic disorderOther type of psychotic disorder
K. Puura 10.9.2009K. Puura 10.9.2009
Parent-infant dyads in adult Parent-infant dyads in adult inpatient unitsinpatient units
Goal:Goal: Support the mother infant bonding Support the mother infant bonding Avoid disruption of parent-infant relationshipAvoid disruption of parent-infant relationship
Best results with postpartum psychosisBest results with postpartum psychosis Less successful with parents with affective Less successful with parents with affective
disorders or schizophreniadisorders or schizophrenia need for intervention focused on need for intervention focused on
parenting behaviourparenting behaviour parental sensitivityparental sensitivity enjoyable interactionenjoyable interaction
K. Puura 10.9.2009K. Puura 10.9.2009
Residential parent-infant care Residential parent-infant care in paediatric units in paediatric units
Focused on treating problematic behaviour in Focused on treating problematic behaviour in the infant inthe infant in FeedingFeeding Settling downSettling down SleepingSleeping
Behavioural context: teaching the infant to Behavioural context: teaching the infant to abandon ”bad habits”abandon ”bad habits”
Need for multifaceted interventions for parents Need for multifaceted interventions for parents with psychological distress or mental health with psychological distress or mental health issuesissues
K. Puura 10.9.2009K. Puura 10.9.2009
Residential parent-infant Residential parent-infant care in other servicescare in other services
Services provided by social and welfare Services provided by social and welfare authoritiesauthorities Focus on teaching parenting – staff not familiar with Focus on teaching parenting – staff not familiar with
infant development and mental health issuesinfant development and mental health issues Residential care for substance abusing Residential care for substance abusing
mothersmothers Extremely demanding: need for expertise in Extremely demanding: need for expertise in
substance abuse, adult psychiatry, child psychiatrysubstance abuse, adult psychiatry, child psychiatry Great need for health care servicesGreat need for health care services Longer stay – better outcome Longer stay – better outcome
K. Puura 10.9.2009K. Puura 10.9.2009
Parent-infant treatment in child Parent-infant treatment in child psychiatric unit: TAUH Family wardpsychiatric unit: TAUH Family ward
Founded in 1993 forFounded in 1993 for Treating parent-child relationship and Treating parent-child relationship and
parenting problemsparenting problems for families with infants, toddlers or for families with infants, toddlers or
preschoolerspreschoolers Today part the Infant and Family Today part the Infant and Family
Psychiatric Unit in the Department of Psychiatric Unit in the Department of Child Psychiatry in Tampere University Child Psychiatry in Tampere University Hospital (process organisation…)Hospital (process organisation…)
K. Puura 10.9.2009K. Puura 10.9.2009
Family WardFamily Ward
Our department in 2004
K. Puura 10.9.2009K. Puura 10.9.2009
Family WardFamily Ward
the whole family participatesthe whole family participates three families at the same timethree families at the same time inpatient period lasts three weeksinpatient period lasts three weeks child psychiatric evaluation and child psychiatric evaluation and
treatment:treatment: childchild familyfamily interactioninteraction
K. Puura 10.9.2009K. Puura 10.9.2009
Reasons for referralReasons for referral
Developmental, behavioural or emotional problems in Developmental, behavioural or emotional problems in infants or young children infants or young children
Serious difficulties in family interactionSerious difficulties in family interaction marital difficulties, divorces or separations with conflicts over marital difficulties, divorces or separations with conflicts over
contact or residence of the childcontact or residence of the child parental psychiatric disordersparental psychiatric disorders problems in the interaction between the child and the parents problems in the interaction between the child and the parents
and/or siblingsand/or siblings
Problems in parentingProblems in parenting inadequate parental careinadequate parental care attachment difficultiesattachment difficulties family violencefamily violence
K. Puura 10.9.2009K. Puura 10.9.2009
Multidisciplinary teamMultidisciplinary team
child psychiatristchild psychiatrist head nursehead nurse family therapists (psychologist, nurse)family therapists (psychologist, nurse) six nursessix nurses doctor in trainingdoctor in training
K. Puura 10.9.2009K. Puura 10.9.2009
What do we do?What do we do?
Build an alliance by being caring but honestBuild an alliance by being caring but honest Integrative child psychiatry in a multilevel Integrative child psychiatry in a multilevel
approachapproach Everyday interactions - work on the parent-infant Everyday interactions - work on the parent-infant
interactioninteraction Attachment Attachment Cognitive-behavioural techniquesCognitive-behavioural techniques Neuropsychiatric treatment techniquesNeuropsychiatric treatment techniques
Family discussions - systemic family levelFamily discussions - systemic family level Discussions with parents - work with representations Discussions with parents - work with representations
of the parentsof the parents Networking – safety nets for the familyNetworking – safety nets for the family
K. Puura 10.9.2009K. Puura 10.9.2009
Model of treatmentModel of treatment
preliminary interview: preliminary interview: family family referring agency (when useful and possible)referring agency (when useful and possible) professionals who have worked with the family in social and health professionals who have worked with the family in social and health
carecare three-week inpatient period:three-week inpatient period:
primary nursing: home visits, functional sessions in the wardprimary nursing: home visits, functional sessions in the ward child psychiatric assessment (e.g MSSB, psychological tests)child psychiatric assessment (e.g MSSB, psychological tests) assessment of interaction (EAS, LTP)assessment of interaction (EAS, LTP) family assessmentfamily assessment meetings:meetings:
family meetingsfamily meetings team meetingsteam meetings meetings with health and social welfare agenciesmeetings with health and social welfare agencies
K. Puura 10.9.2009K. Puura 10.9.2009
Pre-admission phasePre-admission phase
Referral•phone calls to the family and referrer•invitation to the preliminary interview
Preliminary interview•Building alliance, focus of treament, objectives, decisions
Introductory visitHome visit Inpatient period
K. Puura 10.9.2009K. Puura 10.9.2009
Family inpatient Family inpatient periodperiod
Team meetings
Working on the ward
Family meetings
1st week
2nd week
3rd week
Primary nursingTreatment•child•family•interaction
FeedbackReflectionEvaluation
Focuses of treatmentMethods of intervention
Focuses of treatmentMethods of intervention
EvaluationPlanning of further treatmentVisiting professionals
Primary nursingTreatment•child•family•interaction
Primary nursingTreatment•child•family•interaction
FeedbackReflectionEvaluation
FeedbackReflectionEvaluation
K. Puura 10.9.2009K. Puura 10.9.2009
Treatment days include:Treatment days include:
one meal and a snack, one of the nurses one meal and a snack, one of the nurses joins the family in the tablejoins the family in the table
Free play situations with the familyFree play situations with the family Family discussionsFamily discussions Discussion with parents alone while Discussion with parents alone while
children play in another roomchildren play in another room Open feedback to the family each dayOpen feedback to the family each day
K. Puura 10.9.2009K. Puura 10.9.2009
After the family inpatient After the family inpatient periodperiod
1-2 information transfer meetings:1-2 information transfer meetings: agreement of further support/treatmentagreement of further support/treatment
written reports:written reports: familyfamily referrerreferrer professionals providing further professionals providing further
support/treatment, social workers in most of support/treatment, social workers in most of the cases the cases
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Further treatment and Further treatment and recommendationsrecommendations
Individually tailored intervention plannew Individually tailored intervention plannew inpatient period inpatient period outpatient visits and home visits outpatient visits and home visits family therapyfamily therapy individual psychotherapy individual psychotherapy parent-child psychotherapyparent-child psychotherapy support by social services support by social services Sometimes recommendation for foster care Sometimes recommendation for foster care
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Strengths of the modelStrengths of the model
intensive 3-week period - huge amount of intensive 3-week period - huge amount of information and possibilities to observe, information and possibilities to observe, understand and work with families and share understand and work with families and share the experience and understanding with health the experience and understanding with health care and social welfare professionalscare and social welfare professionals
basis for meaningful and appropriate basis for meaningful and appropriate intervention plans: what is needed and what is intervention plans: what is needed and what is possiblepossible
K. Puura 10.9.2009K. Puura 10.9.2009
Statistics: the first half Statistics: the first half of 2008of 2008
Altogether 27 Altogether 27 childrenchildren girls 10girls 10 boys 17boys 17 GIRLS
37 %
BOYS63 %
K. Puura 10.9.2009K. Puura 10.9.2009
Age distribution:Age distribution:
0
1
2
3
4
5
1 2 3 4 5 6 7 8 9 11 14
K. Puura 10.9.2009K. Puura 10.9.2009
Family typesFamily types
Step-parent family
4 %
Single parent44 %
Biological parents
45 %
Foster parents
7 %
K. Puura 10.9.2009K. Puura 10.9.2009
Where did they come Where did they come from?from?
Family guidance center 19%Family guidance center 19% Social services 33%Social services 33% Child health clinic,school health clinic 15%Child health clinic,school health clinic 15% Child psychiatric clinic 30%: family ward period Child psychiatric clinic 30%: family ward period
combined with the care in the Baby-team or the combined with the care in the Baby-team or the home-hospital team when needed home-hospital team when needed
Other 3% Other 3%
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ICD-10 DiagnosesICD-10 Diagnoses
Diagnosis %
Affect disorders (F32, F93) 19
Traumatic and adjustment disorders (F41-43) 11
Developmental and organic disorders (F80-84) 19
Oppositional and conduct disorders (F90-92) ADHD
15 15
Disorders of social interaction (F94) 15
Functional disorders (F98) 11
No F diagnosis 26
K. Puura 10.9.2009K. Puura 10.9.2009
Further treatmentFurther treatment
family guidance center 19%family guidance center 19% new inpatient period 19%new inpatient period 19% outpatient visits and home visits, child outpatient visits and home visits, child
psychiatric clinic 82%psychiatric clinic 82% Support by social services 78%Support by social services 78% public health care 7%public health care 7% other 52% other 52%
K. Puura 10.9.2009K. Puura 10.9.2009
What do the families What do the families think?think?
They like the food…They like the food… That the treatment is tiring, but usefulThat the treatment is tiring, but useful For some families the treatment is too intensiveFor some families the treatment is too intensive Many families wish to come back for a shorter Many families wish to come back for a shorter
interval periodinterval period In families where children have to be taken into In families where children have to be taken into
foster care, parents are often initially angry, but foster care, parents are often initially angry, but are able to consent and work together better are able to consent and work together better with the foster parents with the foster parents
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Future plansFuture plans
Research study on what helps children Research study on what helps children with problems in emotion regulationwith problems in emotion regulation
Follow-up study of families treated in the Follow-up study of families treated in the infant outpatient and inpatient unitinfant outpatient and inpatient unit
Further development of the treatment Further development of the treatment model in the infant outpatient and model in the infant outpatient and inpatient unitinpatient unit
K. Puura 10.9.2009K. Puura 10.9.2009
Thank you for your Thank you for your attention!attention!
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