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

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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

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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

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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

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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

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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

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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…)

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Family WardFamily Ward

Our department in 2004

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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 %

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Age distribution:Age distribution:

0

1

2

3

4

5

1 2 3 4 5 6 7 8 9 11 14

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Family typesFamily types

Step-parent family

4 %

Single parent44 %

Biological parents

45 %

Foster parents

7 %

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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

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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%

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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

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Thank you for your Thank you for your attention!attention!