The following interview about hospitalization of children in crisis was conducted online with Elaine Green, M.A.T., and Director of School at Elmcrest Hospital in Portland, Connecticut. The Elmcrest Behavioral Health Network operates mental health and educational programs throughout Connecticut. Visit their web site at www.elmcrest.org.

Q: When should a parent consider hospitalization?

Hospitalization is appropriate when a child or adolescent is exhibiting behaviors that are unsafe for the child or for other people in the environment. Unsafe behaviors would include suicidal gestures or attempts; extremely aggressive or assaultive behaviors; indications of delusions, such as hearing voices, seeing patterns or movements which others do not see or hear; or paranoia which is characterized by excessive and unjustified fear of other persons. Other behaviors that might warrant hospitalization include frequent panic attacks or obsessive compulsive behaviors.

Sometimes hospitalization is authorized for individuals who are gravely disabled. Another reason is for titration of medication (discontinuation or increased dose), when possible side effects call for close observation and monitoring by nursing staff for safety reasons. Finally, hospitalization can be authorized for the clarification of long-standing diagnostic issues that have been treatment resistant in less restrictive settings. Hospitalization allows professionals to monitor the sequence of events leading to behavioral escalation or decompensation.

Q: What are realistic goals for inpatient treatment?

Realistic goals would include stabilization of presenting problem with medication; education of family members around diagnosis and medications prescribed; discharge plan which connects family and patient to community-based outpatient treatment immediately following hospital discharge. Throughout this process it is desirable that the family reach an understanding of the nature and scope of the child's problem and contribute to the development of an ongoing course of treatment. They also need to build strategies for blocking and/or preventing future escalations that would place the child at risk of danger to self or others.

Q: Do students usually participate in a partial hospitalization program after discharge?

Partial hospital programs are sometimes appropriate after inpatient treatment. Other options include Intensive Outpatient Treatment (IOP) and outpatient treatment. IOP is 3-4 visits per week for 2 hours. Outpatient treatment involves one-hour visits to an outpatient clinician once or twice a week. Oftentimes the step down to a partial hospital program helps shorten the length of inpatient treatment and helps the family and clinical team address real family issues. If someone only receives inpatient treatment, then they may look stable outside the family milieu but escalate rapidly at discharge. There are times when partial hospital program treatment can prevent an inpatient hospitalization. Placement in the least restrictive environment is considered a right within psychiatric settings as well as education settings.

Q: How does Elmcrest support transitions back to local schools?

Transitions back to local schools are a challenge to coordinate. Guardians need to sign authorizations, which allow us to communicate with local schools. If these authorizations are not in place, we cannot communicate. Local Education Agencies (LEAs) frequently avoid talking to hospitals and don't hold Planning and Placement Teams (PPTs) if children are not going to be hospitalized for a minimum of 15 days. Where authorizations and a willingness to communicate are in place, we begin by informing the school of hospitalization, the diagnosis, and treatment goals; student and family commitment to following treatment plans, medications and student behavior during hospitalization. We do attend PPTs and share discharge recommendations whenever invited.

The most difficult transitions to facilitate involve children who are in the hospital setting after an agency placement failure (foster home, residential, family setting) and prior to a new placement. In these situations we can receive placement notification days or even hours prior to discharge. The new setting is frequently new to the child and timely/adequate communication with a new school system is very difficult.

Thanks to Linda Flynn, Marketing Coordinator at Elmcrest, for arranging this interview.