May 1st, 2012

Autism-specific child psychiatry units grow in New England hospitals

A December 2011 study was the first to identify an obvious effect to a high-profile cause: The number of U.S. hospitals with child psychiatric units geared toward the special needs of autistic patients is increasing. Each of the nine nationwide specialized hospital units identified in the study provides a web of services as complex as the patients they serve, many of whose co morbid mental illness diagnoses land them in hospitals each year because of aggression, self injury and elopement. And of the nine units, the majority are in New England.

Matthew Siegel, M.D., wrote the study and published it in the Journal of Autism and Developmental Disorders. Siegel is the medical director of the Developmental Disorders Program at Spring Harbor Hospital in Maine, which is home to one of these specialized units. Siegel, who is also an assistant professor of psychiatry at Tufts University School of Medicine, says the twofold force behind the rise in these units is increased identification of children with autism (66 percent of the population of the inpatient units have an autism spectrum disorder, or ASD), and the increasing recognition that children with ASD have high rates of co-occurring mental illness that can respond to specialized treatment.

For psychologists unfamiliar with these units, they have multiple advantages, Siegel said. Children with ASD don’t usually benefit from admission to standard psychiatric units because most are designed for short-term stays that focus on modifying acute risk factors, he said. They also heavily rely on medication, he said. However, Siegel explained, children with ASD and serious behavioral problems “tend to live in a state of chronic crisis, created by multiple factors such as inadequate communication systems, unmet sensory needs, ineffective behavioral management and undiagnosed mental illness.”

“To effectively treat this picture takes a highly specialized team of practitioners who can manage the acute externalizing behaviors and simultaneously address the sources of chronic crisis,” he said. “If you treat it as an acute crisis with a single facet etiology, then you are simply making a plan for readmission.”

Spring Harbor’s unit, like similar units, employs speech language pathologists, occupational therapists and special educators who help the hospital take a multi-pronged approach to problem behaviors. “A typical admission for us,” Siegel said, “is an 11-year-old child with ASD and mild ID with limited verbal ability who is on four to seven psychotropic medications, has received in-home behavioral services and possibly a day-treatment program, and is still being aggressive or self injurious 20-100 times a day.”

Gerald Tarnoff, M.D., is the unit chief of the Child and Adolescent Treatment Unit at Rhode Island’s Butler Hospital, the location of another of New England’s specialized child psychiatric units. Tarnoff said that aggressive, self-injurious behavior often comes from an autistic adolescent who in many ways is developing like a typical teenager but without a teenager’s typical cognitive skills to cope with maturation.

“A lot of their development is slower, and [specialized psychiatric units] provide a place to evaluate them and the possibility of co morbidity,” said Tarnoff, who has led Butler’s unit for three years. “As hard as it is to diagnose depression, etc., in persons with good verbal skills, it’s even harder to diagnose in someone without them.”

Siegel’s study did more than produce a scholarly paper: All nine units noted in the study have joined forces to forward autism research and develop joint-study protocols that involve the hundreds of patients with autism who are admitted to their programs each year. In 2011, the hospitals formed the national Autism and Developmental Disorders Inpatient Research Collaborative (ADDIRC).

Until recently, Kim Loika-Smith, LICSW and clinical director of the child psychiatry unit at New Hampshire’s Hampstead Hospital said clinicians involved with these units have felt like they were “on their own” because there are so few. She calls Hampstead’s participation in ADDIRC “exciting.”

Hampstead frequently has a waitlist for patients to be admitted, according to Loika-Smith and it is something she attributes to the growth in the autistic population.

“These children really do need specialized care,” she said, while noting that those providing care must be equally special. “There is a lot of risk involved: there is a high rate of staff turnover; staff are continuously managing [patient] aggression.”

“For staff working [on these units] it takes a special dedication,” Tarnoff said. “It takes a lot of patience and skill to understand [this population] and to work with them. The staff who are really good, really enjoy working with these kids. They’re not easy to find.”

In addition to Spring Harbor, Butler and Hampstead Hospitals, Rhode Island’s Bradley Hospital is also an ADDIRC member.

By Jennifer E Chase

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