Inpatient units in IMH Regional WAIMH Conference Acre, Israel 8-10.9.2009

1. Inpatient units in IMH Regional WAIMH ConferenceAcre, Israel 8-10.9.2009 Kaija Puura, MD, PhD Adjunct Professor Tampere University and University Hospital, Department of Child Psychiatry Correspondence: kaija.puura@pshp.fi

2. Introduction • Parents are sensitised to meet the needs of their offspring • Genetic background for parenting behaviour in various species (including beetles…) • Cultural aspects of parenting: what is considered as good parenting – changes with time K. Puura 10.9.2009

3. Introduction • Things can go awry because of • Environmental threats • Parental illness, somatic or mental • Parental distress • Child characteristics making parenting demanding • Problems with regulating physiological and emotional states • Chronic or recurrent illness, or disability K. Puura 10.9.2009

4. Inpatient units in infant mental health • In adult psychiatric units • In paediatric units • In child psychiatric units K. Puura 10.9.2009

5. Parent-infant dyads in adult inpatient units • Since 1950s • Infant hospitalised with the parent (mother) in connection with parental mental illness • Postpartum depression • Postpartum psychosis • Other type of psychotic disorder K. Puura 10.9.2009

6. Parent-infant dyads in adult inpatient units • Goal: • Support the mother infant bonding • Avoid disruption of parent-infant relationship • Best results with postpartum psychosis • Less successful with parents with affective disorders or schizophrenia • need for intervention focused on • parenting behaviour • parental sensitivity • enjoyable interaction K. Puura 10.9.2009

7. Residential parent-infant care in paediatric units • Focused on treating problematic behaviour in the infant in • Feeding • Settling down • Sleeping • Behavioural context: teaching the infant to abandon ”bad habits” • Need for multifaceted interventions for parents with psychological distress or mental health issues K. Puura 10.9.2009

8. Residential parent-infant care in other services • Services provided by social and welfare authorities • Focus on teaching parenting – staff not familiar with infant development and mental health issues • Residential care for substance abusing mothers • Extremely demanding: need for expertise in substance abuse, adult psychiatry, child psychiatry • Great need for health care services • Longer stay – better outcome K. Puura 10.9.2009

9. Parent-infant treatment in child psychiatric unit: TAUH Family ward • Founded in 1993 for • Treating parent-child relationship and parenting problems • for families with infants, toddlers or preschoolers • Today part the Infant and Family Psychiatric Unit in the Department of Child Psychiatry in Tampere University Hospital (process organisation…) K. Puura 10.9.2009

10. Family Ward Our department in 2004 K. Puura 10.9.2009

11. Family Ward • the whole family participates • three families at the same time • inpatient period lasts three weeks • child psychiatric evaluation and treatment: • child • family • interaction K. Puura 10.9.2009

12. Reasons for referral • Developmental, behavioural or emotional problems in infants or young children • Serious difficulties in family interaction • marital difficulties, divorces or separations with conflicts over contact or residence of the child • parental psychiatric disorders • problems in the interaction between the child and the parents and/or siblings • Problems in parenting • inadequate parental care • attachment difficulties • family violence K. Puura 10.9.2009

13. Multidisciplinary team • child psychiatrist • head nurse • family therapists (psychologist, nurse) • six nurses • doctor in training K. Puura 10.9.2009

14. What do we do? • Build an alliance by being caring but honest • Integrative child psychiatry in a multilevel approach • Everyday interactions - work on the parent-infant interaction • Attachment • Cognitive-behavioural techniques • Neuropsychiatric treatment techniques • Family discussions - systemic family level • Discussions with parents - work with representations of the parents • Networking – safety nets for the family K. Puura 10.9.2009

15. Model of treatment • preliminary interview: • family • referring agency (when useful and possible) • professionals who have worked with the family in social and health care • three-week inpatient period: • primary nursing: home visits, functional sessions in the ward • child psychiatric assessment (e.g MSSB, psychological tests) • assessment of interaction (EAS, LTP) • family assessment • meetings: • family meetings • team meetings • meetings with health and social welfare agencies K. Puura 10.9.2009

16. Pre-admission phase K. Puura 10.9.2009

17. Family inpatient period Team meetings Working on the ward Family meetings • Primary nursing • Treatment • child • family • interaction Focuses of treatment Methods of intervention Feedback Reflection Evaluation 1st week • Primary nursing • Treatment • child • family • interaction Focuses of treatment Methods of intervention Feedback Reflection Evaluation 2nd week • Primary nursing • Treatment • child • family • interaction 3rd week Evaluation Planning of further treatment Visiting professionals Feedback Reflection Evaluation K. Puura 10.9.2009

18. Treatment days include: • one meal and a snack, one of the nurses joins the family in the table • Free play situations with the family • Family discussions • Discussion with parents alone while children play in another room • Open feedback to the family each day K. Puura 10.9.2009

19. After the family inpatient period • 1-2 information transfer meetings: • agreement of further support/treatment • written reports: • family • referrer • professionals providing further support/treatment, social workers in most of the cases K. Puura 10.9.2009

20. Further treatment and recommendations • Individually tailored intervention plannew inpatient period • outpatient visits and home visits • family therapy • individual psychotherapy • parent-child psychotherapy • support by social services • Sometimes recommendation for foster care K. Puura 10.9.2009

21. Strengths of the model • intensive 3-week period - huge amount of information and possibilities to observe, understand and work with families and share the experience and understanding with health care and social welfare professionals • basis for meaningful and appropriate intervention plans: what is needed and what is possible K. Puura 10.9.2009

22. Statistics: the first half of 2008 • Altogether 27 children • girls 10 • boys 17 K. Puura 10.9.2009

23. Age distribution: K. Puura 10.9.2009

24. Family types K. Puura 10.9.2009

25. Where did they come from? • Family guidance center 19% • Social services 33% • Child health clinic,school health clinic 15% • Child psychiatric clinic 30%: family ward period combined with the care in the Baby-team or the home-hospital team when needed • Other 3% K. Puura 10.9.2009

26. ICD-10 Diagnoses K. Puura 10.9.2009

27. Further treatment • family guidance center 19% • new inpatient period 19% • outpatient visits and home visits, child psychiatric clinic 82% • Support by social services 78% • public health care 7% • other 52% K. Puura 10.9.2009

28. What do the families think? • They like the food… • That the treatment is tiring, but useful • For some families the treatment is too intensive • Many families wish to come back for a shorter interval period • In families where children have to be taken into foster care, parents are often initially angry, but are able to consent and work together better with the foster parents K. Puura 10.9.2009

29. Future plans • Research study on what helps children with problems in emotion regulation • Follow-up study of families treated in the infant outpatient and inpatient unit • Further development of the treatment model in the infant outpatient and inpatient unit K. Puura 10.9.2009

30. Thank you for your attention! K. Puura 10.9.2009