Day clinic applications in child and adolescent psychiatry

Day clinic applications in child and adolescent psychiatry

Abstract

Objective: In the field of child and adolescent psychiatry, in day clinics, which have an important place in treatment practices in western countries, mental illness severe enough to be admitted to the ward It is recommended to treat patients who are not healthy but difficult to handle in outpatient settings. In this article, daytime clinic practices serving in the field of child and adolescent psychiatry and Child and Adolescent Psychiatry Day Clinic, which was established for the first time in Turkey in the Department of Child Psychiatry and Diseases of Kocaeli University, will be discussed. Method: Since there is no center that provides day clinic services in the field of child and adolescent mental health, apart from the Kocaeli University Child and Adolescent Psychiatry Day Clinic in Turkey, there is no publication in our country about the characteristics of this treatment model. For this reason, in this article, limited studies and reviews about day clinics serving in the field of mental health were used, especially in European countries. Conclusions: Day clinics provide an intensive treatment environment for children and adolescents with various mental problems and are effective in the recovery process. The fact that patients can be treated without leaving their own environment is an important advantage of day clinics compared to inpatient treatment. Discussion: It is known that outpatient treatment units, inpatient centers and day clinics serving in the field of child and adolescent mental health are far below the requirements in Turkey. For this reason, all kinds of initiatives and studies will be important for the dissemination of day clinic practices.

Keywords: Child and adolescent psychiatry, day clinics, treatment models

Day Clinic Approaches in Child and Adolescent Psychiatry

Summary

Objective: Child and adolescents who are suffering from psychological problems should be admitted to day treatment unit if they can not be managed at outpatient settings. In this paper, day treatment approaches in child and adolescent mental health and day treatment experience of Kocaeli University Medical School, Child and Adolescent Psychiatry Day Clinic will be discussed. Method: As our day clinic unit is the only day treatment unit in Turkey, in the literature no study has been found about the day treatment experiences in our country. In this presentation research and review papers especially from European countries which are generally limited in number are reviewed. Results: Day clinics provide an intense therapy for children and adolescents with psychiatric problems, and effects healing process positively. An important advantage of day treatment is that patients do not lose total contact with their social surroundings during the treatment period. Discussion: In Turkey, child and adolescent mental health services, either outpatient, inpatient or day clinic approaches are insufficient in number. So, all kinds of effort and work for dissemination of day clinic modalities will be important.

Key Words: Child and adolescent psychiatry, day clinics, treatment modalities

Introduction

In Germany, the concept of day clinic is “acute or subacute, with adequate and stable social support, It is defined as a unit where patients stay in the clinic for a limited period of time, only during the daytime, and in the evening and at night, where they are found and treated in the home environment they are used to.1

The historical development of day clinics dates back to many years. It is seen that the concept of day clinic was defined for the first time in the Soviet Union of the time. It is reported that the first psychiatric hospital in Moscow in 1937, the day clinic was put into service due to the fact that the hospital was full and urgent patient admission was required. Then, day clinics started to provide services in the field of psychiatry in the United States, then in England and Germany.2 Although there is no center in our country other than Kocaeli University Child and Adolescent Psychiatry Day Clinic in the field of child and adolescent mental health, there are centers that provide assistance in the field of adult mental health. Ankara University Faculty of Medicine Psychiatry Clinic Day Hospital, Kocaeli University Medical Faculty Day Hospital, Bakırköy Mental Health and Diseases Hospital Day Hospital, which has been serving since 1988, are some of the centers that provide help in the field of mental health for adult patients. 3,4,5

In the field of child and adolescent psychiatry, in treatment practices in western countries, day clinics and inpatient services are as important as outpatient treatment. In cases where the psychiatric disease is severe and difficult to control under outpatient treatment conditions, it is preferred that the patient be treated by being admitted to the psychiatry service. It is recommended that patients who do not have a mental illness severe enough to be admitted to the ward, but who are difficult to deal with in outpatient conditions, should be treated in day clinics. In our country, treatment in child and adolescent psychiatry is mainly carried out in outpatient clinics and rarely in inpatient services. Since inpatient and day clinic practices are not common in child and adolescent psychiatry in Turkey, outpatient treatment is mostly applied regardless of the characteristics of the patient. While it is argued that traditional psychiatric day clinics are common in the West, but the number of day clinics that use a specific therapy method such as disease-specific or cognitive behavioral therapy is low, there is only one day clinic for children and adolescents in our country.6

Other treatment methods of the day clinic

The important thing in the treatment practices in the day clinic is to carry out the treatment of the patients without being removed from their social environment and in their own familiar environment.6,7 In this case, it is easy for the patients to adapt to daily life after the treatment. On the other hand, the conflicts that patients experience in their own environment are easily handled in day clinics. Patients find the opportunity every day to resolve their problems instead of avoiding these conflicts.6,7

It is an important advantage that day clinics provide intensive treatment. The patient can be observed throughout the day, and how he reacts in which situations and interactions between people can be monitored. This direct follow-up eliminates the negative effects of biased transfer of caregivers, such as the patient’s parents, on the treatment. Interviews with parents in day clinics are also more frequent and intense than in outpatient treatment. This, in addition to enabling a better understanding of the family structure, is beneficial in terms of including the mother and father in the treatment.

The day clinic offers an important advantage in terms of observing patients more intensively compared to outpatient treatment and in terms of initiating treatment as soon as possible, especially in cases with diagnostic confusion.

The efficacy and side effects of pharmacological agents or psychotherapeutic approaches on patients in outpatient settings are always evaluated in line with the observations of caregivers such as parents. However, in day clinics, the efficacy and side effects of pharmacological agents or psychotherapeutic approaches can be monitored directly by the treatment team on a daily basis.

Day clinics for patients with mental disorders establish an important link between inpatient units and outpatient treatment.6,7 Patients who have been treated in inpatient services are followed up for a while in the day clinic before transitioning to their daily lives, ensuring that the transition is not abrupt and the transition is not abrupt. Day clinics are used to facilitate

Today, “stigma” is still an important issue in psychiatric treatment, thus reducing the prejudice towards children and youth with a day clinic approach compared to inpatient treatment.7 In addition, the regression that can be seen in inpatients is less in day clinics.7

Diagram of a day clinic for children and adolescents

In the treatment team of day clinics, physicians, teachers, psychologists, social workers, pedagogues, occupational therapists (occupational therapists), movement therapists, physiotherapists, nurses, speech therapists 8 Mundt et al. (2002) reported that 1 therapist per 4 patients in their day clinics, and this figure is 7.5:1 in general. 1 recreation specialist, 1 classroom teacher, 1 research assistant, 2 experts who constitutes and 1 therapist per 6 patients.

Table 1 shows the weekly schedule of our day clinic. Since it is not considered appropriate for our patients to come to the day clinic early without breakfast, they are asked to have their breakfast at home. Speaking and reading activity is practiced during the study hours. In our weekly plan, the “quiet time” activity was considered important and included in the weekly plan, in order for the patients to be on their own for a while, to be able to think and realize their feelings, and to digest the treatment and their experiences.

The versatile treatment applied to inpatients in psychiatry wards is also applied in day clinics throughout the day. While the patients participate in activities such as sports activities, handicrafts, culinary practices, games and group activities, their mental treatment is organized by the treatment team. In our clinic, therapy methods such as cognitive behavioral therapy, psychoeducation, occupational therapy, ambient therapy (mileu therapy), pharmacotherapy are applied.

Immediately after each patient starts the day clinic, the class teacher at their school and, if necessary, other teachers are interviewed. In addition to the information about the behaviors and attitudes of the patients in and out of the classroom, the teachers’ observations about their academic success and skills are also considered important. In the light of the information obtained, the academic education and treatment given to the patient is shaped by the classroom teacher working in the day clinic.

Now “organizing the activities of the day” is considered a therapy method in its own right. As in inpatient units, shaping the day is an indispensable treatment tool in day clinics.2 In our day clinic, every week and day is planned in advance with the treatment team and patients.

Visits are also made with patients twice a week. In these visits, the treatment team and the patient come together and discuss the homework given to the patient, the difficulties experienced by the patient, the skills that are planned to be acquired, the effects and side effects of the medication he uses. Each day, the patient is shared with the patient what he or she did the previous day, conflicts, difficulties, emotions and what they plan to do the next day. Lunches are eaten with the treatment team in a comfortable environment by discussing the patients’ social lives and experiences in their daily lives.

Individual interviews are made with patients every day. In individual interviews or visits, patients are supported in transferring what is learned in treatment to daily life, and patients are also provided with the opportunity to practice with a therapist from time to time. In addition, exercises are carried out to increase compliance with the changes that occur with the treatment. The homework given in the interviews is discussed with the patient the next day. It is discussed with the patient in which areas he has difficulties while doing the homework, and the benefits of the homework. At the beginning of the week, the patients plan the week and determine the activities and tasks together with the treatment team.

Patients’ families are interviewed once a week. In these interviews, the family is discussed in detail. When deemed necessary, caregivers are advised to seek help from adult psychiatry and are assisted in treatment.

Our day clinic does not have rest rooms to prevent patients from retreating to their rooms. Apart from individual interviews, patients are constantly together and interacting. They are expected to model and support each other. Being in the group in the day clinic reduces social isolation and increases interaction with other patients and the treatment team.

In the day clinic, it is important for our patients to add sports or an artistic activity to their daily lives in the environment they live in. Assistance is provided to patients or their families who have difficulties in participating in these events, such as finding the address of the event and contacting the responsible person.

Teachers who undertake the training pillar of the treatment team are given information about the patient’s symptoms and diagnosis so that they know what to do in case of worsening or crisis. Every evening, the treatment team comes together and shares their observations about the patients. On the last day of the week, the treatment team gathers again and makes a file visit. In the file visit, information about the patients is reviewed in more detail and a treatment plan is prepared for the next week.

Patients with many different mental disorders such as disruptive behavior disorders, pervasive developmental disorders or mood disorders are treated together in our day clinic. Patients who are not suitable to be treated in day clinics are patients with severe anorexia nervosa requiring intensive care, patients with suicidal ideation, psychotic patients (during the episode), patients with aggressive behavior or substance abuse.6,7 Patients with these diagnoses or those with such symptoms they are not treated in the day clinic and are directed to appropriate centers.

Child and adolescent psychiatrists working in and around Kocaeli can send patients to our day clinic. Mundt et al. reported that 7.5% of the patients who came to the day clinic were from their own inpatient units, 12.5% ​​were from the inpatient units of other hospitals, and that the majority of the patients they followed in the day clinic were patients referred from outpatient treatment.6 Most of the patients followed in our day clinic were in our department. were referred while being treated as an outpatient. Especially patients who have been followed up with outpatient treatment for a long time, but have not improved in their symptoms or who need intensive treatment are admitted to our day clinic.

Cost characteristics of the day clinic

The number of patients followed in day clinics is between 10-12 people in many centers.6,9 The number of patients that make up the patient group in our day clinics varies between 5-7 people. The limited number of personnel specialized in their fields causes us to serve a group less than the number of patients in other day clinics. While admitting patients to our day clinic, the diagnoses and problems of other patients in our day clinic are taken into consideration. For example, if a patient with conduct disorder is being followed up in the day clinic, it is preferred not to recruit another patient with conduct disorder, or if there is a patient with pervasive developmental disorder, it is preferable to recruit another patient from a different group. It was seen that the heterogeneity of the group enabled the strengths of the patients to be taken as an example by each other and increased the interaction.

Mundt et al. reported that the daily cost of treatment per patient in day clinics is lower than that of outpatient and inpatient treatment, with an average of 383.53 DM (414.21 TL). is paying. In the light of this information, it can be said that we provide a very cheap service.

Conclusion

Children and adolescents followed in the day clinic are treated without leaving their families and the environment they are accustomed to. This ensures that the state of well-being continues after the patient is treated and returns to his/her own life.

Although day clinic practices have been used for many years in the field of child and adolescent mental health in Western countries, it is a new concept for our country. It can be said that the day clinic is an effective treatment method in patients for whom outpatient treatment is insufficient, and its use in child and adolescent psychiatry should be expanded.

Due to the newness of this concept in our country, there are some difficulties such as financial support and lack of specialized personnel. However, despite all these difficulties, considering the benefits in the field of child and adolescent mental health, it is thought that the day clinic practice is a treatment method that should be continued and supported.

References

1. Deutscher bundestag (Hrsg.): Bericht über die Lage der Psychiatrie in der Bundesrepublik Deutschland-Zur psychiatrischen und psychotherapeutisch/psychosomstischen Versorgung der Psychiatrie-Energy. Drucksache7/4200;7/4201, p. 222, zitiert nach: Veltin, A. (ohne Vornamen): Leitfaden zur tagesklinischen Behandlung. Schriftenreihe des Bundesministeriums für Jugend, Familie, Frauen und Gesundheit, Band 189. Stuttgart 1986; 36.

2. Asmus Finzen. Eine kurze Geschichte der Psychiatrischen Tagesklinik Edition das Narrenschiff 1. Auflage, Bonn, 2003.

3. Güney M. The place of the day hospital in psychiatric rehabilitation: Ankara University experience. Anatolian Journal of Psychiatry 2008; 9(additional no. 1):1-8.

4. Yıldız M. Psychiatric rehabilitation oriented day hospital practice: Kocaeli University experience. Anatolian Journal of Psychiatry 2008; 9(additional issue. 1):9-13.

5. Yazıcı A, Coşkun S. Bakırköy RSHH day hospital and rehabilitation center patient profile and work schedule. Anatolian Journal of Psychiatry 2008; 9(additional no. 1):14-20.

6. Mundt A, Hand I, Rufer M. Die spezifische verhaltenstherapietagesklinik. Nervenarzt 2002; 73:1082-1087.

7. Hempfling FH. Zur historischen entwicklung und gegenwaertigen situation der tagesklinik als eines psychotherapeutischen behandlungsmodells. In Die vierzigstundenwoche für patienten, Heigel-Evers A, Henneberg-Mönch, Focus C, Standke G (ed) Verlag für medizinische psychologie, Göttingen 1986; 21-29.

8. Kunze, Heinrich und Ludwig Kaltenbach (Hrsg.): Psychiatrie-Personalverordnung – Textausgabe mit Materialien und erläuterungen für die Praxis. 3. erweiterte Auflage, Stuttgart 1996; 7.

9. Berger E, Steinberger K, Huber N Jugendpsychiatrische Tagesklinik-Aufbau und Erfahrungen. Neuropsychiatry 2006; 20:127-130.

Table 1: Kocaeli University Child and Adolescent PsychiatryDay Clinic weekly schedule:

(9800) 706)

Individual and collective events: Jewelry activity, sports, culinary activity, various activities such as wood painting, painting and board games.