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Journal of Intellectual Disability Research
doi: 10.1111/jir.12148
995 volume 59 part 11 pp 995 –998
NOVEMBER
2015
Inpatient Children and Adolescent Mental Health Services (CAMHS): outcomes of young people with and without intellectual disability R. Chaplin,1,2 S. Roach,2 H. Johnson1 & P. Thompson2 1 Oxford Health Foundation NHS Trust, Warneford Hospital, Headington Oxford OX3 7JX, UK 2 Royal College of Psychiatrists, Centre for Quality Improvement, London, UK
Abstract Background Little is known about the effectiveness of inpatient care for young people with co-morbid mental illness and intellectual disability (ID). This study aims to compare the demographics and outcome of young people with mental illness with or without ID admitted to psychiatric hospital. A secondary aim is to look into the outcome of those with ID admitted to general mental health young people’s units. Method Data were collected on the outcome of young people’s admissions to specialist ID and general adolescent mental health units as part of a larger quality improvement project run by the College Centre for Quality Improvement. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scores were completed by local clinical staff at admission and discharge on 38 young people with and 113 people without ID from 14 units. Results Young people with mental disorders significantly improved clinically over the admission whether or not they had ID. There were no differCorrespondence: Dr Robert Chaplin, Warneford Hospital, Headington, Oxford OX3 7JX, UK (e-mail: rchaplin@ cru.rcpsych.ac.uk).
ences between the groups in age or use of the Mental Health Act but people admitted with ID were more likely to be male and had longer lengths of stay. Admission to a general adolescent unit was associated with clinical improvement for people with ID. Conclusions This study needs replication because of the small sample and incomplete data but it suggests that young people with ID and mental disorders significantly improve clinically when admitted to hospital as do their non-disabled peers. Keywords clinical outcomes, intellectual disability, mental illness, psychiatric hospital admission, young people
Introduction Admission of young people with mental health problems to Specialist Child and Adolescent mental health units has been shown to be clinically and cost-effective, associated with substantive improvements across a range of diagnoses (Green et al. 2007). The psychiatric inpatient care of adults intellectual disability (ID) and mental health problems has been studied by comparing the demographics,
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
volume 59 part 11
Journal of Intellectual Disability Research
Nov e mBer
2015
996 R. Chaplin et al. • Young inpatients with intellectual disability
service use patterns and outcomes of adults with ID using general adult psychiatric inpatient units and specialist ID units. Also the outcomes of people with and without ID using general psychiatric units have been studied (Chaplin 2011). No such comparisons have been made for children and adolescents admitted with ID and mental health problems. The primary aim is to compare the outcomes of people with and without ID who are admitted for acute mental health care. The secondary aim is to assess the outcomes for young people with mental illness and ID admitted to general adolescent units.
Methods This study analyses data collected from the Quality Network for Inpatient Child and Adolescent Mental Health Services, Routine Outcome Measures project (Royal College of Psychiatrists’ Centre for Quality Improvement 2013) a quality improvement project. Diagnostic, sociodemographic information and clinical outcome [Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), Gowers et al. 1999] were collected on 1136 young people on admission by local clinicians. The Children’s Global Assessment Scale (CGAS) was also included in the audit but is not reported here because of poor completion rates. The outcomes of people with and without ID were compared with Chi-squared and Mann–Whitney statistical tests.
or without ID, affective disorders, schizophrenia and neurotic/emotional disorders were the most common diagnoses. For the whole sample, there was a highly significant improvement in mean HoNOSCA scores from 21.4 to 12.0 (Wilcoxon, P < 0.001) and improvements in both sub-groups with and without ID. Those with ID had significantly higher HoNOSCA ratings at admission and discharge. However there were no significant differences in the degree of improvements between the groups. The 980 people excluded because of lack of data on ID status made similar gains from 19.9 to 12.8 on HoNOSCA, but insufficient people had their age or gender coded to make further comparisons. Although those with ID had higher rates of detention (16% versus 12%), this was not significant (see Table 2). A subgroup comparison was made for people with ID who were admitted to general units. They admitted more people with mild ID whereas specialised wards admitted more people with severe ID (see Table 2), although numbers were not significant. Those 24 individuals admitted with ID to general units had significant improvements in HoNOSCA of 14.1 between admission (30.7), and discharge (16.6), Mann–Whitney P < 0.001. They improved to a greater extent than those without ID admitted to general units: HoNOSCA mean on admission 20.5, discharge 10.5, mean improvement 10.0 (Mann–Whitney P = 0.029). There were no significant differences in the mean ages or lengths of stay. The 13 young people admitted to specialist ID units also clinically improved but this number was too small to make valid comparisons of outcome.
Results
Discussion
Complete demographic and outcome data were returned on 151 (13.3%) of admissions, 38 with ID and 113 without ID from 14 inpatient units, with an age range of 6–17 years. Thirteen young people with ID were admitted to specialist units for young people with ID, 24 to general units (22 to adolescent and 2 to children’s psychiatric inpatient units) and 1 to a forensic unit. Young people with ID had significantly longer lengths of stay, were more likely to be male, but had similar ages to those without ID (Table 1). For both groups of young people with
This small scale study has shown that within this sample, young people with ID make clinical improvements measured by HoNOSCA when admitted for mental health treatment although needed longer admissions than their peers without ID with a non-significant trend for more compulsory admissions. People with all degrees of ID were admitted to general adolescent units and to specialised ID units. Comparison with the study by Green et al. (2007) shows similar clinical improvements but our study used different outcome measures:
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
volume 59 part 11
Journal of Intellectual Disability Research
Nov e mBer
2015
997 R. Chaplin et al. • Young inpatients with intellectual disability
Table 1 Comparison of admissions for young people with mental health problems and without intellectual disability (ID)
Number of young people Number (%) male Mean age: years (SD) Mean length of stay: days (SD)
People with ID
People without ID
38 24 (63%)
113 74 (40%)
14.2 (2.06)
14.4 (2.51)
109.9 (68.3)
78.2 (117.0)
Compulsory admission
8 (21%)
Χ2 = 7.15 P = 0.0075 Mann–Whitney P = 0.221 Mann–Whitney P < 0.001 Fishers exact P = 0.465 Mann–Whitney P < 0.001 Mann–Whitney P < 0.001 Mann–Whitney P = 0.213
18 (16%)
Mean admission HoNOSCA (SD)
28.0 (10.0)
20.1 (9.2)
Mean discharge HoNOSCA (SD)
16.7 (8.56)
10.5 (6.18)
Mean HoNOSCA improvement at discharge (SD)
11.2 (12.0)
7.9 (10.8)
N = 38/38 Affective Schizophrenia Developmental Neurotic/emotional Intellectual disability only Personality disorder Elective mutism Conduct Autism Other
Primary diagnosis
Significance
N = 97/113 8 8 7 5 3 2 2 1 1 1
22 14 1 27 2 3 1
Eating disorder ADHD Behavioural
7 1 19
HoNOSCA, Health of the Nation Outcome Scales for Children and Adolescents; ADHD, Attention Deficit Hyperactivity Disorder.
Specialised
General
Number Age (SD)
13 13.4 (1.96)
24 14.5 (2.08)
Length of stay: days (SD)
114 (48.6)
103 (73)
HoNOSCA on admission (SD) HoNOSCA on discharge (SD) Difference in HoNOSCA (SD) Degree of ID Mild Moderate Severe
22.8 (4.91) 17.5 (5.63) 5.36 (7.4)
30.7 (10.5) 16.6 (9.70) 14.0 (12.9)
4 2 7
10 8 6
Significance
Table 2 Comparison of the outcomes of young people with intellectual disability (ID) admitted to specialist ID and general units
Mann–Whitney P = 0.22 Mann–Whitney P = 0.122
HoNOSCA, Health of the Nation Outcome Scales for Children and Adolescents.
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
volume 59 part 11
Journal of Intellectual Disability Research
Nov e mBer
2015
998 R. Chaplin et al. • Young inpatients with intellectual disability
HoNOSCA rather than CGAS. This study collected some CGAS data but completion rate was too low to be included in this analysis. The main limitation was the quality of data collection which was performed by clinicians at the local services for reasons that are unclear. There is also the possibility that bias could have been introduced, for example a motivated staff group might have been more likely to recognise people with ID and offer effective treatment. Also there was only one measure of outcome, the HoNOSCA. This limits the generalisability of the study which should be considered preliminary and is in needs further replication with the use of more comprehensive outcome measures and robust methods of data collection. Our study suggests that young people with ID and mental illness make similar gains in clinical recovery as their non-disabled peers when admitted to psychiatric hospital. Further work needs to look into the socio demographic and clinical predictors of outcome, the experiences of young people in hospital and how these can be improved, and role of specialist admission units
References Chaplin R. (2011) Mental health services for people with intellectual disabilities. Current Opinion in Psychiatry 24, 372–6. Gowers S. G., Harrington R. C., Whitton A., Beevor A., Lelliott P. & Jezzard R. (1999) Brief scale for measuring the outcomes of emotional and behavioural disorders in children: Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). British Journal of Psychiatry 174, 413–16. Green J., Jacobs B., Beecham J., Dunn G., Kroll L., Tobias C. et al. (2007) Inpatient treatment in child and adolescent psychiatry – a prospective study of health gain and costs. Journal of Child Psychology and Psychiatry 48, 1259–67. Royal College of Psychiatrists’ Centre for Quality Improvement (2013) Quality Network for Inpatient Child and Adolescent Mental Health Services (QNIC). Royal College of Psychiatrists, London. Available at: http://www.rcpsych.ac.uk/workinpsychiatry/ qualityimprovement/qualityandaccreditation/ childandadolescent/inpatientcamhsqnic/qnicrom.aspx.
Accepted 5 June 2014
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
Journal of Intellectual Disability Research
doi: 10.1111/jir.12148
995 volume 59 part 11 pp 995 –998
NOVEMBER
2015
Inpatient Children and Adolescent Mental Health Services (CAMHS): outcomes of young people with and without intellectual disability R. Chaplin,1,2 S. Roach,2 H. Johnson1 & P. Thompson2 1 Oxford Health Foundation NHS Trust, Warneford Hospital, Headington Oxford OX3 7JX, UK 2 Royal College of Psychiatrists, Centre for Quality Improvement, London, UK
Abstract Background Little is known about the effectiveness of inpatient care for young people with co-morbid mental illness and intellectual disability (ID). This study aims to compare the demographics and outcome of young people with mental illness with or without ID admitted to psychiatric hospital. A secondary aim is to look into the outcome of those with ID admitted to general mental health young people’s units. Method Data were collected on the outcome of young people’s admissions to specialist ID and general adolescent mental health units as part of a larger quality improvement project run by the College Centre for Quality Improvement. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scores were completed by local clinical staff at admission and discharge on 38 young people with and 113 people without ID from 14 units. Results Young people with mental disorders significantly improved clinically over the admission whether or not they had ID. There were no differCorrespondence: Dr Robert Chaplin, Warneford Hospital, Headington, Oxford OX3 7JX, UK (e-mail: rchaplin@ cru.rcpsych.ac.uk).
ences between the groups in age or use of the Mental Health Act but people admitted with ID were more likely to be male and had longer lengths of stay. Admission to a general adolescent unit was associated with clinical improvement for people with ID. Conclusions This study needs replication because of the small sample and incomplete data but it suggests that young people with ID and mental disorders significantly improve clinically when admitted to hospital as do their non-disabled peers. Keywords clinical outcomes, intellectual disability, mental illness, psychiatric hospital admission, young people
Introduction Admission of young people with mental health problems to Specialist Child and Adolescent mental health units has been shown to be clinically and cost-effective, associated with substantive improvements across a range of diagnoses (Green et al. 2007). The psychiatric inpatient care of adults intellectual disability (ID) and mental health problems has been studied by comparing the demographics,
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
volume 59 part 11
Journal of Intellectual Disability Research
Nov e mBer
2015
996 R. Chaplin et al. • Young inpatients with intellectual disability
service use patterns and outcomes of adults with ID using general adult psychiatric inpatient units and specialist ID units. Also the outcomes of people with and without ID using general psychiatric units have been studied (Chaplin 2011). No such comparisons have been made for children and adolescents admitted with ID and mental health problems. The primary aim is to compare the outcomes of people with and without ID who are admitted for acute mental health care. The secondary aim is to assess the outcomes for young people with mental illness and ID admitted to general adolescent units.
Methods This study analyses data collected from the Quality Network for Inpatient Child and Adolescent Mental Health Services, Routine Outcome Measures project (Royal College of Psychiatrists’ Centre for Quality Improvement 2013) a quality improvement project. Diagnostic, sociodemographic information and clinical outcome [Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), Gowers et al. 1999] were collected on 1136 young people on admission by local clinicians. The Children’s Global Assessment Scale (CGAS) was also included in the audit but is not reported here because of poor completion rates. The outcomes of people with and without ID were compared with Chi-squared and Mann–Whitney statistical tests.
or without ID, affective disorders, schizophrenia and neurotic/emotional disorders were the most common diagnoses. For the whole sample, there was a highly significant improvement in mean HoNOSCA scores from 21.4 to 12.0 (Wilcoxon, P < 0.001) and improvements in both sub-groups with and without ID. Those with ID had significantly higher HoNOSCA ratings at admission and discharge. However there were no significant differences in the degree of improvements between the groups. The 980 people excluded because of lack of data on ID status made similar gains from 19.9 to 12.8 on HoNOSCA, but insufficient people had their age or gender coded to make further comparisons. Although those with ID had higher rates of detention (16% versus 12%), this was not significant (see Table 2). A subgroup comparison was made for people with ID who were admitted to general units. They admitted more people with mild ID whereas specialised wards admitted more people with severe ID (see Table 2), although numbers were not significant. Those 24 individuals admitted with ID to general units had significant improvements in HoNOSCA of 14.1 between admission (30.7), and discharge (16.6), Mann–Whitney P < 0.001. They improved to a greater extent than those without ID admitted to general units: HoNOSCA mean on admission 20.5, discharge 10.5, mean improvement 10.0 (Mann–Whitney P = 0.029). There were no significant differences in the mean ages or lengths of stay. The 13 young people admitted to specialist ID units also clinically improved but this number was too small to make valid comparisons of outcome.
Results
Discussion
Complete demographic and outcome data were returned on 151 (13.3%) of admissions, 38 with ID and 113 without ID from 14 inpatient units, with an age range of 6–17 years. Thirteen young people with ID were admitted to specialist units for young people with ID, 24 to general units (22 to adolescent and 2 to children’s psychiatric inpatient units) and 1 to a forensic unit. Young people with ID had significantly longer lengths of stay, were more likely to be male, but had similar ages to those without ID (Table 1). For both groups of young people with
This small scale study has shown that within this sample, young people with ID make clinical improvements measured by HoNOSCA when admitted for mental health treatment although needed longer admissions than their peers without ID with a non-significant trend for more compulsory admissions. People with all degrees of ID were admitted to general adolescent units and to specialised ID units. Comparison with the study by Green et al. (2007) shows similar clinical improvements but our study used different outcome measures:
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
volume 59 part 11
Journal of Intellectual Disability Research
Nov e mBer
2015
997 R. Chaplin et al. • Young inpatients with intellectual disability
Table 1 Comparison of admissions for young people with mental health problems and without intellectual disability (ID)
Number of young people Number (%) male Mean age: years (SD) Mean length of stay: days (SD)
People with ID
People without ID
38 24 (63%)
113 74 (40%)
14.2 (2.06)
14.4 (2.51)
109.9 (68.3)
78.2 (117.0)
Compulsory admission
8 (21%)
Χ2 = 7.15 P = 0.0075 Mann–Whitney P = 0.221 Mann–Whitney P < 0.001 Fishers exact P = 0.465 Mann–Whitney P < 0.001 Mann–Whitney P < 0.001 Mann–Whitney P = 0.213
18 (16%)
Mean admission HoNOSCA (SD)
28.0 (10.0)
20.1 (9.2)
Mean discharge HoNOSCA (SD)
16.7 (8.56)
10.5 (6.18)
Mean HoNOSCA improvement at discharge (SD)
11.2 (12.0)
7.9 (10.8)
N = 38/38 Affective Schizophrenia Developmental Neurotic/emotional Intellectual disability only Personality disorder Elective mutism Conduct Autism Other
Primary diagnosis
Significance
N = 97/113 8 8 7 5 3 2 2 1 1 1
22 14 1 27 2 3 1
Eating disorder ADHD Behavioural
7 1 19
HoNOSCA, Health of the Nation Outcome Scales for Children and Adolescents; ADHD, Attention Deficit Hyperactivity Disorder.
Specialised
General
Number Age (SD)
13 13.4 (1.96)
24 14.5 (2.08)
Length of stay: days (SD)
114 (48.6)
103 (73)
HoNOSCA on admission (SD) HoNOSCA on discharge (SD) Difference in HoNOSCA (SD) Degree of ID Mild Moderate Severe
22.8 (4.91) 17.5 (5.63) 5.36 (7.4)
30.7 (10.5) 16.6 (9.70) 14.0 (12.9)
4 2 7
10 8 6
Significance
Table 2 Comparison of the outcomes of young people with intellectual disability (ID) admitted to specialist ID and general units
Mann–Whitney P = 0.22 Mann–Whitney P = 0.122
HoNOSCA, Health of the Nation Outcome Scales for Children and Adolescents.
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
volume 59 part 11
Journal of Intellectual Disability Research
Nov e mBer
2015
998 R. Chaplin et al. • Young inpatients with intellectual disability
HoNOSCA rather than CGAS. This study collected some CGAS data but completion rate was too low to be included in this analysis. The main limitation was the quality of data collection which was performed by clinicians at the local services for reasons that are unclear. There is also the possibility that bias could have been introduced, for example a motivated staff group might have been more likely to recognise people with ID and offer effective treatment. Also there was only one measure of outcome, the HoNOSCA. This limits the generalisability of the study which should be considered preliminary and is in needs further replication with the use of more comprehensive outcome measures and robust methods of data collection. Our study suggests that young people with ID and mental illness make similar gains in clinical recovery as their non-disabled peers when admitted to psychiatric hospital. Further work needs to look into the socio demographic and clinical predictors of outcome, the experiences of young people in hospital and how these can be improved, and role of specialist admission units
References Chaplin R. (2011) Mental health services for people with intellectual disabilities. Current Opinion in Psychiatry 24, 372–6. Gowers S. G., Harrington R. C., Whitton A., Beevor A., Lelliott P. & Jezzard R. (1999) Brief scale for measuring the outcomes of emotional and behavioural disorders in children: Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). British Journal of Psychiatry 174, 413–16. Green J., Jacobs B., Beecham J., Dunn G., Kroll L., Tobias C. et al. (2007) Inpatient treatment in child and adolescent psychiatry – a prospective study of health gain and costs. Journal of Child Psychology and Psychiatry 48, 1259–67. Royal College of Psychiatrists’ Centre for Quality Improvement (2013) Quality Network for Inpatient Child and Adolescent Mental Health Services (QNIC). Royal College of Psychiatrists, London. Available at: http://www.rcpsych.ac.uk/workinpsychiatry/ qualityimprovement/qualityandaccreditation/ childandadolescent/inpatientcamhsqnic/qnicrom.aspx.
Accepted 5 June 2014
© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd
