Young people admitted on a Form 1 to a general hospital: A worrisome trend.

Paediatricians in primary and secondary level centres in Canada fill many roles. One of those roles for paediatricians practicing in nontertiary level centres is that of psychiatric consultant for young people who present to general hospital emergency rooms. Anecdotally, the number of mental health issues seen in consulting paediatric practice seems to be increasing. Training for this role is lacking in many programs (1,2). In the centre described in this paper, however, there has been a unique program involving a child and adolescent psychiatrist who has worked with paediatricians over a 10-year period providing both patient consultation and education to the physicians. The program has increased the knowledge and comfort level of the paediatricians, enabling them to act as mental health consultants for the paediatric population (3). This program has been necessary because there is a paucity of paediatric psychiatric beds in Ontario for young people who need a mental health admission, and a significant lack of child and adolescent psychiatrists outside of tertiary level centres. This has resulted in the need to hospitalize these patients on a medical paediatric inpatient unit under the care of paediatricians. In Ontario, patients may be admitted involuntarily if a Form 1 (Appendix) is filled out. This form declares that the individual is at serious risk to harm himself/herself or others, and that the reason for this state is a suspected mental disorder. The form states that the patient is incapable of consenting to treatment and authorizes, for a period of seven days, the apprehension of the person and detention in a psychiatric facility for a maximum of 72 h. Essentially, this form allows admission and treatment of children with serious psychiatric disorders when they are at risk and refusing treatment. Many factors and variables affect admissions and the management of young people with psychiatric disorders who are in crisis, including issues of voluntary versus involuntary admission, assessment of risk factors and diagnosis. Attention has been drawn to the increasing psychiatric hospitalization of minors, specifically, involuntary admissions. Significant debate in the literature exists as to the rights of these children. In one centre, 30% of adolescents indicated they had been admitted involuntarily, while a further 22% felt they had been hospitalized only because of parental pressure (4–9). Intoxication or self-poisoning are common reasons for the admission of young people to general hospital inpatient units. However, at times, their risk factors for psychological dysfunction seem to be inadequately assessed (10). Aggressive behaviour, which is believed to be commonly associated with substance abuse, is often associated with the need for inpatient admission and the consideration of a Form 1 application. There are some data indicating that aggression may not be a common acute manifestation of recent substance abuse in the adult psychiatric emergency patient (11). Moreover, in young people, many solvent abusers are managed as outpatients (12). A study in Ontario showed that adult patients admitted on a Form 1 failed to display violent or threatening behaviour after the first 24 h (13). Variables known to affect adult admissions to mental hospitals include demographic, clinical and time factors, although no mention is made of age (2.6% of referrals with 70% admitted)(14). Using tools to assess the appropriateness of admissions, such as the paediatric appropriateness evaluation protocol, (15) may not be useful in young people with psychiatric disorders, especially those requiring Form 1 admissions (15–17). Only 26% of the patients in one Ontario review of adult Form 1 admissions were in the dangerous or self-harm categories (18). In a study of adolescent patients (mean age 16.7 years) admitted to a tertiary level centre, the rate of certification (Form 1) was 8.5% (19). There is a paucity of information in the medical literature regarding the issues of Form 1 use in paediatrics. A MEDLINE review using key words “child”, “psychiatry”, “incompetent” and “acute” yielded 39 articles, with one directly addressing the issue of Form 1 admissions in adults, and three with clinical relevance to the topic in children (4,13,19). The paediatric mental health care team in the Orillia Soldiers’ Memorial Hospital, Orillia, Ontario (paediatrician, paediatric social worker, paediatric nurses, family physician) recognized a trend toward admitting children from the emergency room to the regional paediatric unit with a psychiatric diagnosis and placing them on a Form 1. Consequently, the diagnosis associated with Form 1 application was identified, and the variables which led to this apparent increase were reviewed.