Bringing a Child Home From Psychiatric Hospitalization

Dear Parent,

Congratulations! If your child has been hospitalized, and you have finally made it to discharge, the inpatient saga is in the rearview mirror. Now all you have to do is figure out what happens next. That may suddenly feel like a daunting task.

By now your child has probably idealized what being home is like and you have forgotten how hard it was to have them in the house. By now your other kids have started to like getting some attention again, too.

Expect bumps. Re-entry is hard.

Day one is likely to go okay(ish), for everyone will be glad to put the hospital in the past. You will need a lot of patience for the next week or two. Remember that your child is not cured, and no matter how much you want this ordeal to be over you can’t expect them to behave as if they are all better, or even mostly better. The hospital has only stabilized them enough to allow them to move to outpatient care. Old behaviors have not been extinguished, merely tempered. Long-present triggers have not been deactivated. Your child’s anxiety or rage or paranoia or OCD or depression may spike a little less quickly or have a shorter duration, but it’s far from gone.

So there will be bumps. And because there will be bumps, you will need to remind yourself repeatedly that a bump is not a cliff.

The first time your child acts the way they did before hospitalization your trauma-scarred brain will leap to the conclusion that you are right back where you were before. This is not true. Breathe deep. Do not allow yourself to freak out. Stay patient. Be empathetic.

Your child is going to be just as scared by bumps as you are, if not more. Although neither of you may have thought of it this way, life in the hospital was actually much simpler than life at home. The rules, behavioral expectations and consequences there were carved in stone.  Everything was planned out. Staff didn’t take behavior or outbursts personally; they responded according to protocol rather than with dread or alarm. So arriving home — while definitely a good thing — is also stressful. There are far more stimuli, far more temptations. Home is a place of old habits and parental expectations. What seemed easy to manage in the hospital may feel much more complicated now. The stress level for your child will be higher.

Here’s what you can do to lower it: Tell your child something on the order of, “I am so, so glad you are back. They warned me that re-entry can be stressful, and I want you to know that I don’t expect everything to be perfect. I don’t expect you to be perfect, or to feel perfectly better. I know that I’m not going to be perfect, and I’m not going to handle everything perfectly. That’s okay. I know there will be bumps. And I want you to know that I love you, and we will work through the bumps together.” Then when problems erupt, you pause, take an enormous breath, and say, “Remember how I was saying there would be bumps? That was a bump. And we will work through it.”

Your task is to step back from your expectations and emotions, and to stay as cool as you can. You will offer empathy, tons of empathy, and creature comforts: favorite meals, a cup of tea, a stuffed animal, some soothing music. This will help. Or at least it will help a lot more than screaming at your kid in frustration.

If you have to vent, do it in private to someone who can remind you that what you are seeing is a bump in the road. If you live with a partner, find ways to hand off care when one of you is weary or anxious or losing patience.

If your child had a suicide plan or attempt before hospitalization, you will probably be told that the greatest likelihood of a repeat attempt is within the first three months. This is unhappy news, especially given all you have been through. Your task will be to figure out how monitor your kid’s mental state without being overbearing — and without dissolving into your own puddle of worry. There are three aspects to making this happen.

• You will need to manage your own anxiety well. Use whatever works for you, whether it is exercise, meditation, yoga, mindfulness or slow breathing (there are some good apps available for your phone), journaling, long showers, talking to your own therapist, or something else. Find a combination of approaches that include everyday preventative measures (to keep your baseline anxiety at a reasonable level) and in-the-moment techniques (for specific stressful situations). If you need medication, get it — but be careful not to abuse it.
• You will need to keep lines of communication with your child open. Refresh your memory of good techniques for talking with your teen. In times of stress we all tend to revert to old habits, so it’s a good idea to bring healthy habits to the front of your mind by reading up on them.
• You will need guidance on what to do if your child tells you they still have thoughts of self-harm. Talk to your child’s therapist for tips. Knowing the difference between passive and active suicidal ideation can help you stay calm and practical.

Your child’s outpatient team will probably ask you to set up additional therapy and psychiatry appointments for a period of time. This is expensive and a logistical headache, but you will want someone else to assess your child’s safety regularly, especially while changes in medication are still being made.

One thing that will help both you and the doctors is to start a journal or log. This will take up a ridiculous amount of time, but there’s an excellent reason for doing it: When you are in the thick of an emotionally charged situation it is difficult to track how life is trending. A log creates an objective measure of what you’re seeing and how often you’re seeing it. Plus when your gut is telling you something is wrong, or that your child is getting worse instead of better, it’s much, much easier for a doctor to understand your concerns when you provide actual data.

Write down:

• What medications are being taken, and when dosages change. Frankly, if a side effect kicks in a month from now, the odds you’re going to remember that you increased the dose today are pretty slim. You (and your doctor) may mistakenly conclude that your child has some new symptom and add another medication. Alternately, a future doctor may want to try a medication that you’ve already used, and it’s helpful to have a record of what was tried and why it was later rejected.
• What symptoms you are seeing, and how often. If your child has meltdowns, record how many, how long they last, and how severe they were. Take note of the ABCs: antecedents, behaviors, and consequences. Is there a pattern? If your child is depressed, describe how many hours they have been out of bed each day, when activities are resumed, how long their attention span is for projects, hunger or lack thereof, social interaction or whatever other symptoms are relevant.
• Changes in routine and outside stressors. You will want to be able to figure out if changes in behavior correlate to environmental events, medication adjustments, or are simply variations in mood. Note any big changes in school schedule or family structure, as well as lesser issues like arguments with friends or even the dates of your daughter’s menstrual cycle.
• Things your child says or does that worry you. This is especially helpful if you’re having trouble conveying the extent of the volatility or apathy you’re seeing to the treatment team. Sometimes reading a narrative view of “a day in the life” of your child can give doctors a richer understanding of what is happening at home. Write down events and actual quotes to share with your child’s therapist.

Keeping a log is a lot of work. However, it is work you will not regret.

The hospital probably didn’t give you guidance on how much supervision your child will need upon returning home. Things you will want to discuss with your partner and your child’s treatment team include:

• How long can your child be left alone?
• How quickly can they resume normal activities?
• Are visits to friends’ houses okay? (It may be better to arrange all visits at your house at first.)
• How do we transition back to previous levels of independence?

You may chafe as much as your child does at the amount of supervision required. You will need to trade off care with your partner or get trusted friends or family to provide some respite. Much as you may yearn for a weekend getaway, it’s not a good idea while you are still gauging how stable your child is.

The fact that re-entry feels endless doesn’t make it endless. You can get through this if you pace yourself, figure out how to process your own feelings, and reach out to your child’s treatment team for help.