Complete Guide to Emergency Hospitalization

Assuming your child has been referred to inpatient care from an emergency room, once an inpatient bed is found, your child will be transported by ambulance to the facility. You will be allowed to ride along. There will be another intake assessment upon arrival, at which you will have to retell an account of what led up to the hospitalization. You will be asked about your family’s history of mental illness. Genetics play a huge role in mental health, and your family’s experience may be relevant to the kinds of medications that may be appropriate for your child.

Ask for the number of the nursing station and put it into your phone immediately, so you don’t lose it. This will enable you to call the nurse’s station whenever you want to find out how your child is doing, ask questions or ask to have the doctor or social worker call you.

If you have missed a meal in transit, ask for food. Most intake departments will have sandwiches or something on hand, but the actual unit will not.

Someone will sort through your child’s belongings and decide what can and can’t stay on the unit. Anything sharp, made of glass or long enough to tie around the neck (including belts, drawstrings and shoelaces) will not be permitted. Some hospitals do a body check, so that the hospital has an inventory of the patient’s wounds and scars prior to entry. Then your child will be brought to her room. You will probably be allowed to go along to say goodbye.

The psychiatric unit will almost certainly be locked with a two-stage door system. You will later have to show ID to enter, and phones with cameras are usually not allowed (so no one can post pictures of patients online). A nurse on the unit will ask you whose names should be placed on the visitor list. In some cases only family is permitted. List only people who will be helpful.

Sometime before you leave, ask under what circumstances the hospital will reach out to you. There are likely to be only three situations that trigger a phone call:

1. They want to add to or change your child’s medication and need your permission to do so. They will only contact you for new meds, not for subsequent increases or decreases in dosage. If you get a call like this, write down the date, time, name of the doctor and what was said.
2. Your child has been involved in an “incident.” This may be a physical accident (rare), injury caused by another patient (rare) or notification that your child was taken to a seclusion room because she became violent. If you get a call like this, ask for details. Write the account down in a notebook, record the date of the call and the name of the person calling and later speak to your child to get her version of the story.
3. They want to set up a “family meeting” to discuss plans for discharge. This will happen several days or even a week before the actual discharge, because it takes a while to put plans in place. “Family” in this case means the parent, the child, a social worker and usually the psychiatrist. Take notes at the meeting, or bring someone (spouse or relative, preferably in casual business attire) to take notes for you. If you did not already have a treatment team prior to hospitalization, the social worker will help you find one; in most states you will need an appointment on the books before discharge. Private-pay hospitals may not need to follow the same procedures.

The key bit of information to understand up front is that the sole purpose of an inpatient stay is to stabilize your child enough to be discharged to outpatient care. In other words, they aren’t going to cure anything here. At best, your child’s symptoms or behavior will improve 10 percent, maybe 20 percent.

As with other hospitals, nothing of substance happens on weekends. A child who enters on a Friday, Saturday or Sunday won’t be evaluated by the regular team on the unit until Monday.

Once the doctors have visited with your child (you won’t be there when this happens), they will come up with a working diagnosis.

Your child’s day will be structured on a schedule that includes a daily (brief) check-in by medical staff, school (usually only an hour or two, of limited educational value except that your child will get attendance credit) and various group therapies. These may include classes or groups on coping skills, information on mental health and family therapy. Some hospitals also use experiential therapies that incorporate animals, music, art or horticulture. There is unlikely to be any individual counseling. Remember, the goal isn’t to get to the bottom of anything. The goal is to get your child stable enough to move to outpatient treatment, where the long-term work takes place.

The television in the day room will blare during free time, and much of the day will be very low-key. This can make it seem that the hospital isn’t doing much of anything. What they do is provide structure, medication and monitoring.

Rules and privileges

You may be shocked by the limited visiting hours, which may make it difficult to visit. You don’t need to come every day; the most important time to visit is on the weekends, when there’s less structure and less for the kids to do. If you bring food (which your child will probably beg you to do), ask in advance about what’s allowed. Bring it in a paper bag; plastic won’t be allowed.

There will be a ton of rules. The ridiculous nature of many of them will likely be the topic of your conversation with your child. Likewise, most psychiatric hospitals use some kind of system in which the kids earn privileges if they comply with behavioral expectations. Your child might gripe about them, too. Your job is to nod and empathize.

Medication

The doctor is usually required to discuss medicine changes with you prior to implementing anything. If your child already has a psychiatrist, make sure the two doctors are in contact throughout the stay. Besides knowing your child better than the inpatient doctor, your child’s psychiatrist will also be responsible for monitoring any medication changes over the long haul, so communication is important.

Things to ask about medications (and take notes about):

1. What is the doctor’s thinking in choosing this medication? What alternatives are there? If you have family members with similar problems, tell the doctor which medications have been effective and which haven’t. There’s no guarantee your child will respond to medication in the same way, but when you have a range of options it’s worth considering the one that worked for others in your child’s genetic pool.
2. How long will it take before the medication kicks in? A few psychiatric medications are effective the same day. Many take a good amount of time to take effect. Antidepressants, for example, may not reach full potency for 4-6 weeks. What you want to know is what to expect and when. You may also want to ask what happens if the doctors don’t see that effect. Because changes might not be visible until after your child leaves the hospital, make sure your child’s outpatient psychiatrist is included in medication decisions that are made while your child is in the hospital.
3. What are the common side effects? How long do they tend to last? Many side effects pass after a while, but some don’t. Sleepiness, for example, is usually more of a problem in the first week or two. Other meds are notorious for weight gain, so speak up if diabetes runs in your family. You should also be told about any dangerous but rare side effects, when these are likely to show up and what they look like. Lamictal, for example, causes a rash in a small percentage of cases that can be very serious.

Keep good records of what medications your child is on, when dosages change and any notable changes in behavior.

You are likely to have many intense feelings about having a child in a psychiatric hospital —including shame, guilt, fear, anger, sadness and relief — and you will be better able to help your child if you allow yourself to feel and process these emotions. Your partner’s mix of feelings will undoubtedly be different than yours. You’re both allowed to feel what you feel. Be kind to each other, for you are each hurting in your own way.

No matter what you are feeling, remind yourself over and over again: your child is safe. This, at least, is good.

Now that your child is safe, it’s time to take care of yourself. By all means, take a day or two to give vent to your feelings, then make use of this time to replenish yourself.

Phone calls, anger and distress

Kids often feel ashamed, confused and scared about being in a mental health facility. Because they are kids, they are likely to take their feelings out on the person they love the most, the person who is safest: you.

You will not be the first parent to be called the worst mother or father in the world, nor the last to be on the receiving end of a blistering “How could you do this to me?” Don’t take it personally, even if it’s addressed to you. Regardless of your fear (and your child’s assertion) that she’ll hate you for the rest of her life, she probably won’t. So when you receive that tenth venomous phone call, or hear yet another heart-wrenching plea to get her out of there, breathe.

You can try to reason with your child, but don’t expect to get far. Logic is rarely effective at defanging emotion. You’ll probably make the most progress by acknowledging and empathizing with her underlying feelings:

“It sounds like you’re really scared.”

“You must be really angry that you have to be there.”

“I’m so sorry it’s so rough. I sure wish there were a better way, but there isn’t.”

If you’re too fragile to manage this approach (or the calls simply get to be too much for you), talk to nursing staff about limiting phone access. Alternatively, don’t pick up every call. You don’t have to “be there” for your kid every single hour of the day. It’s healthy to set limits.

If you’ve had experience with other types of hospitals, you know that even in good facilities it’s possible to encounter an overbearing nurse, a doctor who doesn’t listen well or some sort of aggravating glitch in care. To get the best care possible, you will have to advocate for your child.

There are three obstacles to advocating well.

1. Your own emotions are running high. You will need to use caution to avoid overreacting or jumping to conclusions. If your child relates an event that has distressed him or seems to have been handled badly, take notes on his version of what happened. Remind yourself that your child is not well, and his perception of what occurred may not be accurate. This will help you approach staff with an open mind. Questions like “My son seems upset about what he says took place with _______________. Can you tell me about that?” are going to get a more honest reply than if you bluster in with something accusatory.
2. You don’t know how this particular system works. Be pleasant, form alliances with as many staff as possible, get to know people by name and dress in respectable clothes when you visit. Be a reasonable human being. Take lots of notes. If you have a concern and you’ve spoken up about it several times and still aren’t getting a response, put it in writing. You may need to quietly ask one of the staff members you’ve befriended how to get X to happen, or who is in charge of Y. If you are getting stonewalled, push it up the administrative chain.
3. Staff members vary in how responsive they are. Some will be caring and proactive, some will be okay, and you may encounter a few who seem to be phoning it in. The most important consideration here is that any human connection you create with staff is a good thing. The more you can get the empathy going, the more likely it is that people will be kinder. If you have a partner, divvy up who will play bad cop and who will be the good cop. (These roles can change, by the way, depending on which shift you’re dealing with, and which of you has developed rapport with a given staff member.)

As with any other type of hospital visit, you will find it easier to figure out what is going on if you take good notes during each meeting or after every conversation.

Usually the discharge discussion takes place several days or even a week before the actual discharge. Be forewarned that the key determinant of when your child is released is what your insurance company will pay for. You may or may not agree that your child is ready to come home.

If your initial reaction to the news is a screaming “Nooooo!” you will want to pause and examine what’s going on in your head.

On the one hand, you may be remembering how bad things were before the hospitalization, and feel insecure about what life will be like in the next phase. Then again, your reaction may be spot-on intuition that your child truly isn’t ready. Make sure you articulate any specific concerns to the doctor, especially if in your private conversations with your child she has indicated that she still wants to kill herself, or you suspect your son is lying in order to get out.

Some parents become upset because the hospital wants a longer stay than feels strictly necessary. Ask why they want this. Common reasons are that a follow-up plan of care isn’t in place yet or that the doctors feel it isn’t safe to discharge your child until she has met certain conditions.

If your child was suicidal or made an attempt, you will want to ask how much of his new medication constitutes an overdose. Ask this several days before discharge, because you may need to buy a lockbox or safe in which to store medication. You’ll also need a medication dispensing tray (available in any pharmacy) to set up a week’s worth of medication at a time. You don’t want to retrieve bottles multiple times a day, because the more you open and close a lockbox, the greater the odds are that you’ll leave the key somewhere or your child will see the combination.

Ask if it’s safe to leave a tray with a week’s worth of meds out and accessible. Believe it or not, the doctor probably won’t know the answer off the top of her head, unless the medication is particularly potent. If it’s dangerous to leave a week’s worth of meds out, buy a tray with detachable compartments that allow you to take a day’s worth out at a time. That way you can organize the whole week, keep the bulk of it in the lockbox, and take out only a single day’s medication.

If your child has been suicidal or made an attempt, before he comes home do a clean sweep of your home, and especially his room. Hopefully the doctors have told you what method of suicide your child was contemplating. This will help you prioritize what to remove or look for. Lock up high-risk items like firearms, all prescriptions (including your own) and over-the-counter medications like Tylenol and aspirin. Remove poisons (including toxic cleaning products), sharp objects like razors and knives and large plastic bags. You will also need to wrestle with how to make sure that for the next few weeks your child is not left alone for more than very short periods of time at home.

If you suspect your child has hidden something dangerous (sharps, medications, illicit drugs) but you still can’t find it, Google “best places to hide ____ in your bedroom.” Your child may have visited that page ahead of you.

For a more comprehensive list of steps to take to “sanitize” your home, check the Grief Speaks website.

Get the discharge instructions that tell you what to do and be sure to sign a release saying you’d like the discharge summary when it is ready and to whom you want the discharge summary sent. If your child was given any kind of psychological or ed-psych testing, make sure to get a copy of those results before leaving, too.

By now your child may be idealizing what being home is like and you may have forgotten how hard it was to have her in the house. Your other kids will have their own feelings about their sibling coming home, too.

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 him to behave as if he is all better, or even mostly better. The hospital has only stabilized him enough to allow him 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 he did before hospitalization you may 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.

Managing the Stress

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 reentry 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 to 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.

1. 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.
2. 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.
3. You will need guidance on what to do if your child tells you she still has 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 being made.

One thing that will help both you and the doctors is to start a journal or log. This will take up time, but there’s an excellent reason for doing it: When you are in 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 easier for a doctor to understand your concerns when you provide actual data.

Write down:

1. What medications are being taken, and when dosages change. If a new side effect kicks in a month from now, the odds of remembering 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.
2. 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 she has been out of bed each day, when activities are resumed, how long her attention span is for projects, whether she’s hungry or not — whatever symptoms might be relevant.
3. Changes in routine and outside stressors. You will want to be able to figure out if changes in behavior correlate to environmental events. 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.
4. 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.

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 she 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 reentry 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.